Management of a Patient Who Fell 2 Days Ago
For a patient who fell 2 days ago, a comprehensive multifactorial assessment should be performed immediately, including evaluation of injuries, underlying causes of the fall, and future fall risk to reduce morbidity and mortality.
Initial Assessment
- Perform a complete head-to-toe evaluation for ALL patients, even those presenting with seemingly isolated injuries 1
- Assess for traumatic injuries, which may be "occult" in geriatric patients, presenting without classic signs or symptoms 1
- Maintain high suspicion for high-risk injuries such as blunt head trauma, spinal fractures, and hip fractures 1
- Evaluate the underlying cause of the fall by asking "if this patient was a healthy 20-year-old, would they have fallen?" If the answer is "no," a more comprehensive assessment is needed 1
Key Historical Elements to Obtain
- Location and cause of fall 1
- Difficulty with gait and/or balance 1
- Previous falls 1
- Time spent on floor or ground 1
- Loss of consciousness or altered mental status 1
- Near-syncope or orthostatic symptoms 1
- Relevant comorbidities (dementia, Parkinson's, stroke, diabetes, depression) 1
- Visual or neurological impairments 1
- Alcohol use 1
- Current medications 1
- Activities of daily living 1
- Appropriate footwear 1
Physical Examination and Testing
- Perform orthostatic blood pressure assessment 1
- Conduct neurologic assessment with special attention to neuropathies and proximal motor strength 1
- Evaluate gait and balance with standardized tests such as the "get up and go test" 1
- Consider appropriate diagnostic tests: complete blood count, electrolyte panel, EKG, and appropriate imaging 1, 2
Imaging Considerations
- If clinical suspicion for fracture remains high despite normal plain radiographs, obtain an MRI to identify occult fractures 2
- For suspected head injury, CT scanning is the first-line imaging technique to evaluate for scalp injuries, bone fractures, extra-axial hematomas, and parenchymal injury 3
- If CT does not demonstrate pathology adequate to account for the clinical state, consider MRI 3
Medication Review
- Perform medication assessment with special attention to high-risk medications: vasodilators, diuretics, antipsychotics, and sedative/hypnotics 1
- Consider medication discontinuation for those that may increase fall risk, though evidence for this intervention alone is insufficient 1
Interventions
Exercise interventions are strongly recommended for fall prevention 1
Consider vitamin D supplementation (800 IU daily) for those at increased risk for falls 1
For patients requiring hospital admission:
Safety Assessment and Discharge Planning
- Evaluate the patient's ability to rise from bed, turn, and steadily ambulate before discharge 1
- Provide education to the patient, family, and caregiver about increased fall risk and precautions 1
- Provide skills training for safe transfers and mobilization, including what to do if a fall occurs 1
- Consider home safety assessment and modifications 1
- Arrange expedited outpatient follow-up, including home safety assessments 1
- Consider admission if patient safety cannot be ensured 1
Secondary Prevention
- Refer patients to a Fracture Liaison Service or Bone Health Clinic for secondary fracture prevention if fractures are identified 2
- Ensure adequate calcium intake and vitamin D supplementation 2
- Consider pharmacological treatment with bisphosphonates to reduce risk of subsequent fractures if appropriate 2
Common Pitfalls to Avoid
- Failing to perform a complete evaluation in patients presenting with seemingly isolated injuries 1
- Overlooking occult injuries in geriatric patients who may not present with classic signs or symptoms 1
- Neglecting to assess for underlying causes of falls, which are often multifactorial 1
- Discharging patients without ensuring they can safely ambulate 1
- Failing to arrange appropriate follow-up and secondary prevention measures 1, 2