From the Guidelines
A comprehensive recurrent fall workup should include a detailed history, physical examination, and targeted investigations, with interventions addressing modifiable risk factors through medication adjustments, physical therapy, home safety modifications, and assistive devices, as supported by the most recent evidence from 1.
Key Components of the Workup
- Detailed history: assessing circumstances of falls, including frequency, timing, associated symptoms, and environmental factors
- Physical examination: focusing on orthostatic vital signs, cardiovascular assessment, neurological evaluation (including gait and balance testing), musculoskeletal examination, and vision screening
- Laboratory tests: complete blood count, comprehensive metabolic panel, vitamin D level, and thyroid function tests
- Medication review: identifying drugs that may contribute to falls, such as sedatives, antihypertensives, and psychotropics
- Imaging studies: brain CT or MRI if neurological symptoms are present
- Specialized testing: electrocardiogram, Holter monitoring for arrhythmias, carotid sinus massage for hypersensitivity, and bone density scanning for osteoporosis risk
Interventions
- Medication adjustments: to minimize fall risk
- Physical therapy: for strength and balance training (30 minutes, 2-3 times weekly for at least 12 weeks)
- Home safety modifications: to reduce environmental hazards
- Assistive devices: to improve mobility and balance
Importance of a Multifaceted Approach
Falls typically result from multiple interacting factors, and addressing these comprehensively can significantly reduce fall risk and associated complications, as highlighted in 1. A comprehensive approach, including education and counseling, can also help patients and caregivers understand the risks and benefits of different interventions and make informed decisions about their care.
From the Research
Appropriate Workup for Recurrent Falls
The workup for a patient with recurrent falls involves a comprehensive evaluation of various risk factors.
- A thorough medical history, including pre-admission falls, confusion, unsafe gait, and medication use, is essential 2.
- Psychological or sedative drug use has been identified as a predictor of recurrent falls, ED revisits, subsequent hospitalizations, and adverse events 3.
- A comprehensive differential diagnosis is necessary to identify rare neurological conditions that may contribute to weakness and falls in older adults 4.
Risk Factors for Recurrent Falls
Several risk factors have been associated with recurrent falls in older adults, including:
- Balance and mobility issues (RR: 1.32; 95% CI: [1.10,1.59]) 5
- Medication use (RR: 1.53; 95% CI: [1.11,2.10]) 5
- Psychological factors (RR: 1.35; 95% CI: [1.03,1.78]) 5
- Sensory and neuromuscular factors (RR: 1.51; 95% CI: [1.18,1.92]) 5
- Older age and female gender have also been identified as risk factors for falls with consequences 6
Evaluation and Management
A comprehensive evaluation of these risk factors is necessary to develop an effective management plan for patients with recurrent falls.
- This may involve a multidisciplinary approach, including medical, psychological, and environmental assessments 2, 3, 5.
- Strategies to identify and resolve frailty markers, such as balance and mobility issues, medication management, and psychological support, should be a frontline approach to preventing recurrent falls 5.