What is the medical assessment and management for a 62-year-old who fell out of a wheelchair (physical examination)?

Medical Assessment for a 62-Year-Old Who Fell Out of Wheelchair

A comprehensive fall evaluation is essential for any older adult who falls from a wheelchair, including a thorough assessment for traumatic injuries and determination of fall causes to prevent recurrence and reduce morbidity and mortality. 1

Initial Assessment

• Begin by asking the critical question: "If this patient was a healthy 20-year-old, would they have fallen?" If the answer is "no," a more comprehensive assessment of underlying causes is needed 1

• Perform a complete head-to-toe examination for ALL patients, even those presenting with seemingly isolated injuries, as traumatic injuries may be "occult" in older adults 1

• Pay particular attention to high-risk injuries such as:

  • Traumatic brain injury (most common serious injury in wheelchair falls) 2
  • Femur fractures 2
  • Vertebral fractures with potential spinal cord injury 2
  • Hip fractures 1

History Taking Components

• Document the specific circumstances of the fall:

  • Location and cause of fall 1
  • Time spent on floor or ground 1
  • Presence of loss of consciousness or altered mental status 1
  • Near-syncope or orthostatic symptoms 1

• Assess for risk factors that contribute to falls:

  • Medication review, especially psychotropic medications, vasodilators, diuretics, sedative/hypnotics 1, 3
  • Comorbidities such as dementia, Parkinson's, stroke, diabetes, depression 1
  • Visual or neurological impairments including peripheral neuropathies 1
  • Alcohol use 1
  • Activities of daily living capabilities 1
  • Previous falls in the past year 1, 4

Physical Examination

• Perform orthostatic blood pressure assessment 1

• Conduct neurological assessment with special attention to:

  • Presence/absence of neuropathies 1
  • Proximal motor strength 1
  • Mental status 1
  • Lower extremity peripheral nerves, proprioception, reflexes 1
  • Tests of cortical, extrapyramidal, and cerebellar function 1

• Assess vision, gait, balance, and lower extremity joint function 1, 3

• Perform the "Get Up and Go Test" - observe as patient stands from chair without using arms, walks several paces, and returns 1, 3

Diagnostic Testing

• Maintain a low threshold for obtaining:
  • EKG 1
  • Complete blood count 1
  • Standard electrolyte panel 1
  • Measurable medication levels when appropriate 1
  • Appropriate imaging based on clinical findings 1

Safety Assessment Prior to Discharge

• Evaluate gait and perform "get up and go test" - patients unable to rise from bed, turn, and steadily ambulate should be reassessed 1

• Consider admission if patient safety cannot be ensured 1

• Arrange expedited outpatient follow-up including home safety assessments for those discharged 1

Intervention Planning

• For community-dwelling older adults, multifactorial interventions should include:

  • Gait training and advice on appropriate use of assistive devices 1, 3
  • Review and modification of medications, especially psychotropic medications 1, 3
  • Exercise programs with balance training as a key component 1, 3
  • Treatment of postural hypotension 1
  • Modification of environmental hazards 1, 3
  • Treatment of cardiovascular disorders 1

• Ensure proper wheelchair fit and use through education 2

• Consider referral to physical therapy and occupational therapy for all patients admitted to hospital after a fall 1

Common Pitfalls to Avoid

• Overlooking "occult" injuries that may not present with classic signs or symptoms in older adults 1

• Failing to perform medication review, especially of psychotropic medications 3

• Relying solely on fall risk screening without implementing targeted interventions 3

• Not addressing multiple risk factors in high-risk individuals 3, 5

• Neglecting to provide education on proper wheelchair fit and use 2