What is the approach to a complete falls work-up?

Comprehensive Falls Work-up: A Structured Approach

A comprehensive falls work-up should include annual screening for all adults aged 65 and older, with multifactorial risk assessment and targeted interventions for those at increased risk, as falls are a leading cause of morbidity and mortality in older adults. 1, 2

Initial Screening and Assessment

• All older adults (≥65 years) should be asked at least once a year about falls 3
• Perform the "Get Up and Go Test" - observe the patient standing up from a chair without using arms, walking several paces, and returning 3, 4
  • Healthy adults over 60 should complete this in less than 10 seconds 4
  • Those demonstrating difficulty or unsteadiness require further assessment 3
• Patients with one or more falls, abnormalities of gait/balance, or who report recurrent falls should undergo a comprehensive falls evaluation 3, 1

Comprehensive Falls Evaluation Components

Medical History Assessment

• Detailed circumstances of falls, including witness accounts when available 3, 1
• Time spent on floor/ground, presence of loss of consciousness or altered mental status 1
• Symptoms of near-syncope or orthostasis 1
• Review of acute and chronic medical conditions 3
• Medication review with special attention to high-risk medications (psychotropics, sedatives, antihypertensives, diuretics) 3, 1
• Assessment of mobility levels and functional status 3

Physical Examination

• Vision assessment 3
• Gait and balance evaluation 3, 4
• Lower extremity joint function examination 3
• Basic neurological function assessment including:
  • Mental status 3
  • Muscle strength 3
  • Lower extremity peripheral nerve function 3
  • Proprioception 3
  • Reflexes 3
  • Tests of cortical, extrapyramidal, and cerebellar function 3
• Cardiovascular assessment:
  • Heart rate and rhythm 3
  • Postural pulse and blood pressure 3
  • Carotid sinus massage (in appropriate patients) 3

Environmental Assessment

• Home safety evaluation for hazards 1, 5
• Lighting adequacy, especially in pathways to bathrooms 5
• Presence of grab bars in bathrooms and handrails on stairs 5
• Loose rugs or clutter on floors 1, 5

Evidence-Based Interventions

Exercise and Physical Therapy

• Exercise or physical therapy has shown moderate benefit in falls prevention with high certainty of evidence 3, 4
• Balance training should be performed 3+ days per week 1
• Strength training should be done twice weekly 1
• Consider T'ai chi for patients with mild cognitive impairment 5

Medication Management

• Review and minimize high-risk medications 1
• Consider withdrawal or dose reduction of psychoactive medications 3
• Manage postural hypotension 3

Environmental Modifications

• Home hazard assessment and modification by a health professional 1, 5
• Remove loose rugs and clutter 1, 5
• Improve lighting, especially in pathways to bathrooms 5
• Install grab bars in bathrooms and handrails on stairs 5

Vitamin D Supplementation

• Consider vitamin D supplementation (800 IU daily) for those at increased risk for falls 1
• Note that recent USPSTF guidelines no longer recommend vitamin D supplementation for community-dwelling older adults not known to have vitamin D deficiency 3

Additional Interventions

• Management of foot problems and appropriate footwear 3
• Scheduled voiding to prevent falls when rushing to the bathroom 1
• For patients with cognitive impairment, implement consistent daily routines and use simple, clear instructions with visual cues 5

Special Considerations

For Patients with Cognitive Impairment

• Use the "three R's" approach: repeating simple instructions, reassuring the patient, and redirecting attention 5
• Break down activities into simple steps 5
• Involve caregivers in fall prevention strategies 5

For Frail Elderly

• Consider multifactorial clinical assessment with comprehensive management 3
• Distribute physical activity throughout the day in short sessions 5
• Ensure adequate hydration and nutrition 5

Follow-up Care

• Arrange appropriate follow-up based on risk stratification 1
• Consider multidisciplinary approach for high-risk patients 1
• Regularly reassess fall risk as the patient's condition changes 5

Common Pitfalls to Avoid

• Failing to address underlying causes of falls such as orthostatic hypotension or medication side effects 5
• Not considering the impact of cognitive impairment on the ability to follow safety instructions 5
• Overlooking the need for caregiver education and support in patients with cognitive impairment 5
• Neglecting to assess for occult injuries in patients who have fallen 1