What is the appropriate management for a 90-year-old patient with a lump on the head after a fall due to generalized weakness?

Management of Head Lump After Fall in a 90-Year-Old

This 90-year-old patient requires immediate emergency department evaluation with head CT imaging to rule out intracranial hemorrhage, followed by comprehensive fall risk assessment and multidisciplinary intervention to prevent future falls and reduce mortality risk.

Immediate Emergency Assessment

Head Injury Evaluation

• Obtain detailed fall circumstances including exact mechanism, time on ground, loss of consciousness, and any witnessed altered mental status 1
• Perform complete head-to-toe examination to identify occult injuries, with particular attention to the scalp lump, neurological status, and signs of skull fracture 1
• Assess vital signs and orthostatic blood pressure (supine and after 1-3 minutes standing; a drop ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension) 1, 2
• Complete neurological examination focusing on level of consciousness, pupillary response, focal deficits, and signs of increased intracranial pressure 1

Diagnostic Testing

• Obtain head CT scan given the patient's advanced age, presence of scalp hematoma, and mechanism involving loss of balance—all high-risk features for intracranial injury 1
• Order ECG to evaluate for arrhythmias that may have precipitated the fall, as up to 30% of falls in older adults may be due to syncope 2
• Consider complete blood count, electrolyte panel, and glucose to identify metabolic contributors 1

Cardiovascular Evaluation for Fall Etiology

Syncope Assessment

• Determine if loss of consciousness occurred, recognizing that syncope in older adults often presents atypically as a fall without clear loss of consciousness due to amnesia 2
• Assess for cardiac symptoms preceding the fall including palpitations, chest pain, or shortness of breath 2
• Evaluate for carotid sinus hypersensitivity in appropriate patients without carotid bruits or stroke history, as approximately 30% of older adults with non-accidental falls may have had syncope 2

Medication Review

Perform comprehensive medication assessment with special attention to high-risk medications including vasodilators, diuretics, antipsychotics, and sedative/hypnotics that significantly increase fall risk 1, 2

Disposition and Safety Planning

Admission Criteria

• Admit if patient safety cannot be ensured or if abnormal neurological findings persist 1
• Consider admission if imaging shows acute findings or reliable follow-up cannot be arranged 1

Discharge Planning (if appropriate)

• Perform "get up and go test" before discharge; patients unable to rise from bed, turn, and steadily ambulate require reassessment 1
• Arrange expedited outpatient follow-up including home safety evaluation 1

Comprehensive Fall Prevention Program

Multifaceted Intervention Strategy

Implement a structured interdisciplinary approach combining medical assessment, home safety evaluation, and targeted interventions, as this reduces future falls more effectively than single interventions 3

Specific Interventions

Physical Therapy and Exercise

• Refer to physical therapy for gait and balance assessment 1
• Prescribe balance training 3 or more days per week and strength training twice weekly for patients with mild deficits 3, 1
• Target interventions to postural hypotension, balance, transfers, and gait, as these are particularly effective 3

Home Safety Modifications

• Arrange home safety assessment by occupational therapy with direct intervention, advice, and education 3
• Recommend environmental changes including removing loose rugs, ensuring adequate lighting, and creating clear walking paths 1
• Ensure proper footwear with non-skid soles 1

Medical Management

• Review and modify medications contributing to fall risk, particularly those causing orthostatic hypotension 1, 2
• Initiate vitamin D supplementation (800 IU daily) for fall prevention 1
• Treat cardiovascular disorders identified during evaluation, including consideration of cardiac pacing for carotid sinus hypersensitivity if recurrent falls occur 2

Osteoporosis Evaluation

• Order DEXA scan and check vitamin D, calcium, and parathyroid hormone levels 3
• Refer to bone health clinic for osteoporosis treatment to reduce fracture risk with future falls 3

Patient and Caregiver Education

• Educate about personal risk factors including age, gait/balance difficulties, medications, and orthostatic symptoms 1
• Teach recognition of orthostatic hypotension symptoms and strategies to minimize effects 1
• Instruct on safe transfer techniques and importance of slowing down movements during transitions 1
• Emphasize scheduled voiding to prevent falls when rushing to bathroom 1

Follow-Up Care

Arrange multidisciplinary follow-up with primary care, cardiology if syncope suspected, and occupational therapy for home assessment within one week 1, 2

Common Pitfalls to Avoid

• Do not dismiss the fall as simply "mechanical" without evaluating for syncope, as cognitive impairment reduces symptom recall accuracy in older adults 2
• Do not delay imaging in elderly patients with scalp hematomas, as they are at high risk for intracranial hemorrhage even with seemingly minor mechanisms 1
• Do not provide assessment alone without active intervention and referrals, as this does not reduce future falls 3