What is the workup for a patient who experienced a fall due to weakness?

Workup for Falls Due to Weakness in Older Adults

Perform a comprehensive fall assessment focusing on identifying reversible causes of weakness, with immediate attention to ruling out occult injuries, followed by systematic evaluation of medications, neurological function, and environmental factors to prevent recurrence. 1, 2

Immediate Assessment

History of the Fall Event

Document specific circumstances that distinguish weakness-related falls from other mechanisms 1, 2:

• Location and exact cause of the fall
• Time spent on floor or ground (prolonged time suggests inability to rise due to weakness)
• Presence of loss of consciousness or altered mental status
• Symptoms of near-syncope or orthostasis (suggests cardiovascular vs. neuromuscular cause)
• Prodromal symptoms preceding the fall

Physical Examination

Conduct a complete head-to-toe examination even if the patient appears to have isolated injuries, as traumatic injuries may be occult in older adults 1, 2:

Orthostatic vital signs: Measure blood pressure and heart rate supine, after 1 minute standing, and after 3 minutes standing 1, 2

Neurological examination focusing on weakness patterns 2, 3:

• Proximal muscle strength (hip flexors, shoulder abductors) - weakness suggests myopathy or neuromuscular junction disorder
• Distal muscle strength - weakness suggests peripheral neuropathy
• Presence/absence of neuropathies (sensory testing, proprioception)
• Reflexes (hyperreflexia suggests upper motor neuron; hyporeflexia suggests lower motor neuron or neuropathy)
• Mental status and cognitive function
• Cerebellar function (coordination, tandem gait)

Musculoskeletal examination: Assess for occult fractures, particularly hip fractures, and evaluate lower extremity joint function 1, 2

Vision assessment: Visual impairment is a significant fall risk factor 2

Functional Testing

"Get Up and Go Test": Patient rises from chair, walks 3 meters, turns, returns, and sits down - time >12 seconds indicates increased fall risk and impaired mobility 4, 1, 2

4-Stage Balance Test: Progress through feet side-by-side, semitandem, tandem (inability to hold <10 seconds indicates high fall risk), and single-foot stand 4, 1

Diagnostic Testing

Order the following tests when evaluating weakness-related falls 1:

• EKG (rule out arrhythmias, conduction abnormalities)
• Complete blood count (anemia can cause weakness and falls)
• Comprehensive metabolic panel (electrolyte abnormalities, renal function affecting medication clearance)
• Medication levels when applicable (digoxin, anticonvulsants)
• Vitamin D, calcium, and parathyroid hormone levels (evaluate for osteomalacia contributing to weakness) 1
• DEXA scan for osteoporosis evaluation 1
• Imaging as indicated for suspected trauma

Risk Factor Assessment Using P-SCHEME Mnemonic

Systematically evaluate the following contributors to weakness and falls 4:

• Pain: Axial or lower extremity pain limiting mobility
• Shoes: Suboptimal footwear characteristics
• Cognitive impairment: Dementia, delirium
• Hypotension: Orthostatic or medication-induced
• Eyesight: Vision impairment
• Medications: Centrally acting drugs (see below)
• Environmental factors: Home hazards

High-Risk Medication Review

Pay special attention to medications that cause weakness or increase fall risk 1, 2:

• Vasodilators and antihypertensives (orthostatic hypotension)
• Diuretics (volume depletion, electrolyte abnormalities)
• Antipsychotics (sedation, extrapyramidal symptoms, orthostasis)
• Sedative/hypnotics (impaired cognition and balance)
• Psychotropic medications (multiple mechanisms)
• Polypharmacy (≥5 medications increases risk)

Management and Prevention

Immediate Interventions

Physical therapy referral for patients with gait, balance problems, or weakness 1, 2:

• Balance training ≥3 days per week
• Strength training twice weekly focusing on proximal muscle groups
• Gait training and assistive device assessment

Medication optimization: Review and deprescribe high-risk medications with primary physician 1, 2

Vitamin D supplementation: 800 IU daily for those at increased fall risk 1

Home Safety Assessment

Refer for occupational therapy home evaluation addressing 1, 2:

• Removal of loose rugs and floor clutter
• Adequate lighting throughout home
• Installation of grab bars in bathroom
• Proper footwear with non-skid soles

Discharge Planning

Safety assessment before discharge: Patient must be able to rise from bed, turn, and steadily ambulate 1, 2

Consider admission if patient safety cannot be ensured or if weakness is severe enough to prevent safe ambulation 1, 2

Arrange expedited outpatient follow-up including multidisciplinary approach with primary care, physical therapy, occupational therapy for home safety evaluation, and bone health clinic for osteoporosis management 1, 2

Common Pitfalls

Do not assume isolated injury without full examination - occult injuries are common in older adults who fall 1, 2

Do not overlook medication-induced weakness - many commonly prescribed medications contribute to both weakness and fall risk through multiple mechanisms 1, 2

Do not discharge without functional testing - patients who cannot perform the "Get Up and Go Test" safely require further intervention before discharge 1, 2

Do not miss neuromuscular causes - progressive proximal weakness may indicate treatable conditions like polymyositis, myasthenia gravis, or medication-induced myopathy that require specific workup 3