What is the recommended workup for falls in an elderly patient with dementia?

Falls Workup in Elderly Demented Patients

Perform a comprehensive multifactorial assessment that includes medication review, orthostatic blood pressure measurement, gait and balance evaluation, vision assessment, cognitive evaluation, and environmental hazard assessment, as this approach addresses the multiple risk factors that commonly coexist in elderly patients with dementia. 1

Initial Clinical Assessment

History and Circumstances

• Document detailed fall circumstances including location, time of day, activities preceding the fall, presence of witnesses, and any loss of consciousness, recognizing that up to 40-60% of falls in elderly patients with dementia occur without witnesses and patients may have amnesia for the event 1
• Obtain witness accounts whenever possible, as cognitive impairment significantly affects accuracy of patient recall and up to one-third of syncope events may present simply as falls 1
• Assess for injuries immediately with complete head-to-toe examination to identify fractures, lesions, and occult injuries, as these are common even with seemingly isolated complaints 2
• Evaluate vital signs including shock index (heart rate/systolic blood pressure ratio) - if ≥0.9, consider comprehensive evaluation for occult hemorrhage 2
• Assess weight-bearing ability, as inability to bear weight indicates potential serious injury requiring imaging 2

Key Risk Factor Assessment

• Review all medications systematically, particularly psychotropic medications, neuroleptics, sedatives, vasodilators, and diuretics, as these are strongly associated with falls in dementia patients 1, 3, 4
• Measure orthostatic blood pressure (supine and after 1-3 minutes standing), as symptomatic orthostatic hypotension is a significant modifiable predictor of falls (HR: 2.13) 1, 3
• Assess for autonomic symptoms using a standardized scale, as higher autonomic symptom scores independently predict falls 3
• Screen for depression using a validated tool (such as Cornell Depression Scale), as depression is both a modifiable risk factor (HR per point: 1.053) and commonly undertreated in this population 1, 3

Physical Examination Components

Cardiovascular Evaluation

• Perform carotid sinus massage (if no contraindications such as carotid bruits or history of stroke/TIA) to evaluate for carotid sinus hypersensitivity, which is present in approximately 30% of older adults with unexplained falls 1, 5
• Obtain 12-lead ECG to identify arrhythmias, conduction abnormalities, or structural heart disease 5

Neurological and Functional Assessment

• Evaluate gait and balance systematically, as disease-specific motor impairments show particular characteristics in dementia patients and are major contributors to fall risk 1, 4
• Assess vision formally, as visual deficits are common risk factors that may be correctable 1, 4
• Document functional status including activities of daily living, as functional impairment is a key risk factor 1, 4
• Evaluate for behavioral disturbances, as these contribute uniquely to fall risk in dementia patients 3, 4

Laboratory and Diagnostic Testing

Initial Laboratory Work

• Screen for reversible conditions including vitamin B12 deficiency, hypothyroidism, and depression, as recommended for all cognitively impaired older adults 1
• Consider complete blood count and electrolyte panel when clinically appropriate 6
• Check vitamin D, calcium, and parathyroid hormone levels to evaluate osteoporosis risk, as dementia patients are at higher risk for injurious falls 6

Imaging Considerations

• Obtain appropriate imaging if trauma suspected - start with anteroposterior and lateral radiographs for suspected fractures, with CT as follow-up if radiographs negative but clinical suspicion remains high 2
• Order DEXA scan to evaluate bone health and fracture risk for future falls 6
• Consider structural neuroimaging for recently diagnosed cognitive impairment to identify lesions 1

Dementia-Specific Considerations

Type and Severity Assessment

• Recognize that Lewy body dementia and Parkinson's disease dementia carry particularly high fall risk (HR: 3.33), with patients experiencing nearly 8 times more falls than controls 7, 3, 4
• Document dementia severity, as this influences both fall risk and appropriateness of interventions 1
• Note that vascular dementia is present in over 50% of elderly patients presenting with falls and suspected syncope 8

Clinical Presentation Pitfalls

• Recognize atypical presentations - elderly dementia patients often present with unexplained falls rather than clear syncope, and moderate hemodynamic changes insufficient to cause syncope in others may result in falls due to gait instability and slow protective reflexes 1, 8
• Understand that clinical presentation is often atypical and unexplained falls are particularly frequent in this population 8
• Be aware that patients with severe dementia are typically excluded from falls studies, so recommendations may not fully apply to this group 1

Intervention Planning

Modifiable Risk Factor Management

• Prioritize management of symptomatic orthostatic hypotension, autonomic symptoms, and depression, as these provide the core elements for the most effective fall reduction strategy 3
• Conduct comprehensive medication review with particular attention to withdrawal of psychotropic medications when appropriate, as this can significantly reduce fall risk 1
• Encourage physical activity within patient capabilities, as higher activity levels are protective (HR per point: 0.827) 3

Multifactorial Interventions

• Implement targeted interventions focusing on balance, transfers, gait training, and postural hypotension management 6
• Arrange occupational therapy home safety evaluation with direct intervention, advice, and education 6
• Refer to physical therapy for individualized exercise programs including balance training (≥3 days/week) and strength training (twice weekly) 6

Safety and Prognosis Considerations

• Assess fall history, as previous falls in the preceding 12 months significantly predict future falls (HR: 2.52) 3
• Evaluate patient safety before discharge using the "get up and go test" - patients unable to rise from bed, turn, and steadily ambulate require reassessment and possible admission 6
• Modify evaluation rigor based on patient prognosis in frailer patients, as invasive procedures may not be appropriate for all 1
• Consider palliative approach in advanced dementia, recognizing that recurrent falls may be symptomatic of disease progression and not all falls are preventable 9

Communication and Follow-up

Family Involvement

• Provide clear information to family members about fall circumstances, assessment findings, and care plan 2
• Offer families opportunity to be present if patient is severely injured or approaching end of life 2
• Use technology to enable patient-family connection when in-person presence is not possible 2

Ongoing Management

• Arrange appropriate follow-up including home safety evaluation and multidisciplinary assessment for high-risk patients 6
• Document impact on activities of daily living and confidence, as these affect quality of life 1
• Recognize that elderly dementia patients have high comorbidity (average CIRS score 3.6), severe functional impairment (average 3 BADL lost), and polypharmacy (average 6 drugs), requiring coordinated care 8