What is the recommended approach for a falls workup in a patient?

Falls Workup in Older Adults

All older adults should be screened annually for falls, and those reporting a fall, recurrent falls, or demonstrating gait/balance abnormalities require a comprehensive fall evaluation including detailed history, physical examination with gait assessment, medication review, cardiovascular evaluation with orthostatic vital signs, neurological testing, and vision assessment. 1, 2

Initial Screening Approach

For Routine Care (Not Presenting After a Fall)

• Ask all older adults at least once yearly: Have you fallen in the past 12 months? Do you have difficulty with walking or balance? 1, 3, 4
• If patient reports a single fall, perform the "Get Up and Go Test": observe them stand from a chair without using arms, walk several paces, and return 1, 2
• Those with no difficulty or unsteadiness need no further assessment at that time 1
• Any difficulty with this test, two or more falls in past year, or presenting acutely after a fall mandates comprehensive evaluation 1, 4

Comprehensive Fall Evaluation Components

History of Fall Circumstances

Document the following specific details: 1, 2, 5

• Location and cause of fall
• Time spent on floor or ground after falling
• Presence of loss of consciousness or altered mental status
• Symptoms of near-syncope or orthostatic hypotension
• Whether a witness was present (40-60% of falls occur without witnesses) 6
• Ask the critical question: "If this patient was a healthy 20-year-old, would they have fallen?" If no, deeper assessment is needed 2

Physical Examination

Gait and Balance Assessment: 1, 2

• Perform "Get Up and Go Test" (timed version preferred) 2, 4
• Conduct 30-second chair stand test 4
• Perform four-stage balance test 4
• Assess lower extremity joint function 1

Cardiovascular Evaluation: 1, 2, 5

• Measure heart rate and rhythm
• Orthostatic vital signs: blood pressure and pulse supine, then after 1 and 3 minutes of standing 2, 5, 7
• Consider carotid sinus stimulation if appropriate (20% of patients >70 with cardiovascular syncope present as falls) 1, 6

Neurological Assessment: 1, 2

• Mental status examination
• Muscle strength, particularly proximal lower extremity
• Lower extremity peripheral nerve function
• Proprioception testing
• Deep tendon reflexes
• Tests of cortical, extrapyramidal, and cerebellar function
• Assess for presence/absence of neuropathies 2

Vision Assessment: 1, 4

• Visual acuity testing
• Consider ophthalmology referral for cataract evaluation (cataract surgery reduces falls with RR 0.68) 7

Additional Examination: 2, 5

• Complete head-to-toe examination to identify occult injuries
• Pay particular attention to hip examination for fractures 2

Medication Review

Critical medication assessment focusing on: 1, 2, 5

• Total number of medications (polypharmacy ≥4 medications increases risk) 1, 3
• Psychotropic medications: neuroleptics, benzodiazepines, antidepressants (consistent association with falls across all settings) 1
• Cardiovascular medications: antihypertensives, diuretics, vasodilators 5, 6
• Other high-risk medications: sedative/hypnotics, tramadol (causes dizziness, sedation, orthostatic hypotension) 2, 5
• Medication reduction is a prominent component of effective fall-reducing interventions 1

Risk Factor Identification

Modifiable risk factors: 1, 7

• Muscle weakness
• Gait and balance disorders (major modifiable risk factor) 7
• Medication side effects
• Postural hypotension
• Environmental hazards
• Visual impairment
• Vitamin D deficiency 8

Non-modifiable risk factors: 1, 2

• Age >65 years
• Prior falls (most common risk factor) 4
• Dementia 4
• Hemiplegia
• Blindness
• Parkinson's disease 2

Diagnostic Testing (When Indicated)

Consider the following based on clinical presentation: 5

• Electrocardiogram
• Complete blood count
• Electrolyte panel
• Medication levels when applicable
• Imaging if trauma suspected 5

Referral Considerations

Refer to specialist (geriatrician) when: 1

• Recurrent falls
• Living in nursing home
• Prone to injurious falls
• Complex multifactorial presentation requiring comprehensive assessment 1

Physical therapy referral for: 2, 5, 3

• Gait or balance problems
• Assistive device prescription and training
• Balance training programs (≥3 days per week) 5
• Strength training (twice weekly) 5

Occupational therapy referral for: 2, 5

• Home safety assessment with direct intervention
• Environmental modification recommendations 5

Common Pitfalls to Avoid

• Do not rely solely on patient history in those with cognitive impairment, as fall circumstances may be inaccurately reported 4
• Do not assume single interventions are sufficient: advice alone without implementation measures shows equivocal or no benefit 1
• Do not overlook cardiovascular causes: approximately 20% of cardiovascular syncope in patients >70 presents as falls 6
• Do not discharge without gait assessment: perform "get up and go test" before discharge and reassess if patient cannot safely ambulate 5
• Do not ignore polypharmacy: reduction of medications in patients taking >4 preparations is beneficial 1