What is the evaluation and management plan for an elderly patient with chronic unsteadiness and a recent fall?

Evaluation and Management of Chronic Unsteadiness with Recent Fall in an Elderly Patient

This patient requires a comprehensive fall evaluation with multifactorial interventions including physical therapy referral, medication review, home safety assessment, and investigation for underlying causes of chronic unsteadiness, particularly vestibular dysfunction given the positive Romberg's test. 1

Immediate Assessment Priorities

Complete Fall Evaluation

The patient has already answered "yes" to all three key screening questions (fallen in past year, feels unsteady, recent fall), which mandates a broader fall risk assessment and intervention 2. The positive Romberg's test is particularly significant and suggests proprioceptive or vestibular dysfunction requiring further investigation 3.

Key components to complete:

• Medication review with focus on high-risk drugs: Specifically assess for vasodilators, diuretics, antipsychotics, sedative/hypnotics, and any vestibular suppressants that increase fall risk 1, 4
• Vision assessment: Formal visual acuity testing, as visual impairment is a modifiable fall risk factor 2, 1
• Cognitive screening: Use Mini-Cog or Memory Impairment Screen, as cognitive impairment significantly increases fall risk 2
• Depression screening: Administer PHQ-2, as late-life depression is common and contributes to falls 2

Diagnostic Testing for Chronic Unsteadiness

Given the 2-3 year history of progressive unsteadiness with positive Romberg's test, specific investigations are warranted:

Laboratory studies:

• Complete blood count, electrolytes, vitamin B12, thyroid function 1
• Vitamin D level: Consider supplementation at 800 IU daily if deficient, as this reduces fall risk 1

Vestibular function testing:

• The positive Romberg's test combined with chronic unsteadiness without vertigo suggests presbyvestibulopathy or bilateral vestibular hypofunction 3, 5
• Quantitative vestibular testing should be considered, as reduced vestibular function correlates with increased sway velocity and fall risk in older adults with unexplained disequilibrium 3
• Video head impulse test (vHIT), rotary chair testing, or caloric testing can identify bilateral vestibular deficits 5

Neurological considerations:

• The positive Romberg's test with absent vertigo raises concern for sensory ataxia from peripheral neuropathy or posterior column dysfunction 6
• Consider nerve conduction studies if examination reveals diminished proprioception or vibratory sense, as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) can present with ataxic gait 6
• Brain MRI if any focal neurological findings, to exclude structural lesions, normal pressure hydrocephalus, or cervical spondylosis 7, 8

Multifactorial Intervention Plan

Physical Therapy Referral (Priority Intervention)

• Immediate referral for gait training and balance assessment 2, 1
• Prescribe balance training exercises 3 or more days per week 1
• Strength training twice weekly 1
• Evaluation for appropriate assistive devices (cane, walker) 2, 1
• Consider tai chi or similar balance-focused exercise programs 2

Medication Management

• Conduct comprehensive medication review with attention to polypharmacy 4
• Avoid vestibular suppressants (e.g., meclizine) in chronic vestibular conditions, as they impair central compensation and increase fall risk 4, 9
• Review and potentially discontinue psychotropic medications if present 2, 4

Home Safety Evaluation

• Arrange occupational therapy home assessment with direct intervention 1, 4
• Remove loose rugs and floor clutter 1
• Ensure adequate lighting throughout home 1
• Install grab bars in bathroom 1
• Recommend properly fitting non-skid footwear 1

Cardiovascular Optimization

• The orthostatic vital signs were normal, but continue monitoring 2, 1
• Treat any identified cardiovascular disorders including arrhythmias 2

Follow-Up and Monitoring

Short-term (1-2 weeks):

• Reassess gait stability with "Get Up and Go Test" - time >12 seconds indicates increased fall risk 2
• Review results of vestibular testing and laboratory studies 3
• Confirm physical therapy and occupational therapy appointments are scheduled 1, 4

Long-term:

• Continue multifactorial interventions with ongoing medication review and environmental modification 4
• Monitor for recurrence of falls, as this patient is at high risk 1, 4
• Consider bone health evaluation with DEXA scan to assess fracture risk 4

Critical Pitfalls to Avoid

• Do not prescribe meclizine or other vestibular suppressants for chronic unsteadiness, as these medications cause drowsiness, increase fall risk, and impair vestibular compensation 4, 9
• Do not attribute symptoms solely to "normal aging" - the positive Romberg's test and progressive nature demand investigation for treatable causes 3, 7, 5
• Do not discharge without ensuring safe ambulation - patient must demonstrate ability to rise from chair and walk steadily before leaving clinic 1
• Do not overlook the P-SCHEME mnemonic for fall risk factors: Pain, Shoes, Cognitive impairment, Hypotension, Eyesight, Medications, Environment 2