What is the recommended management for an elderly patient after a fall?

Post-Fall Management in Elderly Patients

All elderly patients presenting after a fall require a comprehensive trauma evaluation with specific attention to occult injuries, followed by systematic assessment of fall causes, multifactorial risk stratification, and implementation of targeted interventions including exercise programs with balance training, medication review, and environmental modification. 1

Immediate Assessment Framework

Critical Initial Question

Begin by asking: "If this patient was a healthy 20-year-old, would they have fallen?" If the answer is "no," proceed with comprehensive evaluation of underlying causes rather than treating the fall as an isolated traumatic event. 2, 1

High-Risk Injury Screening

• Perform complete head-to-toe examination even with seemingly isolated injuries, as traumatic injuries may be occult in older adults presenting without classic signs or symptoms 2, 1
• Maintain high suspicion for blunt head trauma, spinal fractures, and hip fractures which warrant extensive workup 2, 1
• Lower threshold for CT head imaging in patients on anticoagulation, even with normal neurological examination 3
• Evaluate for rib fractures and chest injuries which can exacerbate cardiopulmonary disease and increase pneumonia risk 3

Essential History Components

Document the following specific elements systematically: 2, 1

• Fall circumstances: Location, cause, time spent on floor/ground 2, 1
• Consciousness status: Loss of consciousness, altered mental status, near-syncope, or orthostatic symptoms 2, 1
• Previous falls: Number of falls in past year (≥2 falls indicates high-risk status) 4
• Medication review: Focus on psychotropic medications, polypharmacy (multiple medications), and vestibular suppressants 1, 4
• Comorbidities: Dementia, Parkinson's disease, stroke, diabetes, hip fracture history, depression 2, 1
• Functional status: Activities of daily living, gait/balance difficulties 2, 1
• Other risk factors: Visual impairments, peripheral neuropathies, alcohol use, inappropriate footwear 2, 1

Physical Examination Protocol

Cardiovascular Assessment

• Measure orthostatic blood pressure (lying, sitting, standing) to assess for orthostatic hypotension 1, 4

Neurological Examination

Assess the following specific components: 1

• Presence/absence of peripheral neuropathies
• Proximal motor strength
• Mental status
• Lower extremity peripheral nerve function
• Proprioception
• Reflexes
• Cortical, extrapyramidal, and cerebellar function

Functional Assessment

• Vision screening 1
• Gait and balance evaluation using the "Get Up and Go Test" 1, 5
• Lower extremity joint function 1
• Activity Measure for Post Acute Care (AM-PAC) 6 clicks and Barthel ADL scores predict discharge disposition and 6-month outcomes 5

Diagnostic Testing

Maintain low threshold for: 3

• EKG to evaluate cardiac causes
• Complete blood count to assess for anemia or infection
• Electrolyte panel including renal function
• Appropriate imaging based on mechanism and examination findings

Medication Management

High-Risk Medication Review

• Psychotropic medications have consistent association with falls and should be reviewed for discontinuation or dose reduction 1, 4
• Benzodiazepines significantly increase fall risk and should be avoided despite effectiveness for anxiety disorders 4
• Tramadol causes dizziness, sedation, and orthostatic hypotension, increasing fall risk 1
• Polypharmacy is an independent fall risk factor requiring comprehensive medication reconciliation 1, 4
• Refer to primary physician for medication review when polypharmacy or high-risk medications identified 2

Specific Interventions

• Vitamin D supplementation in patients with low vitamin D levels reduces fall risk 6
• Adjustment of psychotropic medications and modification of polypharmacy are evidence-based interventions 6

Multifactorial Intervention Strategy

Exercise Programs (Highest Priority Intervention)

Physical exercise including multiple training modalities, especially balance and strength training, is the only intervention that reduces both number of fallers and number of falls in community dwellers. 6

Specific components include: 1, 4

• Balance training (can reduce falls by up to 26% in high-risk individuals)
• Gait training with advice on assistive devices
• Strength training
• Tai Chi as promising balance exercise

Environmental Modification

• Home safety assessment with removal of tripping hazards, improved lighting, installation of grab bars 1, 4
• Home hazards modification has best effects in high-risk groups when led by occupational therapists 6
• Anti-slip shoe devices for those walking outdoors during icy conditions 6

Additional Interventions

• Treatment of postural hypotension 1
• Vision correction: First eye cataract surgery has fall-reducing effect 6
• Multifaceted podiatry for patients with specific foot disability 6
• Pacemaker placement in patients with cardio-inhibitory carotid sinus hypersensitivity 6

Disposition Decision-Making

Safety Assessment Before Discharge

• Perform gait evaluation and "Get Up and Go Test" before discharge 1, 3
• TUG times and AM-PAC 6 clicks scores predict discharge disposition: faster TUG times and higher AM-PAC scores associated with discharge to original residence 5
• Slower TUG times at index visit predict nursing home residence at 6 months 5

Admission Criteria

• Consider admission if patient safety cannot be ensured at home 2, 1, 3
• All patients admitted after fall should be evaluated by physical therapy and occupational therapy 2, 1, 3

Discharge Planning

• Arrange expedited outpatient follow-up including home safety assessments for discharged patients 2, 1
• Physical therapy and occupational therapy referral for community-dwelling patients 1

Special Considerations for Anticoagulated Patients

Rivaroxaban-Specific Management

• Lower threshold for trauma activation in patients on rivaroxaban with heart rate ≥90 bpm and systolic blood pressure <110 mmHg 3
• Liberal use of CT head imaging due to high risk of intracranial hemorrhage 3
• Early assessment of coagulation tests and direct DOAC level measurement using chromogenic anti-FXa assay 3
• Reversal with andexanet alfa only for life-threatening bleeding with dosable plasma levels, not for all falls 3
• Assess renal function as rivaroxaban clearance depends on kidney function 3

Common Pitfalls to Avoid

• Do not focus solely on traumatic injury without evaluating underlying fall causes 7
• Do not assume straightforward falls require minimal workup - maintain low threshold for comprehensive assessment 3
• Do not prescribe benzodiazepines for anxiety without considering significant fall risk increase 4
• Do not routinely reverse anticoagulation in all fallers - only those with life-threatening bleeding and dosable drug levels 3
• Do not withhold anticoagulation based on fall risk alone - stroke prevention benefit typically outweighs bleeding risk 3
• Do not discharge without gait assessment and safety evaluation 1, 3

Equipment and Environmental Safety in ED

Ensure the following are available: 2

• Rubber or nonskid floor surfaces/mats
• Even floor surfaces
• Handrails on walls and hallways
• Adequate aisle lighting
• Bedside commodes and grab bars in restrooms
• Properly positioned and functioning bedrails
• Appropriate patient gowns that minimize fall risk (avoid long, baggy, loose tie strings)