What is the best course of action for an elderly female who fell at home, is unable to get up after 24 hours, and suspects her arthritis is the cause?

Immediate Emergency Department Evaluation and Hospitalization Required

This elderly female who has been unable to get up for 24 hours after a fall requires immediate emergency department evaluation and likely hospitalization, regardless of her attribution to arthritis. Ground-level falls in elderly patients carry significant morbidity and mortality risk, with up to 7% mortality rate, and prolonged immobilization for 24 hours places her at extreme risk for rhabdomyolysis, acute kidney injury, pressure ulcers, dehydration, and occult fractures 1.

Critical Immediate Actions

Emergency Transport and Initial Assessment

• Call 911 immediately for emergency transport - this patient requires urgent medical evaluation given the 24-hour period of immobilization 2
• The prolonged time on the floor dramatically increases risk of complications including:
  • Rhabdomyolysis from muscle compression 1
  • Acute kidney injury from dehydration and muscle breakdown 1
  • Pressure ulcers 1
  • Hypothermia 1
  • Occult fractures, particularly hip, femoral neck, or pelvic fractures 1

Emergency Department Workup

The following comprehensive assessment must be performed 2, 3:

Laboratory Testing:

• Complete blood count (leucocytosis may indicate infection; anemia assessment) 3
• Complete metabolic panel including electrolytes (hypokalemia, hyponatremia) 3
• Creatine kinase and myoglobin (rhabdomyolysis screening) 1
• Urinalysis 3
• Vitamin D, calcium, and parathyroid hormone levels 2

Cardiac Evaluation:

• ECG in all elderly patients with falls 3
• Orthostatic blood pressure assessment 2

Imaging:

• AP pelvis and lateral hip radiographs to rule out hip fracture 1
• If plain films are normal but clinical suspicion remains high, obtain MRI to identify occult fractures 3
• Additional imaging based on examination findings 2

Physical Examination Focus:

• Complete head-to-toe examination for occult injuries 2
• Assess for shortened and externally rotated lower extremity (classic hip fracture presentation) 1
• Neurological assessment focusing on neuropathies and proximal muscle strength 2
• Evaluate for palpable pulses and sensation 1

Why Arthritis Attribution is Dangerous

The patient's self-attribution to arthritis is a critical red flag that must not delay proper evaluation. While arthritis is extremely common in elderly patients (affecting 50.4% of those ≥65 years), it does not cause sudden inability to ambulate or get up 4. Ground-level falls are the most common mechanism of injury in patients ≥65 years, with 6% sustaining fractures and 10-30% having polytrauma 1. Elderly women are particularly at high risk, with hip fractures being a leading cause of morbidity and mortality 1.

Admission Criteria and Interdisciplinary Management

Hospitalization Decision

• Admit if patient safety cannot be ensured or if the "get up and go test" cannot be safely performed 2
• Given 24 hours of immobilization, admission is highly likely necessary for medical stabilization 1

Orthogeriatric Comanagement

If hip fracture is identified:

• Immediate orthogeriatric team involvement is mandatory to decrease complications and improve outcomes 1
• Surgery should occur within 24-48 hours of admission to significantly reduce mortality 1, 3
• Interdisciplinary care should be provided throughout hospitalization 1

Medical Optimization

The American Academy of Orthopaedic Surgeons recommends comprehensive assessment for 3:

• Malnutrition
• Electrolyte and volume disturbances
• Anemia
• Cardiac and pulmonary diseases
• Cognitive function

Post-Acute Management and Secondary Prevention

Immediate Post-Discharge Interventions

A structured multidisciplinary approach combining medical assessment, home safety evaluation, and targeted interventions is essential 2:

Physical Therapy Referral:

• Mandatory for patients with gait or balance problems 2
• Balance training 3+ days per week 2
• Strength training twice weekly 2

Medication Review:

• Perform comprehensive medication assessment with attention to high-risk medications (vasodilators, diuretics, antipsychotics, sedative/hypnotics) 2
• Patients taking ≥4 medications require particular scrutiny 1
• Psychotropic medications (neuroleptics, benzodiazepines, antidepressants) have consistent association with falls 1

Home Safety Assessment:

• Occupational therapy home evaluation with direct intervention, advice, and education 1, 2
• Remove loose rugs and floor clutter 2
• Ensure adequate lighting 2
• Recommend properly fitting shoes with non-skid soles 2

Vitamin D Supplementation:

• 800 IU daily for those at increased risk for falls 2

Fracture Liaison Service Referral

• All patients should be referred to a Fracture Liaison Service or Orthopaedics Bone Health Clinic for secondary fracture prevention 3
• DEXA scan should be ordered 2
• Consider bisphosphonate therapy to reduce subsequent fracture risk 3

Multifactorial Fall Risk Assessment

Perform comprehensive evaluation incorporating 3:

• Gait, mobility, and balance assessment
• Lower limb strength testing
• Cognitive capacity evaluation
• Footwear assessment
• Environmental factors
• Use standardized tests such as Timed Up and Go test 3

Common Pitfalls to Avoid

1. Never accept patient's self-diagnosis of "just arthritis" - this delays critical fracture diagnosis 1
2. Never discharge without safety assessment - perform "get up and go test" before discharge 2
3. Never overlook the 24-hour immobilization period - this creates multiple medical emergencies requiring urgent intervention 1
4. Never provide single-intervention fall prevention - multifaceted programs are significantly more effective than isolated interventions 1, 2
5. Never delay surgical intervention if fracture identified - surgery within 24-48 hours significantly reduces mortality 1, 3