What assessment do I do on an elderly patient who fell on the ice?

Assessment of an Elderly Patient Who Fell on Ice

Perform a comprehensive fall assessment focusing on identifying both acute injuries and underlying fall risk factors, as this approach is essential to prevent future falls and reduce morbidity and mortality in elderly patients. 1

Immediate History Taking

Obtain detailed information about the fall circumstances:

• Location and mechanism of fall (slipped on ice, tripped, collapsed) 1
• Time spent on the ground - prolonged immobility suggests higher injury severity 1
• Loss of consciousness or altered mental status - critical for ruling out syncope or head injury 1
• Symptoms of near-syncope, dizziness, or orthostatic symptoms before the fall 1
• Previous fall history - any falls in the past year significantly increases risk 2, 1
• Current medications, especially high-risk drugs: vasodilators, diuretics, antipsychotics, sedative/hypnotics 1

Physical Examination

Complete Head-to-Toe Assessment

Perform a thorough examination to identify occult injuries from the fall:

• Head and neck: examine for lacerations, hematomas, cervical spine tenderness 1
• Chest and abdomen: assess for rib fractures, internal injuries 1
• Extremities: check for fractures, particularly hip, wrist, and ankle injuries 1
• Skin: look for bruising, abrasions, signs of prolonged ground contact 1

Neurological Assessment

• Level of consciousness and cognitive status - use Mini-Cog if appropriate 3
• Pupillary response and signs of increased intracranial pressure 4
• Peripheral neuropathy assessment and proximal muscle strength 1
• Perform Dix-Hallpike maneuver to identify benign paroxysmal positional vertigo (BPPV), a common but treatable cause of falls 3

Cardiovascular Assessment

• Orthostatic blood pressure measurement - check supine, sitting, and standing pressures 1
• Pulse rate and rhythm - irregular rhythm may indicate arrhythmia 5

Functional Assessment

• "Get Up and Go Test" - observe the patient rise from bed, turn, and ambulate; inability to do so safely requires reassessment before discharge 1
• Gait and balance evaluation - time >12 seconds on Get-Up-and-Go indicates increased fall risk 2, 3

Diagnostic Testing

Consider the following tests based on clinical presentation:

• EKG - to evaluate for arrhythmias or cardiac causes 1
• Complete blood count - assess for anemia or infection 1
• Standard electrolyte panel - check for metabolic derangements 1
• Medication levels when applicable (e.g., digoxin, anticonvulsants) 1
• Imaging studies if trauma is suspected - X-rays for suspected fractures, CT head if head injury or altered mental status 1
• Glucose level - hypoglycemia can cause falls 5

Risk Factor Assessment

Systematically evaluate modifiable fall risk factors:

• Age over 65 years 1
• Gait and balance difficulties 2, 1
• Visual impairment - formal visual acuity testing 3
• Neurological impairments including peripheral neuropathy 1
• Polypharmacy and high-risk medications 1, 3
• Cognitive impairment - screen with Mini-Cog 3
• Depression - screen with PHQ-2 3
• Environmental hazards - assess home safety concerns 1

Disposition and Immediate Management

Safety Assessment Before Discharge

• Patient must demonstrate ability to safely ambulate using the Get-Up-and-Go test 1
• Consider admission if patient safety cannot be ensured or if serious injuries require inpatient management 1

Multifactorial Intervention Plan

Physical Therapy Referral:

• Refer for gait training and balance assessment 3
• Prescribe balance training exercises 3+ days per week 1, 3
• Prescribe strength training twice weekly 1, 3
• Evaluate for assistive devices (cane, walker) 3

Medication Review:

• Comprehensive review focusing on polypharmacy 1, 3
• Consider discontinuing or reducing psychotropic medications 3
• Avoid vestibular suppressants 3
• Refer to primary physician for medication optimization 1

Home Safety Assessment:

• Arrange occupational therapy home evaluation 1, 3
• Remove loose rugs and floor clutter 1, 3
• Ensure adequate lighting throughout home 1, 3
• Install grab bars in bathroom 3
• Recommend properly fitting non-skid footwear 1, 3

Vitamin D Supplementation:

• Consider 800 IU daily for patients at increased fall risk 1

Patient Education:

• Discuss personal risk factors that contributed to the fall 1
• Teach recognition of orthostatic hypotension symptoms 1
• Educate on environmental hazards and safe transfer techniques 1

Follow-Up Arrangements

• Arrange expedited outpatient follow-up including home safety evaluation 1
• Consider multidisciplinary approach for high-risk patients 1
• Bone health evaluation - order DEXA scan to assess fracture risk with future falls 3
• Reassess at follow-up with repeat Get-Up-and-Go test and review of intervention effectiveness 3

Common Pitfalls to Avoid

• Do not focus solely on the acute injury - failure to assess underlying fall risk factors leads to recurrent falls 6, 5
• Do not discharge without functional assessment - patients unable to safely ambulate require further intervention 1
• Do not overlook BPPV - this treatable condition is often missed in elderly patients with vague unsteadiness 3
• Do not forget medication review - polypharmacy and high-risk medications are major modifiable risk factors 1, 3