What are the recommended steps after a fall with prolonged downtime?

Management of Falls with Prolonged Downtime in Older Adults

All geriatric patients presenting after a fall with prolonged downtime require comprehensive assessment focusing on time spent on the ground, complete head-to-toe injury evaluation regardless of presenting complaint, and investigation of underlying causes—asking "would a healthy 20-year-old have fallen in this situation?" 1

Critical Initial Assessment Components

History Elements Specific to Prolonged Downtime

• Document exact time spent on floor or ground as this is a key historical element that indicates severity and risk 1
• Assess for loss of consciousness or altered mental status during or after the fall 1
• Evaluate for syncope, near-syncope, or orthostatic symptoms that may have precipitated the fall 1
• Screen for melena, as gastrointestinal bleeding can cause falls 1

Mandatory Physical Examination

• Perform complete head-to-toe evaluation for ALL patients, including those with seemingly isolated injuries, as occult injuries are common in geriatric trauma 1
• Conduct orthostatic blood pressure assessment to identify postural hypotension 1
• Complete neurologic assessment with special attention to peripheral neuropathies and proximal motor strength 1
• Maintain high suspicion for occult blunt head trauma, spinal fractures, and hip fractures even without classic signs 1

Diagnostic Testing Threshold

• Maintain low threshold for obtaining EKG, complete blood count, standard electrolyte panel, measurable medication levels, and appropriate imaging 1
• Consider rhabdomyolysis workup (CK, creatinine, urinalysis) in patients with prolonged downtime, though not explicitly stated in guidelines, this is critical in real-world practice

Comprehensive Medication Review

All patients must have medications reviewed and altered or stopped as appropriate, with particular attention to those taking four or more medications and psychotropic medications 1

High-Risk Medication Classes Requiring Special Attention

• Vasodilators 1
• Diuretics 1
• Antipsychotics 1
• Sedative/hypnotics 1
• Benzodiazepines (both long- and short-acting carry similar fall risk) 1
• Antidepressants 1

Underlying Cause Investigation

Medical Conditions to Evaluate

• Cardiovascular disorders including orthostatic hypotension, carotid sinus syndrome, and vasovagal syndrome 1
• Specific comorbidities: dementia, Parkinson's disease, stroke, diabetes, previous hip fracture, and depression 1
• Visual or neurological impairments including peripheral neuropathies 1

Disposition Decision-Making

Safety Assessment Before Discharge

• Perform "Get Up and Go Test"—patients unable to rise from bed, turn, and steadily ambulate out of the ED should be reassessed and not discharged 1
• Evaluate gait stability as part of safety assessment 1

Admission Criteria

• Consider admission if patient safety cannot be ensured at home 1
• All patients admitted after a fall must be evaluated by physical therapy and occupational therapy 1

Discharge Planning for Appropriate Candidates

• Arrange expedited outpatient follow-up including home safety assessments 1
• Refer for facilitated environmental home assessment, as this has been shown effective in reducing subsequent falls 1
• Ensure follow-up with primary physician for medication review if polypharmacy or high-risk medications identified 1

Post-Discharge Interventions to Prevent Recurrence

Evidence-Based Components

• Offer long-term exercise and balance training to all patients with falls 1
• Implement multifactorial interventions including comprehensive assessment, medication reduction, and assistive devices 1
• Management of postural hypotension and cardiovascular disorders is essential 1
• Facilitated home modification programs after hospital discharge reduce falls 1

Interventions to Avoid

• Advice alone about fall risk modification without implementation measures is ineffective 1
• Self-management programs without professional intervention do not reduce falls 1
• Environmental modifications alone without other multifactorial components are not beneficial 1

Special Considerations for Hospice/Palliative Patients

Hospice patients who fall should NOT be sent to the ED for workup, as management should focus on comfort, dignity, and quality of life rather than aggressive diagnostic interventions 2

Decision Framework for Hospice Patients

• Ask: "Can this patient's comfort be maintained at the nursing home?" If yes, avoid transfer 2
• Consider: "Does the patient have advance directives (DNR/POLST) that would preclude aggressive intervention?" If yes, honor these directives 2
• Evaluate: "Would diagnostic workup change management in a way that improves comfort?" If no, workup is not indicated 2
• Transfer to ER should only be considered if symptoms cannot be adequately managed at the facility (uncontrolled pain, severe bleeding, distressing neurological symptoms) 2

Common Pitfalls to Avoid

• Failing to perform complete head-to-toe examination in patients presenting with isolated complaints leads to missed occult injuries 1
• Discharging patients who cannot pass the "Get Up and Go Test" without reassessment increases immediate fall risk 1
• Overlooking medication review, especially in patients on four or more medications or psychotropic drugs 1
• Providing advice alone without implementing actual interventions or follow-up mechanisms 1
• Reflexively transferring hospice patients to the ED without considering goals of care 2