What is the initial approach for a patient who has experienced a fall, including a complete history and physical examination (PE)?

Complete History and Physical Examination for Falls in Older Adults

Initial History Components

When evaluating an older adult who has fallen, immediately document the exact circumstances of the fall, time spent on the ground, and presence of loss of consciousness or altered mental status, as these factors indicate severity and guide management. 1, 2

Critical Historical Elements to Obtain

• Fall circumstances: Exact location where fall occurred, what the patient was doing at the time, and any precipitating factors 1, 2

• Time on ground: Document precise duration patient remained on floor/ground, as prolonged downtime indicates higher severity and risk for complications 2

• Loss of consciousness: Specifically ask about any period of unconsciousness, confusion, or altered mental status during or immediately after the fall 1, 2

• Syncope/presyncope symptoms: Assess for lightheadedness, dizziness, near-fainting, or orthostatic symptoms that may have preceded the fall 1, 2

• Associated symptoms: Screen for chest pain, palpitations, shortness of breath, melena (as GI bleeding can cause falls), and neurological symptoms 2

Fall Risk Factor Assessment

• Prior fall history: Ask specifically about any falls in the past year, as history of falls is the strongest predictor of future falls 3, 4

• Gait and balance problems: Inquire about difficulty walking, unsteadiness, need for support when walking, or fear of falling 3, 1

• Medication review: Document all current medications, with particular attention to:

  • Total number of medications (≥4 medications increases risk) 2, 4
  • Psychotropic medications (benzodiazepines, antidepressants, antipsychotics) 2
  • Sedative/hypnotics 2
  • Vasodilators and diuretics 2
  • Any recent medication changes 1

• Chronic medical conditions: Document presence of cardiovascular disease, dementia, Parkinson's disease, stroke history, diabetes, previous hip fracture, depression, visual impairment, and arthritis 2, 4, 5

• Functional status: Assess baseline ability to perform activities of daily living and any recent decline 4

• Alcohol use: Document current alcohol consumption 1

Complete Physical Examination

Perform a complete head-to-toe examination on all patients who have fallen, regardless of their chief complaint, as occult injuries are commonly missed when focusing only on isolated complaints. 2

Systematic Physical Examination Components

• Vital signs with orthostatic assessment:

  • Measure blood pressure and heart rate supine, then after standing for 1-3 minutes 1, 2
  • Positive orthostatic hypotension is a key modifiable risk factor 2

• Head and neck examination: Inspect for trauma, hematomas, lacerations, and cervical spine tenderness 2

• Cardiovascular examination: Auscultate for arrhythmias, murmurs, and carotid bruits 2

• Neurological examination:

  • Assess mental status and cognition 2
  • Test for peripheral neuropathies (light touch, vibration, proprioception) 1, 2
  • Evaluate proximal muscle strength in upper and lower extremities 1, 2
  • Assess cranial nerves, coordination, and reflexes 2

• Musculoskeletal examination:

  • Palpate all extremities for tenderness, deformity, or occult fractures 2
  • Examine joints for arthritis and range of motion limitations 4
  • Inspect feet for problems and assess footwear 3

• Visual assessment: Screen for visual impairment that may contribute to falls 3, 1

Functional Assessment Tests

• "Get Up and Go" test:

  • Have patient rise from chair, walk 10 feet, turn around, walk back, and sit down 1, 2
  • Inability to complete this test safely indicates patient cannot be discharged home 2
  • This is a mandatory safety assessment before discharge 1, 2

• Gait and balance evaluation: Observe patient walking to assess stability, stride length, and balance 3, 1

• Dix-Hallpike maneuver: Perform this bedside test to diagnose benign paroxysmal positional vertigo (BPPV), which is a common but treatable cause of falls in older adults 1

Diagnostic Testing

Maintain a low threshold for obtaining diagnostic tests, as underlying medical causes frequently contribute to falls. 2

Recommended Laboratory and Imaging Studies

• Electrocardiogram: Obtain to evaluate for arrhythmias, conduction abnormalities, or ischemia 1, 2

• Complete blood count: Check for anemia or infection 1, 2

• Basic metabolic panel: Assess electrolytes, renal function, and glucose 1, 2

• Medication levels: Measure levels of relevant medications (e.g., digoxin, anticonvulsants) when applicable 1, 2

• Imaging studies: Order appropriate imaging based on mechanism and physical findings:

  • Consider whole-body CT (pan-scan) if injury status cannot be determined and suspicion remains high, particularly in patients with cognitive impairment or unreliable history 5
  • Obtain targeted imaging for areas of tenderness or suspected fracture 2

• Additional testing when indicated:

  • DEXA scan for osteoporosis evaluation 1
  • Vitamin D, calcium, and parathyroid hormone levels 1

Common Pitfalls to Avoid

• Failing to perform complete head-to-toe examination: Do not focus only on the patient's chief complaint, as occult injuries are frequently missed 2

• Discharging patients who fail the "Get Up and Go" test: Patients who cannot safely complete this test require reassessment or admission 2

• Inadequate medication review: Always review all medications, especially in patients taking ≥4 medications or any psychotropic drugs 2

• Missing cognitive impairment: Recognize that patients with dementia may provide inaccurate history, requiring collateral information and more thorough evaluation 5