How to evaluate an elderly patient after a fall?

Evaluation of an Elderly Patient After a Fall

Perform a comprehensive structured assessment that includes detailed fall circumstances, complete head-to-toe examination for occult injuries, medication review with focus on high-risk drugs, orthostatic blood pressure measurement, neurological and gait assessment, and immediate implementation of multifactorial interventions targeting identified risk factors. 1

Immediate Assessment: History and Circumstances

Fall Details

• Document the exact location and cause of the fall, time spent on the floor or ground, presence of loss of consciousness or altered mental status, and symptoms of near-syncope or orthostatic hypotension 1
• Ask the critical screening question: "If this patient was a healthy 20-year-old, would they have fallen?" If the answer is "no," a comprehensive assessment of underlying causes is mandatory 2
• Determine if this is a recurrent fall—patients with more than one fall in the preceding year require more intensive evaluation 2, 3

Risk Factor Assessment

• Age over 65 years is the primary demographic risk factor 1
• Evaluate for difficulty with gait and/or balance, which are among the most common risk factors 1
• Screen for comorbidities including dementia, Parkinson's disease, diabetes mellitus, and cardiovascular disease 2, 4
• Assess for visual or neurological impairments 1
• Document alcohol use 1
• Perform comprehensive medication review with special attention to high-risk medications including vasodilators, diuretics, antipsychotics, sedative/hypnotics, psychotropic medications, and tramadol 1, 2

Physical Examination: Head-to-Toe Assessment

Complete Injury Evaluation

• Perform a complete head-to-toe examination on all patients, even those presenting with seemingly isolated injuries, as traumatic injuries may be occult in older adults 2
• Pay particular attention to high-risk injuries such as hip fractures 2
• If injury status cannot be determined and suspicion remains high, consider whole-body computed tomography (pan-scan) to evaluate the head, cervical spine, chest, abdomen, and pelvis 4

Cardiovascular Assessment

• Measure orthostatic blood pressure (lying, sitting, and standing) to assess for postural hypotension, which is a particularly effective target for intervention 5, 1, 2

Neurological Examination

• Assess mental status and cognitive function 2
• Evaluate for presence or absence of neuropathies 2
• Test proximal motor strength 2
• Examine lower extremity peripheral nerves, proprioception, and reflexes 2
• Perform tests of cortical, extrapyramidal, and cerebellar function 2

Functional Assessment

• Assess vision 2
• Evaluate gait and balance 2
• Examine lower extremity joint function 2
• Perform the "Get Up and Go Test": observe the patient rise from a chair, walk, turn, and return to sitting—this simple test predicts likelihood of future falls 2, 6
• Consider the 30-second chair stand test and four-stage balance test if STEADI screening is positive 4

Additional Assessments

• Evaluate foot and footwear problems 6
• Assess for fear of falling, which can lead to activity restriction and social isolation 4, 7

Diagnostic Testing

The American College of Emergency Physicians recommends considering the following when appropriate: 1

• Electrocardiogram (EKG) to evaluate for arrhythmias
• Complete blood count
• Standard electrolyte panel
• Medication levels when applicable
• Appropriate imaging if trauma is suspected
• DEXA scan and vitamin D, calcium, and parathyroid hormone levels to evaluate osteoporosis risk 1

Special Diagnostic Maneuver

• Perform the Dix-Hallpike maneuver to identify benign paroxysmal positional vertigo (BPPV), as this simple bedside test can reliably diagnose the condition and make expensive radiologic testing unnecessary 1

Pre-Discharge Safety Assessment

• Perform the "get up and go test" before discharge—patients unable to rise from bed, turn, and steadily ambulate should be reassessed 1
• Consider admission if patient safety cannot be ensured 1

Multifactorial Intervention Implementation

Prioritize programs that include more than one intervention, as these are more effective than single interventions. 5, 1

Core Interventions to Target

Medication Management

• Perform medication assessment with special attention to high-risk medications including psychotropic drugs, vasodilators, diuretics, antipsychotics, and sedative/hypnotics 1, 2
• Reduce polypharmacy when possible, as the number of medications is a particularly effective target 5
• Consider referral to primary physician for medication review if polypharmacy concerns exist 1

Exercise and Physical Therapy

• Refer to physical therapy for patients with gait or balance problems 1
• Recommend balance training 3 or more days per week for those at risk 1
• Prescribe strength training twice weekly 1
• Consider participation in Tai Chi as an evidence-based intervention 6
• Implement gait training and advice on appropriate use of assistive devices 2

Home Safety and Environmental Modifications

• Arrange home safety assessment by occupational therapy with direct intervention, advice, and education 5, 1
• Recommend removing loose rugs or clutter on the floor to create clear walking paths 1
• Ensure adequate lighting throughout the home 1
• Advise wearing properly fitting shoes with non-skid soles 1
• Make referrals to relevant healthcare professionals (general practitioners, occupational therapists) as needed 5

Specific Medical Interventions

• Address postural hypotension through medication adjustment and patient education on recognizing symptoms and minimizing effects 5, 1
• Consider vitamin D supplementation (800 IU daily) for those at increased risk for falls 1
• Optimize vision and hearing correction 4
• Manage chronic conditions including diabetes mellitus, hypertension, osteoporosis, pain, urinary urgency and incontinence, and depression 4
• If BPPV is identified, perform the canalith repositioning procedure (Epley maneuver) immediately, as it is highly effective 1

Osteoporosis Management

• Refer to a bone health clinic for osteoporosis treatment to reduce fracture risk with future falls 1

Follow-Up and Ongoing Management

Structured Follow-Up Program

• Establish a programme of follow-up for medical and occupational therapy for older people who have presented after a fall 5
• Arrange expedited outpatient follow-up including home safety evaluation 1
• Consider multidisciplinary approach for high-risk patients 1

Patient and Caregiver Education

• Provide education on personal risk factors that contributed to the fall 1
• Teach patients to recognize symptoms of orthostatic hypotension and how to minimize its effects 1
• Instruct on slowing down movements during transfers or walking, as quick or impulsive movements can cause dizziness 1
• Educate on safe transfer techniques from sitting to standing and getting in/out of bed 1
• Recommend scheduled voiding to prevent falls when rushing to the bathroom 1
• Discuss appropriate footwear and environmental hazards 1
• For BPPV patients, educate on recurrence risk (10-18% at 1 year, up to 36% long-term) and importance of early return if symptoms recur 1

Common Pitfalls to Avoid

• Do not simply treat the injury without finding the cause of the fall—this is the most common error in management 6
• Do not discharge patients who cannot safely ambulate without reassessment or admission 1
• Do not overlook occult injuries in older adults who may not present with typical symptoms 2
• Do not implement single interventions when multifactorial programs combining interventions (especially including exercise) are more effective 5, 1
• Do not ignore home assessment without referral—home assessment of risk and education alone without further referral does not reduce falls 5