What is the next best step in evaluating an elderly patient with a history of falls, chronic low back pain, and decreased proprioception, who is taking metformin, gabapentin, lisinopril, rosuvastatin, and acetaminophen?

Functional Gait Assessment

The next best step is a functional gait assessment, as this patient has multiple positive fall risk screening indicators (recent fall, decreased proprioception, diabetic neuropathy) that mandate immediate evaluation of gait and balance function to guide targeted fall prevention interventions. 1, 2

Rationale for Functional Gait Assessment

This patient has already answered "yes" to all three critical fall screening questions (fallen in past year, feels unsteady, recent fall), which automatically triggers the need for broader fall risk assessment beyond simple screening. 1, 2 The Mayo Clinic guidelines specifically state that any observed gait abnormalities, positive answers to screening questions, or inability to hold a tandem stand for 10 seconds should prompt broader fall risk assessment. 1

Key Clinical Findings Supporting This Approach

• Decreased proprioception bilaterally is a major fall risk factor that directly impairs balance and gait stability, requiring formal assessment of functional mobility. 1
• Diabetic peripheral neuropathy (evidenced by decreased monofilament sensation and burning feet) significantly increases fall risk through impaired sensory feedback during ambulation. 1
• Recent unwitnessed fall in an elderly patient with multiple comorbidities places him at 12-fold increased risk for future falls. 1

Specific Functional Tests to Perform

The Timed Up and Go (TUG) test should be performed immediately in the office: have the patient rise from a chair, walk 3 meters, turn around, walk back, and sit down. A time >12 seconds indicates increased fall risk and need for physical therapy referral. 1, 2

The 4-Stage Balance Test should also be conducted: instruct the patient to stand in 4 increasingly challenging positions for 10 seconds each (feet side by side, semitandem stand, tandem stand, single-foot stand). Inability to hold tandem stand <10 seconds is associated with increased fall risk. 1

The Functional Gait Assessment (FGA) with a cutoff score of ≤22/30 provides 100% sensitivity and 72% specificity for predicting prospective falls in community-dwelling older adults. 3

Why Not the Other Options

TSH Measurement - Not Indicated

While thyroid dysfunction can contribute to falls, there are no clinical features suggesting hypothyroidism (normal vital signs, no mention of weight changes, cold intolerance, or other thyroid symptoms). This would be a low-yield test given the clear mechanical and neurological fall risk factors already identified. 1, 2

EMG and Nerve Conduction Study - Premature

The diagnosis of diabetic peripheral neuropathy is already clinically established (decreased monofilament sensation, burning feet, longstanding diabetes). EMG/NCS would not change immediate management and delays the critical fall prevention interventions this patient needs now. 2, 4

MRI Lumbar-Sacral Spine - Not Indicated

His chronic low back pain is longstanding and stable, with normal neurological examination except for the expected diabetic neuropathy findings. There are no red flags (no new neurological deficits, no bowel/bladder dysfunction, no progressive weakness) that would warrant imaging. The recent fall evaluation already included appropriate imaging that was unremarkable. 4, 5

Immediate Multifactorial Interventions Required

Physical Therapy Referral

Immediate referral to physical therapy for gait training, balance assessment, and prescription of balance training exercises 3+ days per week plus strength training twice weekly is essential. 1, 2, 6 The American Geriatrics Society specifically recommends gait training and advice on appropriate use of assistive devices as a Grade B recommendation for community-dwelling older adults. 1

Medication Review - Critical Safety Issue

Gabapentin carries significant fall risk through somnolence, dizziness, and ataxia (reported in 19%, 17%, and 13% of patients respectively), and the FDA label explicitly warns about impaired driving and operating machinery. 7 Given that gabapentin shows no benefit for nonspecific chronic low back pain (the likely indication here) and significantly increases fall risk, deprescribing should be strongly considered. 8

The medication review should focus on the P-SCHEME acronym for fall risk factors: Pain medications, Shoes, Cognitive impairment, Hypotension, Eyesight, Medications (centrally acting), and Environmental factors. 1

Home Safety Assessment

Arrange occupational therapy home assessment with direct intervention to remove loose rugs and floor clutter, ensure adequate lighting throughout the home, install grab bars in bathrooms, and recommend properly fitting non-skid footwear. 2, 6

Vision and Cognitive Screening

Formal visual acuity testing is essential as visual impairment is a modifiable fall risk factor. 2 Cognitive screening using Mini-Cog is necessary as cognitive impairment significantly increases fall risk. 1, 2

Common Pitfalls to Avoid

• Do not delay functional assessment while pursuing diagnostic testing that won't change immediate fall prevention management. 1, 2
• Do not continue gabapentin without reassessing risk-benefit, especially given the lack of efficacy for nonspecific low back pain and significant adverse effects including dizziness, fatigue, difficulties with mentation, and visual disturbances (NNH of 7,8,6, and 6 respectively). 7, 8
• Do not assume the fall was a one-time event - this patient has multiple persistent risk factors requiring ongoing intervention. 1, 2
• Do not focus solely on one risk factor - falls in elderly patients are multifactorial and require comprehensive assessment addressing mobility, medications, environment, and sensory impairments simultaneously. 1, 2