What is the best approach to managing falls in a geriatric patient?

Approach to Geriatric Falls: A Systematic Framework

Initial Assessment: The Critical Question

Begin every fall evaluation by asking: "If this patient was a healthy 20-year-old, would they have fallen?" If the answer is "no," a comprehensive multifactorial assessment is mandatory. 1

Immediate History Components

Obtain these specific historical elements for every geriatric fall patient 1:

• Fall circumstances: Location, activity during fall, time spent on ground
• Loss of consciousness or altered mental status (suggests syncope vs. mechanical fall)
• Near-syncope, dizziness, or orthostatic symptoms
• Prior falls in past 12 months (≥2 falls = high risk)
• Difficulty with gait or balance
• Fear of falling (independent risk factor)
• Specific comorbidities: Dementia, Parkinson's disease, stroke, diabetes, prior hip fracture, depression
• Complete medication list including over-the-counter drugs
• Visual impairments and peripheral neuropathies
• Alcohol use
• Activities of daily living status
• Footwear assessment

Physical Examination Priorities

Perform a complete head-to-toe examination even with seemingly isolated injuries, as traumatic injuries may be "occult" in older adults without classic signs or symptoms. 1, 2 Pay particular attention to high-risk injuries: blunt head trauma, spinal fractures, and hip fractures 1.

Mandatory Examination Components 1:

• Vision testing: Formal visual acuity assessment
• Cardiovascular: Heart rate and rhythm, postural pulse and blood pressure (measure supine, then after 1 and 3 minutes standing)
• Neurological: Mental status, muscle strength (especially proximal lower extremity), lower extremity peripheral nerves, proprioception, reflexes, cortical/extrapyramidal/cerebellar function
• Musculoskeletal: Gait observation, balance testing, lower extremity joint function
• Footwear inspection

Functional Testing (Choose Based on Setting)

Perform at least one standardized test 1, 3:

• Timed Up and Go (TUG): Rise from chair, walk 3 meters, turn, return, sit. >12 seconds = increased fall risk requiring intervention 1, 3
• 4-Stage Balance Test: Side-by-side stand, semitandem, tandem, single-foot stand for 10 seconds each. Tandem stand <10 seconds = increased fall risk 1
• 30-second chair stand test 4

Risk Factor Identification: The P-SCHEME Mnemonic 1

Systematically evaluate these modifiable factors:

• Pain (axial or lower extremity)
• Shoes (suboptimal footwear)
• Cognitive impairment (use Mini-Cog or Memory Impairment Screen)
• Hypotension (orthostatic or iatrogenic)
• Eyesight (vision impairment)
• Medications (centrally acting)
• Environmental factors

Medication Review: High-Priority Intervention

Review and modify medications, especially psychotropic drugs, as this is a Class B recommendation with consistent evidence of benefit. 1

Specific Actions 1, 5:

• Reduce total medication count if ≥4 medications (polypharmacy independently increases fall risk)
• Withdraw or minimize psychotropic medications: Benzodiazepines (even short-acting), antidepressants, neuroleptics, sedative-hypnotics
• Review high-risk drugs: Antihypertensives, diuretics, vestibular suppressants, opioids
• Benzodiazepine caution: FDA labeling warns that elderly patients are more susceptible to sedative effects; initial dose should not exceed 2 mg, and there is no clear difference in fall risk between long- and short-acting formulations 5
• Refer hospitalized patients with polypharmacy to multidisciplinary team including pharmacist 1

Multifactorial Interventions: Setting-Specific Recommendations

Community-Dwelling Older Adults 1

Implement these evidence-based interventions (Class B recommendations):

1. Gait training and assistive device prescription

   • Refer to physical therapy for proper fitting and training
   • Devices must be properly fitted to avoid becoming fall hazards themselves 3
   • Document medical necessity with ICD-10 codes: Z91.81 (history of falls), R26.9 (abnormality of gait), R42 (dizziness) 3

2. Exercise programs with balance training as core component

   • Prescribe balance training ≥3 days per week 2, 3
   • Strength training twice weekly 2, 3
   • Tai Chi is promising but requires further evaluation (Class C) 1

3. Medication review and modification (as detailed above)

4. Treatment of postural hypotension

   • Manage if systolic BP drops ≥20 mmHg or diastolic ≥10 mmHg upon standing 1

5. Environmental hazard modification (Class C)

   • Home safety assessment by occupational therapy with direct intervention (not just advice) 2, 3
   • Remove loose rugs and floor clutter
   • Ensure adequate lighting throughout home
   • Install grab bars in bathroom
   • Recommend properly fitting non-skid footwear

6. Treatment of cardiovascular disorders including arrhythmias (Class D) 1

7. Vitamin D supplementation: ≥800 IU daily for those with deficiency or at increased fall risk 2, 3

Long-Term Care Settings 1

Effective components differ from community settings:

• Staff education programs (effective in long-term care, unlike community settings)
• Gait training and assistive device advice
• Medication review and modification, especially psychotropics
• Comprehensive assessment

Acute Hospital Settings 1

Evidence is insufficient to recommend for or against multifactorial interventions in hospitals. However, practical measures include 1:

• Rubber/non-skid floor surfaces
• Even floor surfaces
• Handrails on walls and hallways
• Adequate lighting
• Bedside commodes and grab bars
• Properly positioned bedrails
• Appropriate patient gowns (avoid long, baggy, loose tie strings)

Critical Pitfalls to Avoid

Advice alone without implementation is ineffective. 1 Three studies showed equivocal benefit and two showed no benefit from advice alone about fall risk modification without measures to implement recommended changes. Direct intervention is required.

Home environmental modification alone (without other interventions) is not beneficial. 1 One study showed equivocal benefit and another showed no benefit when used as sole intervention. Environmental modification must be part of multifactorial approach.

Self-management programs were not beneficial in five Class I studies. 1

Disposition and Follow-Up

Discharge Criteria 1, 2:

• Consider admission if patient safety cannot be ensured
• Perform "Get Up and Go" test before discharge
• Arrange expedited outpatient follow-up within 1-2 weeks including home safety assessment

For Admitted Patients 1:

• All patients admitted after a fall must be evaluated by physical therapy and occupational therapy
• Multidisciplinary team review for medication optimization

Ongoing Management 2, 3:

• Order DEXA scan to assess fracture risk in high-risk patients
• Depression screening using PHQ-2 (late-life depression contributes to falls)
• Cognitive screening if not already performed
• Annual fall risk reassessment with established instruments
• Monitor for recurrence of falls

Special Considerations

About 20% of cardiovascular syncope in patients >70 years presents as a fall, and >20% of older adults with Carotid Sinus Syndrome complain of falls. 6 Therefore, patients with unexplained falls should undergo cardiovascular and neuroautonomic assessment beyond standard fall evaluation.

In 40-60% of cases, falls occur without witnesses, and syncope-related falls often have retrograde amnesia. 6 This means history may be unreliable, requiring lower threshold for comprehensive workup.