What is the appropriate workup and management for an older adult patient presenting with falls and balance issues?

Workup of Falls and Balance Issues in Older Adults

Initial Risk Stratification

All older adults presenting with falls require immediate comprehensive multifactorial assessment if they have ≥2 falls in the past year, a single fall with gait/balance problems, or present with an acute fall. 1, 2

Start by asking the critical question: "If this patient was a healthy 20-year-old, would they have fallen?" If the answer is "no," proceed with a comprehensive evaluation of underlying causes rather than attributing the fall to aging alone. 3, 4, 5

Essential History Components

Document these specific elements for every fall patient:

• Fall circumstances: exact location, cause, time spent on ground, presence of loss of consciousness or altered mental status 3, 2, 4
• Near-syncope or orthostatic symptoms 3, 4
• Previous falls in the past year (≥2 falls indicates high-risk status) 1, 2
• Difficulty with gait and balance 3, 1
• Specific comorbidities: dementia, Parkinson's disease, stroke, diabetes, depression 3, 4
• Visual or neurological impairments, particularly peripheral neuropathies 3, 1
• Complete medication review, especially psychotropic medications, antihypertensives, and polypharmacy 3, 2, 4
• Alcohol use 3
• Activities of daily living and functional status 3, 1

Physical Examination and Diagnostic Testing

Mandatory Assessments

Perform the Timed Up and Go test on all patients before discharge or disposition—this is a fast, reliable diagnostic tool that identifies those requiring further evaluation. 3, 4, 5

Complete the following standardized assessments:

• Orthostatic blood pressure measurement (check for postural hypotension, a major modifiable risk factor) 1, 2, 4
• Vision assessment (visual impairment is a key reversible risk factor) 3, 1, 2
• Gait and balance evaluation using standardized testing 3, 1, 4
• Cognitive screening for depression, B12 deficiency, and hypothyroidism as reversible causes 1, 2
• Neurological examination: assess for peripheral neuropathy, proprioception deficits, proximal motor strength, reflexes, and cerebellar function 1, 4
• Lower extremity joint function and foot examination 4

Trauma Assessment

Even for seemingly minor falls, perform a complete head-to-toe examination as traumatic injuries may be "occult" in older adults without classic signs or symptoms. 3, 4 Pay particular attention to high-risk injuries including blunt head trauma, spinal fractures, and hip fractures. 3, 4

Evidence-Based Interventions

Exercise Programs (Highest Priority)

Prescribe supervised exercise programs with balance, gait, and strength training components—this reduces fall risk by approximately 17% and is the single most effective intervention. 1, 6

The optimal exercise prescription includes:

• Minimum dose: 50 hours total of exercise to protect against falls 6
• Frequency: 3 sessions per week 3
• Duration: 12 months minimum 3, 6
• Components: moderate to high-intensity balance exercises, gait training, resistance training, and functional training 3, 6
• Referral: Physical therapy and occupational therapy for all admitted patients 3, 2, 4

Vitamin D Supplementation

Administer vitamin D 800 IU daily for at least 12 months—this reduces fall risk with a number needed to treat of 10. 1, 2 This is particularly important for patients with vitamin D deficiency or those at increased risk for falls. 3

Medication Management

Conduct mandatory medication review with focus on deprescribing or minimizing psychotropic medications, antihypertensives, and addressing polypharmacy. 2, 4 High-risk medications like diphenhydramine should be reviewed with a goal of limiting use in geriatric populations. 3

Multifactorial Interventions

For high-risk patients (≥2 falls in past year), implement comprehensive multifactorial interventions that can reduce fall risk by 25%: 1, 2

• Environmental modification: home safety assessment and removal of tripping hazards 3, 2, 4
• Treatment of postural hypotension 2, 4
• Management of foot problems and appropriate footwear 3
• Urinary incontinence management 3
• Psychological interventions (cognitive behavioral therapy if indicated) 3

Disposition and Follow-Up

Before Discharge

• Evaluate gait and perform Timed Up and Go test 4
• Ensure patient safety can be maintained 3, 4
• Counsel patients and families on fall risk and home safety 2

Outpatient Management

Arrange expedited outpatient follow-up including home safety assessments for all discharged patients. 3, 4 Consider admission if patient safety cannot be ensured. 3, 4

Continue multifactorial interventions long-term including ongoing medication review, environmental modification, and supervised mobility to reduce recurrence rates. 2, 4

Critical Pitfalls to Avoid

• Never dismiss patient reports of falls—they are frequently unreported and underdetected 1
• Do not perform superficial assessment without comprehensive follow-up and management—this is ineffective 1
• Do not overlook reversible causes: depression, B12 deficiency, hypothyroidism, and medication effects 1, 2
• Do not rely on fall risk screening alone without implementing targeted interventions 2
• Do not address single risk factors in isolation—falls are multifactorial and require comprehensive intervention 2
• Do not discharge patients without gait assessment 2, 4