What is the appropriate workup for an elderly patient presenting with balance issues and an increased risk of falls?

Workup for Balance Issues and Fall Risk

Begin with rapid screening using the three key questions: (1) Have you fallen in the past year? (2) Do you feel unsteady when standing or walking? (3) Are you worried about falling? A "yes" to any question mandates comprehensive fall risk assessment. 1

Initial Screening and Functional Testing

Perform objective functional assessment immediately:

• Timed Up and Go (TUG) test: Patient rises from chair, walks 3 meters, turns, returns, and sits; >12 seconds indicates increased fall risk and triggers comprehensive evaluation 1
• 4-Stage Balance Test: Progress through feet side-by-side, semitandem, tandem, and single-foot stands for 10 seconds each; inability to hold tandem stand <10 seconds indicates high risk 1
• Alternative: Stay Independent questionnaire evaluates multiple domains; score ≥4 (maximum 12) indicates increased risk 1

Mandatory History Components

Document these specific elements systematically:

• Fall history details: Exact number of falls in past year, circumstances, time spent on ground (prolonged downtime indicates severity), witnessed vs. unwitnessed 2
• Syncope assessment: Loss of consciousness, near-syncope, presyncope symptoms, palpitations preceding fall 2
• Associated symptoms: Dizziness, vertigo, chest pain, melena (GI bleeding can cause falls) 2
• Functional status: Gait aid use, difficulty with activities of daily living, fear of falling 1

Physical Examination Requirements

Complete head-to-toe examination is mandatory, even with isolated complaints, to identify occult injuries:

• Orthostatic vital signs: Blood pressure and pulse supine, after 1 minute standing, and after 3 minutes standing; drop ≥20 mmHg systolic or ≥10 mmHg diastolic indicates orthostatic hypotension 2, 1
• Neurologic examination: Peripheral neuropathy assessment, proximal motor strength testing, cerebellar signs, proprioception 2
• Musculoskeletal examination: Palpate all extremities for occult fractures, assess joint range of motion, identify arthritis 2
• Vision screening: Formal visual acuity testing to identify correctable impairment 3
• Gait observation: Watch patient walk; any abnormality triggers broader assessment 1

P-SCHEME Risk Factor Assessment

Systematically evaluate modifiable factors using this mnemonic: 1, 4

• Pain: Axial or lower extremity pain limiting mobility 1
• Shoes: Suboptimal footwear characteristics (loose, poor tread) 1, 4
• Cognitive impairment: Screen with Mini-Cog or Memory Impairment Screen; abnormal results require further evaluation 1, 3
• Hypotension: Orthostatic or iatrogenic from medications 1
• Eyesight: Vision impairment requiring correction 1, 3
• Medications: Centrally acting drugs (detailed below) 1
• Environmental factors: Home hazards requiring occupational therapy assessment 1, 4

Comprehensive Medication Review (Critical Priority)

All patients must have medications reviewed and modified—this is a Class B recommendation with consistent benefit: 4

• High-risk medications requiring special attention: Vasodilators, diuretics, antipsychotics, sedative/hypnotics, benzodiazepines, antidepressants, class 1a antiarrhythmics, digoxin 2, 4
• Polypharmacy threshold: Taking ≥4 medications independently increases fall risk; reduce total count when possible 1, 4
• Action required: Alter or stop inappropriate medications, not just document them 2

Laboratory and Diagnostic Testing

Maintain low threshold for obtaining: 2

• Electrocardiogram: Evaluate for arrhythmias, conduction abnormalities 2
• Complete blood count: Assess for anemia 2
• Comprehensive metabolic panel: Electrolyte abnormalities, renal function, glucose 2
• Measurable medication levels: If on digoxin, anticonvulsants, or other drugs with narrow therapeutic windows 2
• Vitamin D level: Deficiency is modifiable risk factor 1, 5
• Additional imaging: Based on examination findings and mechanism 2

Screening for Contributing Conditions

Depression and cognitive impairment mimic and contribute to fall risk:

• Depression screening: PHQ-2 (sensitivity nearly 100%); positive screen requires PHQ-9 interview 1, 3
• Cognitive screening: Mini-Cog or Memory Impairment Screen; abnormal requires neurologic exam, multidomain testing, labs, and imaging 1, 3
• Delirium assessment: Use Confusion Assessment Method if acute change or in institutional settings 1

Underlying Medical Conditions Investigation

Systematically evaluate for: 2, 3

• Cardiovascular disorders (arrhythmias, valvular disease, heart failure) 2
• Neurological conditions (Parkinson's disease, stroke, peripheral neuropathy) 2
• Metabolic disorders (diabetes, thyroid dysfunction) 2
• Previous hip fracture history 2
• Vestibular dysfunction (consider referral for vestibular testing if indicated) 3

Disposition and Safety Assessment

Before discharge or concluding evaluation:

• Repeat "Get Up and Go Test": Patient must demonstrate safe mobility; inability to pass safely requires admission or intensive home services 2, 3
• Gait stability verification: Observe ambulation with and without assistive device if prescribed 2
• Safety determination: If patient safety cannot be ensured at home, consider admission 2

Common Pitfalls to Avoid

• Failing to perform complete head-to-toe examination in patients with isolated complaints leads to missed occult injuries 2
• Discharging patients who cannot pass Get Up and Go Test without reassessment increases immediate fall risk 2
• Overlooking medication review, especially in patients on ≥4 medications or psychotropic drugs, is the most common preventable error 2, 4
• Treating vision impairment or environmental hazards alone without multifactorial intervention is marginally successful; combined approach required 6
• Assuming gait changes are inevitable aging when most relate to underlying treatable medical conditions 7