Blood Work for Elderly Patients with Balance Issues and Fall Risk
Yes, specific blood work is necessary and should include screening for vitamin B12 deficiency, thyroid function (TSH), complete blood count, comprehensive metabolic panel, and vitamin D levels, as these represent treatable causes of balance impairment and falls in older adults. 1
Essential Laboratory Testing
Mandatory Initial Blood Work
Vitamin B12 level - The American Academy of Neurology guidelines specifically recommend screening for B12 deficiency in older adults with cognitive impairment or balance problems, as deficiency can cause peripheral neuropathy and proprioceptive dysfunction contributing to falls 1
Thyroid function (TSH) - Hypothyroidism screening is explicitly recommended as it can cause muscle weakness, cognitive slowing, and balance impairment 1
Complete blood count (CBC) - The American College of Emergency Physicians recommends CBC to screen for anemia, which can cause weakness, fatigue, and orthostatic symptoms leading to falls 2
Comprehensive metabolic panel - This identifies electrolyte abnormalities (particularly sodium, potassium, calcium), renal dysfunction affecting medication clearance, and glucose abnormalities in diabetic patients 2
Vitamin D level - Vitamin D deficiency is a modifiable fall risk factor, and supplementation (800 IU daily) reduces fall risk in deficient patients 3, 2
Additional Testing Based on Clinical Context
Hemoglobin A1c or fasting glucose - For patients with diabetes or suspected diabetes, as poor glycemic control increases fall risk through neuropathy, visual impairment, and hypoglycemic episodes 1
Medication levels - When applicable (e.g., digoxin, anticonvulsants), as toxic levels can cause ataxia and balance problems 2
EKG - The American College of Emergency Physicians recommends EKG when cardiac arrhythmias or syncope may have precipitated the fall 2
Clinical Context for Laboratory Testing
When Cognitive Impairment is Present
If cognitive screening (Mini-Cog or Memory Impairment Screen) is abnormal, the American Academy of Neurology mandates screening for depression, B12 deficiency, and hypothyroidism within 3 months of diagnosis 1
This triad of reversible causes must be excluded before attributing cognitive decline to irreversible dementia 1
When Orthostatic Symptoms are Present
Electrolyte panel is critical to identify hyponatremia, hypokalemia, or hypercalcemia that can worsen orthostatic hypotension 2
CBC helps identify anemia as a contributor to orthostatic intolerance 2
When Neuropathy or Weakness is Present
B12 and thyroid testing become even more important, as both can cause peripheral neuropathy affecting proprioception and balance 1
Glucose testing identifies diabetic neuropathy as a contributor 1
Common Pitfalls to Avoid
Failing to check B12 and TSH - These are the most commonly missed reversible causes of balance impairment in older adults, explicitly called out in guidelines 1
Overlooking vitamin D deficiency - This modifiable risk factor is frequently present but undertreated, despite clear evidence that supplementation reduces falls 3, 2
Not screening for anemia - Anemia contributes to weakness, fatigue, and orthostatic symptoms but is easily treatable once identified 2
Ignoring medication levels - In patients on narrow therapeutic index drugs, toxic levels can directly cause ataxia and falls 2
Integration with Comprehensive Fall Assessment
Blood work represents only one component of the multifactorial fall evaluation, which must also include 1, 4:
Medication review - Particularly for vasodilators, diuretics, antipsychotics, sedative/hypnotics, and benzodiazepines 2
Orthostatic blood pressure measurement - Supine and standing measurements to identify postural hypotension 1, 2
Vision assessment - Formal visual acuity testing as visual impairment is a modifiable fall risk factor 4
Gait and balance evaluation - Timed Up and Go test (>12 seconds indicates high risk) 4, 2
Cognitive screening - Mini-Cog or Memory Impairment Screen 4, 2
Depression screening - PHQ-2 followed by PHQ-9 if positive 2