What are the management and treatment recommendations for an older adult patient with a history of falls, who has undergone a CT brain scan showing cerebellar atrophy, mild frontal convexity atrophy, and small frontal subdural hygromas, without evidence of hemorrhage or mass effect?

Management of Older Adult with Fall, Cerebellar Atrophy, and Subdural Hygromas

This patient requires immediate comprehensive multifactorial fall risk assessment with multicomponent interventions, as the combination of recurrent falls, brain atrophy, and subdural hygromas places them in the highest-risk category for future falls and serious injury. 1

Immediate Clinical Assessment

Document Fall History Specifics

• Record the exact number of falls in the past 12 months, circumstances of each fall, presence of loss of consciousness, near-syncope symptoms, orthostatic symptoms, and any injuries sustained 1
• Critical pitfall to avoid: Do not assume falls are "just part of aging"—40% of elderly patients with syncope have complete amnesia for the event, and cardiovascular syncope in patients over 70 presents as a fall in 20% of cases 2

Neurological and Cognitive Evaluation

• Perform focused neurological examination, as 93% of patients with acute CT abnormalities after falls have new neurological findings 3
• Evaluate cognitive function using the Mini-Cog or Memory Impairment Screen, with specific attention to executive function deficits, which are a known and prominent risk factor for falls even without formal dementia diagnosis 4, 1
• If cognitive impairment is present, screen for reversible causes including depression, B12 deficiency, and hypothyroidism within the first 3 months 4

Cardiovascular Assessment

• Measure orthostatic blood pressure immediately (supine and standing), as orthostatic hypotension causes syncope presenting as falls in 6-33% of elderly patients 2
• Obtain 12-lead ECG to evaluate for cardiac arrhythmias and conduction abnormalities, particularly given the history of falls 2
• Consider carotid sinus massage evaluation, as carotid sinus hypersensitivity accounts for approximately 30% of unexplained syncope in the elderly and over 20% complain of falls rather than classic syncope symptoms 2

Gait and Balance Testing

• Perform the Timed Up and Go test, where completion time >12 seconds indicates high fall risk 1
• Conduct standardized gait and balance assessment, as recommended for all older adults who have experienced a fall 4

Subdural Hygroma Management

Conservative Monitoring Approach

• The subdural hygromas described are small and without mass effect, requiring conservative management only. 5, 6
• Subdural hygromas are common epiphenomena of head injury that typically resolve when the brain is well expanded; surgery is rarely required when no mass effect is present 5, 6
• Most subdural hygromas resolve spontaneously, though a small percentage may evolve into chronic subdural hematomas if conditions persist over several weeks 5, 7
• Monitor clinically for development of neurological symptoms that would indicate mass effect requiring neurosurgical evaluation 6

Medication Management (Highest Priority Intervention)

Immediate Comprehensive Medication Review

• Conduct immediate comprehensive medication review focusing on fall risk-increasing drugs 1, 4
• Target these high-risk medications for deprescribing: antipsychotics, sedative/hypnotics, anticholinergic agents, diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates, tricyclic antidepressants, antihistamines, dopamine agonists/antagonists, narcotics, benzodiazepines, and vestibular suppressants 1, 2
• Psychotropic and cardiovascular medications warrant judicious deprescribing 4

Physical Exercise Interventions

Structured Exercise Program

• Prescribe supervised balance training exercises 3 or more days per week combined with strength training twice weekly 1
• Refer immediately to physical therapy for gait training, balance assessment, and supervised exercise program implementation 1
• Exercise interventions, particularly those involving balance and lower limb strengthening, are among the most effective fall prevention strategies 4

Environmental Modifications

Home Safety Assessment

• Arrange occupational therapy home assessment with direct intervention for environmental hazard removal 1
• Remove specific hazards: loose rugs and floor clutter, ensure adequate lighting, and install grab bars in the bathroom 1
• Environmental modification is a strongly recommended component across all fall prevention guidelines 4

Nutritional Interventions

Vitamin D Supplementation

• Prescribe vitamin D supplementation at 800 IU daily 1, 4
• Assess nutritional status and evaluate for nutritional deficits that contribute to muscle weakness and fall risk 1

Additional Assessments

Vision and Footwear

• Conduct vision assessment, as visual deficits contribute significantly to fall risk 4, 2
• Evaluate footwear appropriateness 4

Metabolic Screening

• Screen for metabolic derangements including hypoglycemia, hyponatremia, hypocalcemia, hypomagnesemia, and renal dysfunction 2
• If cognitive impairment is present, screen for thyroid dysfunction and B12 deficiency 4, 2

Psychosocial Factors

• Screen for depression, as it increases recurrent fall risk and is associated with unexpected hospitalizations and functional decline 2
• Screen for loneliness and social isolation using the 3-item UCLA Loneliness Scale or open-ended questions 1
• Refer to social assistance programs including local support groups, community centers, and social engagement opportunities 1

Follow-Up Protocol

Structured Monitoring

• Schedule reassessment at regular intervals with ongoing multifactorial intervention adjustments 1
• Confirm therapy appointments, verify physical therapy and occupational therapy sessions are scheduled and attended, and monitor for fall recurrence 1
• Follow-up and comprehensive management of identified risk factors are essential to the effectiveness of this strategy 4

Critical Clinical Pitfalls to Avoid

• Do not overlook cardiovascular evaluation: Over 20% of older people with carotid sinus syndrome complain of falls rather than classic syncope symptoms 2
• Do not miss neurally mediated syncope: Classic pre-episode and post-episode symptoms are often absent in older patients 2
• Do not focus solely on the imaging findings: The cerebellar atrophy and subdural hygromas are markers of vulnerability, but establishing and managing underlying modifiable risk factors is essential to prevent recurrent falls and reduce morbidity and mortality 2
• Do not discharge without gait assessment: Perform "Get Up and Go Test" before any discharge to evaluate safety 2