What questions should a primary‑care clinician ask a patient hospitalized after a fall to assess the circumstances, health status, and fall‑risk factors?

Post-Fall Follow-Up Assessment in Primary Care After Hospitalization

When evaluating a patient in primary care after a fall-related hospitalization, systematically assess fall circumstances, time on ground, injury patterns, medication risks, functional status, and modifiable risk factors using the P-SCHEME framework to prevent recurrence and reduce mortality.

Essential Historical Questions About the Fall Event

Immediate Circumstances

• Document exact time spent on the floor or ground, as prolonged downtime indicates severity and predicts complications 1
• Ask about loss of consciousness or altered mental status during or immediately after the fall 1, 2
• Inquire about pre-fall symptoms: dizziness, near-syncope, palpitations, chest pain, or orthostatic lightheadedness that may indicate cardiac or neurologic causes 1, 2
• Determine the exact location and activity when the fall occurred (e.g., walking to bathroom, transferring from bed, reaching for objects) 2
• Screen for gastrointestinal bleeding symptoms (melena, hematochezia), as GI bleeding can precipitate falls 1

Fall History and Pattern Recognition

• Prior fall history is the strongest predictor of future falls and must be documented in detail, including frequency and circumstances of previous falls 1, 3
• Ask specifically: "Are you worried about falling?" as fear of falling independently increases fall risk and affects quality of life 3
• Determine if this represents a pattern (single event vs. recurrent falls) 3

Critical Physical and Functional Assessment Questions

Mobility and Balance Status

• Assess gait and balance problems by asking about difficulty walking, unsteadiness, or need for support when ambulating 1, 3
• Document use of assistive devices (cane, walker) and whether the patient was using them at the time of the fall 1
• Inquire about difficulty with activities of daily living and any recent functional decline 1
• Ask about the "Get Up and Go" ability: Can they rise from a chair, walk, turn, and sit without difficulty? 1, 2

P-SCHEME Risk Factor Assessment

The Mayo Clinic recommends systematically evaluating modifiable factors using this mnemonic 3:

• Pain: Axial or lower extremity pain that affects mobility 3
• Shoes: Type of footwear worn during the fall and typical footwear habits 3
• Cognitive impairment: Memory problems, confusion, or dementia diagnosis 3, 4
• Hypotension: Symptoms of orthostatic hypotension (lightheadedness on standing, syncope) 3, 1
• Eyesight: Visual impairment or recent vision changes 3
• Medications: Detailed review below 3
• Environmental factors: Home hazards, lighting, clutter, loose rugs 3, 2

Comprehensive Medication Review

This is mandatory for all post-fall patients, especially those taking ≥4 medications or any psychotropic drugs 1, 2:

High-Risk Medication Classes to Specifically Ask About

• Vasodilators and antihypertensives (can cause orthostatic hypotension) 1, 2
• Diuretics (volume depletion, electrolyte abnormalities) 1, 2
• Psychotropic medications: antipsychotics, benzodiazepines, sedative-hypnotics 1, 3
• Antidepressants, particularly SSRIs 1, 5
• Opiates (sedation, impaired cognition) 5
• Polypharmacy burden: Document total number of medications including over-the-counter and supplements 3, 1

Medication-Specific Questions

• When were medications last adjusted? Recent changes may correlate with fall timing 1
• Is the patient taking medications as prescribed? Non-adherence or confusion about dosing 3
• Are there multiple prescribers? This increases polypharmacy risk 3

Assessment of Underlying Medical Conditions

Cardiovascular and Neurologic Screening

• Screen for cardiovascular disorders: history of arrhythmias, heart failure, myocardial infarction 1, 6
• Ask about neurologic conditions: Parkinson's disease, stroke history, peripheral neuropathy, dementia 1, 4
• Inquire about diabetes and symptoms of hypoglycemia 1
• Document depression symptoms using PHQ-2 screening 1

Functional and Psychosocial Factors

• Living situation: Does the patient live alone? This increases risk for medically serious falls 6
• Caregiver availability and support 7
• Recent hospitalizations or skilled nursing facility stays that may have caused deconditioning 6, 7
• Alcohol use, which increases fall risk 2, 4

Hospital Course and Injury Assessment

Hospitalization Details

• Length of hospital stay, as longer stays correlate with increased fall risk post-discharge 6
• Injuries sustained from the fall: head trauma, fractures, lacerations 3, 8
• New diagnoses made during hospitalization that may affect fall risk 1
• Discharge medications and any changes from pre-hospitalization regimen 1

Post-Discharge Recovery

• Current recovery status: Has the patient returned to baseline function? 7
• Persistent symptoms: ongoing pain, weakness, dizziness 7
• Psychological impact: fear of falling, anxiety, loss of confidence 7
• Changes in mobility or independence since discharge 7

Home Safety and Environmental Assessment

Direct Questions About Home Environment

• Presence of loose rugs, clutter, or obstacles in walking paths 2
• Adequacy of lighting, especially in hallways and bathrooms 2
• Bathroom safety: grab bars, raised toilet seat, non-slip mats 2
• Stairs and railings: condition and patient's ability to navigate safely 2
• Has an occupational therapy home safety evaluation been completed? If not, this should be arranged 2

Functional Testing to Perform or Inquire About

Bedside Tests from Hospital or to Repeat

• Timed Up and Go (TUG) test result: >12 seconds indicates high fall risk 3, 1
• 4-Stage Balance Test: Inability to hold tandem stand for 10 seconds indicates high risk 3, 1
• Orthostatic vital signs: Document if checked during hospitalization and results 1, 2

Critical Pitfalls to Avoid

• Failing to ask about time spent on the ground misses a key severity indicator 1
• Incomplete medication review, especially overlooking over-the-counter medications and supplements 1, 3
• Not screening for cognitive impairment, which is a major independent risk factor 3, 4
• Discharging patients who cannot safely ambulate without reassessment or home safety plan 1, 2
• Missing the psychological impact of falls, including fear of falling and loss of independence 7
• Overlooking caregiver burden and support needs, particularly for patients with cognitive impairment 7