What is the recommended comprehensive work‑up for an older adult with comorbidities (dementia, polypharmacy, visual impairment, gait instability, cardiovascular disease) who presents after a fall?

Comprehensive Work-Up for Falls in Older Adults

All geriatric patients presenting after a fall require a systematic evaluation beginning with the critical question: "Would a healthy 20-year-old have fallen in this situation?"—if the answer is "no," a comprehensive multifactorial assessment is mandatory. 1

Critical Historical Elements

The history is the most critical component of fall evaluation and must systematically document the following key elements: 1

• Fall circumstances: Exact location, mechanism, and time spent on the floor or ground (prolonged downtime indicates severity and risk of rhabdomyolysis or pressure injuries) 1, 2
• Loss of consciousness or altered mental status during or after the fall 1, 2
• Syncope, near-syncope, or orthostatic symptoms that may have precipitated the event 1, 2
• Melena or gastrointestinal symptoms (bleeding can cause falls) 1, 2
• Prior fall history: This is the strongest predictor of future falls (RR 3.0) and automatically designates the patient as high-risk 3, 4
• Gait and balance difficulties: Unsteadiness or need for assistive devices (RR 2.9 for gait deficit, RR 2.9 for balance deficit) 1, 3
• Fear of falling: Independently raises risk and negatively impacts quality of life 2, 4

Comorbidity Assessment

Document specific conditions that increase fall risk: 1, 2

• Dementia or cognitive impairment (RR 1.8) 3
• Parkinson's disease, stroke, or other neurological disorders 1
• Diabetes mellitus 1
• Depression (RR 2.2) 3
• Previous hip fracture 1
• Visual impairment (RR 2.5) 1, 3
• Peripheral neuropathies 1
• Cardiovascular disease 1

Medication Review (Mandatory)

A comprehensive medication assessment must be performed on all patients, with special attention to high-risk drug classes and polypharmacy (≥4 medications). 1, 2, 3

High-risk medication classes requiring immediate review: 1, 2

• Psychotropic medications (OR 1.7): antipsychotics, benzodiazepines, sedative-hypnotics, antidepressants
• Cardiovascular agents: vasodilators, diuretics (OR 1.1), class 1a antiarrhythmics (OR 1.6), digoxin (OR 1.2)
• Beta-blockers (OR 1.88) and calcium channel blockers (OR 2.05), especially in combination 5
• Spironolactone (OR 4.10) 5

Document total number of medications including over-the-counter products and supplements, as polypharmacy independently increases fall risk. 2, 3

Mandatory Physical Examination

Complete Head-to-Toe Evaluation

Perform a complete head-to-toe examination for ALL patients, including those with seemingly isolated injuries, to identify occult injuries. 1, 2 This is a common pitfall—failing to do this can lead to missed fractures, subdural hematomas, or other serious injuries. 2

Orthostatic Vital Signs

Measure blood pressure and heart rate supine, then after standing for 1-3 minutes to identify postural hypotension (a drop ≥20 mmHg systolic or ≥10 mmHg diastolic). 1, 2

Neurological Assessment

Focus on: 1, 2

• Peripheral neuropathies (light touch, vibration, proprioception)
• Proximal motor strength in lower extremities
• Cognitive screening using Mini-Cog or Montreal Cognitive Assessment 1, 2

Functional Assessment

Perform the "Get Up and Go Test" before discharge: Patient rises from chair, walks 3 meters, turns, returns, and sits. 1, 2, 6

• Time >12 seconds indicates high fall risk and triggers comprehensive evaluation 2, 3
• Patients unable to complete this test safely should NOT be discharged without reassessment or admission consideration 1, 2, 6

Alternative functional tests: 2, 3

• 4-Stage Balance Test: Inability to hold tandem stance <10 seconds indicates high risk
• 30-second chair stand test 4

Diagnostic Testing

Maintain a low threshold for obtaining the following tests: 1, 2, 6

• Electrocardiogram (to evaluate for arrhythmias, conduction abnormalities, or ischemia)
• Complete blood count (to assess for anemia or infection)
• Basic metabolic panel (electrolyte abnormalities, renal function, glucose)
• Measurable medication levels when applicable (digoxin, anticonvulsants)
• Vitamin D level (deficiency is a modifiable risk factor) 2, 3
• Appropriate imaging based on mechanism and examination findings

For patients with cognitive impairment and suspected delirium, screen for reversible causes: 1

• Depression screening
• Vitamin B12 level
• Thyroid function tests
• Consider structural neuroimaging if recently diagnosed

Disposition Decision-Making

Admission Criteria

Consider admission if patient safety cannot be ensured at home. 1, 6, 3 Specific indications include: 1, 2

• Failure of "Get Up and Go Test"
• Inability to ambulate steadily
• Unsafe home environment without immediate modification capability
• Serious injuries requiring inpatient management
• Prolonged downtime with concern for rhabdomyolysis

All patients admitted after a fall must be evaluated by physical therapy and occupational therapy. 1, 3

Discharge Planning

For patients discharged from the emergency department: 1, 6

• Arrange expedited outpatient follow-up within 1-2 weeks including home safety assessment
• Refer to physical therapy for gait training and assistive device prescription if indicated
• Provide fall prevention education
• Ensure medication review with primary care physician

Multifactorial Intervention Framework (P-SCHEME)

Use this mnemonic to systematically address modifiable risk factors: 2, 3

• Pain: Axial or lower-extremity pain limiting mobility
• Shoes: Inappropriate footwear (loose-fit, high heels)
• Cognitive impairment: Memory problems, confusion, dementia
• Hypotension: Orthostatic symptoms, syncope
• Eyesight: Visual impairment or recent vision changes
• Medications: Review and deprescribe high-risk drugs, reduce polypharmacy
• Environmental factors: Home hazards (loose rugs, poor lighting, clutter)

Evidence-Based Interventions to Reduce Future Fall Risk

Exercise and Physical Therapy (Highest Priority)

Refer all patients with gait or balance problems to physical therapy for individualized exercise programs. 1, 6 Evidence shows exercise reduces fall risk by 23% (RR 0.77). 3

Specific recommendations: 6, 3

• Balance training ≥3 days per week
• Strength training focusing on lower extremities twice weekly
• Gait training protocols

Medication Optimization

Review and modify medications, especially psychotropic drugs—this is a Class B recommendation with consistent evidence of benefit. 3 Specific actions: 2, 3

• Reduce total medication count if ≥4 medications
• Deprescribe or reduce doses of sedative-hypnotics, benzodiazepines, antipsychotics
• Adjust cardiovascular medications causing orthostasis

Vitamin D Supplementation

Prescribe vitamin D ≥800 IU daily for patients with deficiency or at increased fall risk. 6, 3

Home Safety Modifications

Arrange occupational therapy home safety evaluation with direct intervention, advice, and education. 6, 3 Key modifications include: 6

• Remove loose rugs and floor clutter
• Ensure adequate lighting throughout home
• Install handrails in hallways and grab bars in bathrooms
• Address slippery surfaces

Osteoporosis Evaluation

Order DEXA scan and check vitamin D, calcium, and parathyroid hormone levels in high-risk patients to assess fracture risk. 6, 3 Consider referral to bone health clinic for osteoporosis treatment. 6

Additional Assessments

• Vision evaluation: Refer to ophthalmology for visual impairment 1, 2
• Hearing assessment: New evidence supports evaluation and intervention for hearing impairment 7
• Dix-Hallpike maneuver: Perform to identify benign paroxysmal positional vertigo (BPPV), which is highly treatable with canalith repositioning 6
• Depression screening: Use PHQ-2, followed by PHQ-9 if positive 2, 3
• Footwear assessment: Ensure properly fitting shoes with non-skid soles 1, 2

Common Pitfalls to Avoid

• Discharging patients who fail the "Get Up and Go Test" without reassessment or admission increases immediate fall risk 1, 2
• Failing to perform complete head-to-toe examination in patients with isolated complaints leads to missed occult injuries 1, 2
• Overlooking medication review, especially in patients on ≥4 medications or psychotropic drugs 2, 3
• Attributing falls solely to "old age" or "accident" without investigating underlying multifactorial causes 1, 2
• Single-intervention approaches: Environmental modification alone without other interventions is not beneficial 3

Follow-Up and Ongoing Management

Schedule reassessment within 1-2 weeks including: 3

• Medication optimization review
• Physical therapy progress
• Home safety evaluation completion
• DEXA scan results if ordered
• Annual fall risk reassessment for all patients ≥65 years 1, 7