What is the differential diagnosis for falls in an elderly resident of an assisted‑living facility?

Differential Diagnosis for Falls in Geriatric Assisted-Living Residents

Falls in elderly assisted-living residents result from an interaction of intrinsic medical conditions, medication effects, and environmental hazards—you must systematically evaluate all three domains because falls are rarely due to a single cause. 1

Intrinsic (Patient-Related) Causes

Neurological & Cognitive Disorders

• Acute delirium precipitates 10% of falls in residential facilities and must be ruled out first, as it signals underlying infection, metabolic derangement, or medication toxicity 2
• Dementia and cognitive impairment (RR 1.8) impair judgment, spatial awareness, and safety awareness 3, 4
• Parkinson's disease causes gait freezing, postural instability, and bradykinesia 5, 6
• Prior stroke with residual motor deficits or sensory loss 5
• Peripheral neuropathy (commonly diabetic) impairs proprioception and balance 5, 6

Cardiovascular & Syncope-Related

• Orthostatic hypotension from autonomic dysfunction, dehydration, or medications—check orthostatic vital signs in every patient 5, 6
• Cardiac arrhythmias (obtain EKG; Class 1a antiarrhythmics have OR 1.6 for falls) 1, 5
• Vasovagal syncope or carotid sinus hypersensitivity 5

Musculoskeletal & Functional Impairment

• Lower extremity weakness is the single strongest intrinsic risk factor (RR 4.4) 3
• Gait deficit (RR 2.9) and balance deficit (RR 2.9) 3
• Arthritis (RR 2.4) limiting joint range of motion and causing pain 3
• Impaired activities of daily living (RR 2.3) 3, 4
• Use of assistive device paradoxically signals underlying instability (RR 2.6) 3

Sensory Deficits

• Visual impairment (RR 2.5) from cataracts, macular degeneration, or uncorrected refractive error 3, 6
• Hearing problems contribute to spatial disorientation 4

Psychiatric & Behavioral

• Depression (RR 2.2) is independently associated with falls 3, 4
• Fear of falling creates a vicious cycle of activity restriction, deconditioning, and increased fall risk 7
• Insomnia is strongly associated with falls in nursing home residents 4

Acute Medical Illness

• Urinary tract infection is the most common infection precipitating falls (7.9% of all falls) 2
• Pneumonia, sepsis, or other acute infections 2
• Gastrointestinal bleeding causing anemia and orthostasis—screen for melena 5
• Metabolic derangements (hypoglycemia, hyponatremia, hypercalcemia) 2

Chronic Comorbidities

• Diabetes mellitus (neuropathy, hypoglycemia, visual impairment) 5, 6
• Osteoporosis increases fracture risk but also correlates with frailty 3
• Prior hip fracture signals both bone fragility and fall history 5

Extrinsic (Medication-Related) Causes

Polypharmacy (≥4 medications) is an independent risk factor and must trigger comprehensive medication review. 1, 5

High-Risk Medication Classes

• Psychotropic medications (OR 1.7): antipsychotics, sedative-hypnotics, benzodiazepines 1, 5, 4
• Antidepressants (especially tricyclics and SSRIs) 5, 2, 4
• Benzodiazepines and anxiolytics cause sedation and impaired balance 2, 4
• Class 1a antiarrhythmics (OR 1.6) 1, 3
• Digoxin (OR 1.2) 1, 3
• Diuretics (OR 1.1) cause volume depletion and orthostasis 1, 3
• Vasodilators (antihypertensives, nitrates) 5
• Tramadol causes dizziness, sedation, and orthostatic hypotension 6

Environmental & Situational Causes

Environmental hazards precipitate 50.3% of falls in assisted-living facilities, with residents' rooms (57%) and bathrooms being the highest-risk locations. 8

Physical Environment

• Poor lighting, especially at night 1, 7, 8
• Loose carpets, rugs, or floor clutter 1, 8
• Slippery bathroom surfaces without non-slip mats 5
• Lack of grab bars in bathrooms and handrails in hallways 5, 8
• Furniture placement creating obstacles 8
• Uneven or poor ambulatory surfaces 7

Activity-Related

• Transfers (bed-to-chair, toilet, wheelchair) account for many falls 8, 9
• Ambulation attempts without appropriate supervision or assistive devices 9
• Rushing to bathroom (urgency incontinence) 8

Institutional & Behavioral Factors

• Misinterpretation of physical capacity (overestimation of ability) precipitates 17.2% of falls 2
• Misuse of roller walkers or other assistive devices 2
• Staff errors in supervision or assistance 2
• Unwillingness to accept age-related changes or use walking aids 7

Critical Historical Red Flags

Prior fall history (RR 3.0) is the strongest predictor of future falls and automatically classifies the patient as high-risk. 3, 6

Essential Questions to Ask

• "How many falls have you had in the past 6 months?" (≥1 fall = high-risk) 3
• Time spent on floor/ground after fall (prolonged downtime signals inability to self-rescue) 5
• Loss of consciousness or altered mental status during fall 5, 6
• Near-syncope, lightheadedness, or palpitations suggesting cardiovascular cause 5, 6
• Symptoms of acute illness (fever, dysuria, cough, chest pain) 2

Systematic Assessment Algorithm

Step 1: Rule Out Acute Medical Illness

• Obtain vital signs including orthostatic blood pressure (drop ≥20 mmHg systolic or ≥10 mmHg diastolic) 5, 6
• Screen for delirium (10% of falls) using confusion assessment or Mini-Cog 2
• Check for infection (urinalysis, chest X-ray if indicated) 2
• Obtain EKG, CBC, electrolytes, glucose, medication levels with low threshold 5

Step 2: Comprehensive Medication Review

• Document total number of medications (including OTC and supplements) 5
• Identify and deprescribe psychotropics, benzodiazepines, anticholinergics 5, 2
• Reduce polypharmacy when ≥4 medications 5, 3

Step 3: Functional & Neurological Assessment

• Perform Timed Up-and-Go test (>12 seconds = high risk) 5, 3, 6
• Assess 4-Stage Balance Test (inability to hold tandem stance <10 seconds = high risk) 3
• Complete neurological exam focusing on strength, proprioception, reflexes, cerebellar function 6
• Evaluate gait and use of assistive devices 6

Step 4: Sensory & Cognitive Screening

• Vision assessment (Snellen chart, visual fields) 6
• Cognitive screening (Mini-Cog or Memory Impairment Screen) 5, 3
• Depression screening (PHQ-2) 3

Step 5: Environmental Hazard Identification

• Conduct home safety assessment (lighting, rugs, bathroom safety equipment, furniture placement) 5, 6
• Assess footwear appropriateness 3

Common Pitfalls to Avoid

• Attributing falls solely to "old age" or "accident" without investigating multifactorial causes is inadequate 5
• Discharging patients who fail the "Get Up and Go" test without further evaluation markedly increases immediate fall risk 5, 6
• Omitting complete head-to-toe examination can miss occult fractures or subdural hematomas 5, 6
• Overlooking medication review in patients on ≥4 medications or psychotropics 5
• Failing to screen for delirium when acute illness may be the precipitant 2