What labs and tests are indicated for an 87-year-old female with a history of recurrent falls and chronic weakness, presenting with new onset weakness?

From the Guidelines

For an 87-year-old female with recurrent falls, chronic weakness, and new weakness complaints, a comprehensive evaluation including a complete blood count (CBC), complete metabolic panel, and orthostatic blood pressure assessment is crucial. This approach is based on the guidelines for geriatric emergency department care, which emphasize the importance of a thorough assessment for patients presenting with falls 1. The evaluation should also include a detailed history, focusing on key elements such as difficulty with gait and/or balance, previous falls, loss of consciousness, and specific comorbidities like dementia, Parkinson’s, and diabetes.

Key components of the evaluation include:

• A thorough medication assessment, paying special attention to high-risk medications like vasodilators, diuretics, antipsychotics, and sedative/hypnotics 1
• Neurologic assessment with emphasis on the presence or absence of neuropathies and proximal motor strength
• Consideration of additional tests such as EKG, measurable medication levels, and appropriate imaging based on the patient's presentation and history
• A complete head-to-toe evaluation for injuries, even in patients with seemingly isolated injuries
• Safety assessment prior to discharge, including an evaluation of gait and a “get up and go test” to ensure the patient can safely ambulate 1

Given the patient's new weakness, it is essential to consider potential acute conditions such as stroke, infection, or medication effects that require prompt identification and intervention. A comprehensive and thoughtful assessment, as outlined in the geriatric emergency department guidelines, is necessary to address the patient's complex needs and prevent further falls and functional decline 1.

From the Research

Initial Assessment and Labs

To address the 87-year-old female patient's complaint of new weakness, in addition to her history of recurrent falls and chronic weakness, the following steps can be considered:

• A complete blood count (CBC) with differential can be performed to evaluate the patient's oxygen-carrying capacity, immune system, and to diagnose conditions such as anemia, infection, or blood dyscrasias 2.
• A basic metabolic panel, liver function tests, thyroid function testing, and a urine protein/creatinine ratio can be obtained to assess for potential underlying causes of edema or weakness 3.
• Brain natriuretic peptide levels can be measured to evaluate for heart failure, which may contribute to weakness and edema 3.

Physical Assessment

A thorough physical assessment is crucial in this patient, including:

• Evaluating airway patency, respiratory rate, work of breathing, and oxygen saturation to assess respiratory function 4.
• Assessing circulation by palpating pulse rate and rhythm, measuring blood pressure, and evaluating urine output 4.
• Evaluating the patient's level of consciousness, speech, and pain to assess neurological function 4.
• Inspecting skin integrity, observing for signs of pressure injury, and assessing bowel movements to evaluate for potential complications 4.

Medication Review

A review of the patient's medications is essential to identify potential contributors to weakness, such as:

• Anticholinergic and sedative medications, which have been associated with cognitive and physical impairment in older adults 5.

Additional Tests

Depending on the results of the initial assessment and labs, additional tests may be necessary to evaluate for specific conditions, such as:

• D-dimer test or compression ultrasonography to evaluate for deep venous thrombosis if acute unilateral lower-extremity edema is present 3.
• Echocardiography to assess for heart failure if pulmonary edema or elevated brain natriuretic peptide levels are present 3.