Assessment and Management of Falls in Older Adults

Initial Evaluation

A comprehensive fall evaluation is essential for any older adult who falls from a wheelchair, including a thorough assessment for traumatic injuries and determination of fall causes to prevent recurrence and reduce morbidity and mortality, as recommended by the American College of Emergency Physicians 1, 2
The American Geriatrics Society suggests beginning the assessment by asking the critical question: "If this patient was a healthy 20-year-old, would they have fallen?" If the answer is "no," a more comprehensive assessment of underlying causes is needed 1, 3
Perform a complete head-to-toe examination for all patients, even those presenting with seemingly isolated injuries, as traumatic injuries may be "occult" in older adults, according to the American College of Emergency Physicians 1, 2
The American College of Emergency Physicians recommends paying particular attention to high-risk injuries such as hip fractures 1

Document the specific circumstances of the fall, including location and cause of fall, time spent on floor or ground, presence of loss of consciousness or altered mental status, and near-syncope or orthostatic symptoms, as suggested by the American College of Emergency Physicians 1, 2
Assess for risk factors that contribute to falls, including medication review, especially psychotropic medications, comorbidities such as dementia and Parkinson's, visual or neurological impairments, alcohol use, and previous falls in the past year, according to the American College of Emergency Physicians 1, 2, 4

Perform orthostatic blood pressure assessment, as recommended by the American College of Emergency Physicians and the Journal of the American Geriatrics Society 1, 2, 5
Conduct neurological assessment with special attention to presence/absence of neuropathies, proximal motor strength, mental status, lower extremity peripheral nerves, proprioception, reflexes, and tests of cortical, extrapyramidal, and cerebellar function, as suggested by the Journal of the American Geriatrics Society 5
The Journal of the American Geriatrics Society recommends assessing vision, gait, balance, and lower extremity joint function 5, 4
Perform the "Get Up and Go Test" to evaluate gait and balance, as recommended by the Journal of the American Geriatrics Society 6, 5, 4

For community-dwelling older adults, multifactorial interventions should include gait training and advice on appropriate use of assistive devices, review and modification of medications, exercise programs with balance training, treatment of postural hypotension, and modification of environmental hazards, as recommended by the Journal of the American Geriatrics Society and the American Geriatrics Society 5, 4
Consider referral to physical therapy and occupational therapy for all patients admitted to hospital after a fall, as suggested by the American College of Emergency Physicians 1, 2

Evaluate gait and perform "get up and go test" before discharge, as recommended by the American College of Emergency Physicians 1, 2
Consider admission if patient safety cannot be ensured, and arrange expedited outpatient follow-up including home safety assessments for those discharged, as suggested by the American College of Emergency Physicians 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery suggests that tramadol, a medication known to cause dizziness, sedation, and orthostatic hypotension, increases fall risk, particularly in elderly patients 7
Polypharmacy, defined as the use of multiple medications, is an independent fall risk factor, with vestibular suppressants and psychotropic medications significantly increasing fall risk in the elderly 7

The Annals of Internal Medicine recommends performing orthostatic blood pressure measurements to assess for orthostatic instability, a significant fall risk factor 8
A comprehensive fall assessment should include evaluation of balance and mobility, vision, orthostatic hypotension, medication use, cognitive function, and environmental hazards, as recommended by the American Geriatrics Society 9

The American Geriatrics Society recommends a multifactorial approach to fall prevention, including medication review, environmental modification, and supervised mobility, to address identified risk factors 9
Individualized exercise programs focusing on balance training, gait training, and strength training can help reduce fall risk, as suggested by the Annals of Internal Medicine and JAMA 8, 9

The JAMA recommends continuing multifactorial interventions, including ongoing medication review, environmental modification, and supervised mobility, to prevent recurrent falls in high-risk patients 9
Counseling family/caregivers about fall risk and the need for constant supervision is crucial in preventing recurrent falls, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 10, 11