Assessment and Management of Falls in Older Adults

Assessment Components

• A comprehensive assessment should be performed to identify the cause of the fall and prevent future falls in older adults, as falls are a leading cause of morbidity and mortality in this population 1, 2
• The American College of Emergency Physicians recommends obtaining detailed information about the fall circumstances, including location and cause of fall, time spent on floor or ground, presence of loss of consciousness or altered mental status, and symptoms of near-syncope or orthostasis 1
• Assessment for risk factors should include age, particularly those over 65, difficulty with gait and/or balance, comorbidities, visual or neurological impairments, alcohol use, and current medications, especially high-risk medications 1, 2, 3
• A complete head-to-toe examination should be performed to rule out occult injuries, including orthostatic blood pressure assessment and neurological assessment focusing on neuropathies and proximal muscle strength 1

Diagnostic Testing

• The American College of Emergency Physicians recommends considering the following tests when appropriate: EKG, complete blood count, standard electrolyte panel, medication levels when applicable, and appropriate imaging if trauma is suspected 1

Plan

Immediate Management

• Safety assessment prior to discharge using the "get up and go test" should be performed, and patients unable to rise from bed, turn, and steadily ambulate should be reassessed 1
• Consider admission if patient safety cannot be ensured, as recommended by the American College of Emergency Physicians 2

Fall Prevention Interventions

Exercise and Physical Therapy

• Refer to physical therapy for patients with gait or balance problems, and recommend balance training 3 or more days per week for those at risk, as well as strength training twice weekly 2, 3, 4

Medication Review

• Perform medication assessment with special attention to high-risk medications, and consider referral to primary physician for medication review if polypharmacy concerns exist 1, 3, 5

Environmental Modifications

• Recommend home safety assessment, and consider expedited outpatient follow-up including home safety evaluation 2

Vitamin D Supplementation

• Consider vitamin D supplementation (800 IU daily) for those at increased risk for falls, as recommended by the American College of Internal Medicine 4

Education

• Provide patient and caregiver education on fall prevention strategies, including discussion of appropriate footwear and environmental hazards 3, 6

Follow-up

• Arrange appropriate follow-up based on risk stratification, and consider multidisciplinary approach for high-risk patients 2, 6

Fall Prevention Strategies

Risk Assessment Education

• The American College of Emergency Physicians recommends educating patients about personal risk factors that contributed to their fall, including age, gait/balance difficulties, comorbidities, visual or neurological impairments, alcohol use, and high-risk medications 7
• Medication assessment is crucial, with special attention to high-risk medications such as vasodilators, diuretics, antipsychotics, and sedative/hypnotics, as recommended by the American College of Emergency Physicians 7
• Patients should be taught to recognize symptoms of orthostatic hypotension and how to minimize its effects, according to the American College of Emergency Physicians 7

Home Safety Modifications

• The American Heart Association recommends removing loose rugs or clutter on the floor to create clear walking paths, avoiding slippery surfaces, ensuring adequate lighting, and wearing properly fitting shoes with non-skid soles to prevent falls 8

Behavioral Strategies

• The American Heart Association suggests teaching patients to slow down movements during transfers or walking, as quick or impulsive movements can cause dizziness or falls 8
• Patients should be educated on the importance of using assistive devices properly if prescribed, such as canes or walkers, as recommended by the American Heart Association 8
• The American Heart Association recommends instructing patients on safe transfer techniques from sitting to standing and getting in/out of bed 9
• Scheduled voiding is crucial to prevent falls that occur when rushing to the bathroom, according to the American Heart Association 9

Follow-up Care

• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes the importance of follow-up appointments with healthcare providers to assess and address ongoing fall risk 10
• Patients should be explained the potential for recurrence of fall risk and the need for ongoing assessment, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 10

Special Considerations

• For patients with a history of multiple falls, the American Academy of Otolaryngology-Head and Neck Surgery recommends emphasizing the increased risk and need for more intensive prevention strategies 10
• Patients with specific conditions like stroke or vestibular disorders should receive targeted education addressing their unique risk factors, as suggested by the American Heart Association and the American Academy of Otolaryngology-Head and Neck Surgery 8, 10

Management of Falls in Older Adults

Comprehensive Fall Prevention Program

• The British Medical Journal recommends implementing a structured interdisciplinary approach combining medical assessment, home safety evaluation, and targeted interventions to reduce future falls, as this approach is more effective than single interventions 11, 12, 13, 14
• Targeted interventions should focus on postural hypotension, balance, transfers, and gait, as these are particularly effective in preventing falls 11, 12
• Home safety assessment by occupational therapy with direct intervention, advice, and education is recommended to reduce fall risk 11, 13, 14, 15

Osteoporosis Evaluation and Management

• The American Academy of Orthopaedic Surgeons recommends ordering a DEXA scan and checking vitamin D, calcium, and parathyroid hormone levels to evaluate osteoporosis risk 16
• Referral to a bone health clinic for osteoporosis treatment is recommended to reduce fracture risk with future falls 16

Evaluation and Management of Dizziness and Falls

Diagnostic Assessment

• The American Academy of Otolaryngology-Head and Neck Surgery recommends performing the Dix-Hallpike maneuver to identify benign paroxysmal positional vertigo (BPPV), as this simple bedside test can reliably diagnose the condition and make expensive radiologic testing unnecessary 17
• The Dix-Hallpike test is a crucial diagnostic tool for BPPV, and its implementation can help diagnose the condition in older adults who frequently present with vague unsteadiness rather than classic vertigo 17

Treatment and Intervention

• The American Academy of Otolaryngology-Head and Neck Surgery suggests performing the canalith repositioning procedure (Epley maneuver) immediately for BPPV, as it is highly effective and responds well to treatment 17
• The evidence strongly supports multifaceted interventions, including physical therapy, medication review, and home safety assessment, over single interventions for fall prevention, as recommended by the BMJ 18
• A multifaceted fall prevention program that includes medication review, home safety evaluation, and physical therapy referral is effective in reducing fall risk, according to the BMJ 18
• The BMJ recommends arranging occupational therapy home safety evaluation with direct intervention, advice, and education to reduce fall risk 19
• Patient education on BPPV recurrence risk and the importance of early return if symptoms recur is crucial, with a recurrence risk of 10-18% at 1 year and up to 36% long-term, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 20, 17