Approach
The approach to evaluating falls, and the risk of falls, remains under debate. One approach has been to identify factors intrinsic or extrinsic to individual patients.
Intrinsic factors may include:
Gait, balance, or musculoskeletal dysfunction
Foot problems (e.g., foot drop, calluses/bony abnormalities associated with neuropathy)
Cognitive, sensory or other neurologic impairment
Behaviors and symptoms contributing to falls risk, including urinary urgency/incontinence
Age
Cardiovascular disease or other acute or chronic illnesses.
Extrinsic factors may include:
Environmental hazards
Medications and their adverse effects and interactions
Substance misuse
Restraints
Use of a cane or walker
Being housebound or living alone
A prior history of falls.
Events that precipitate the fall are then identified; for example, loss of footing, dizziness, or syncope. However, many falls may be multifactorial in origin. For example, a combination of environmental factors such as slippery floors and rugs, along with a proprioceptive problem, may place a patient at risk for loss of balance.
History
Circumstances surrounding a fall should be elicited:
Location: helps to identify any potential environmental factors and situations in which falls are more likely to occur.
Activity at the time of the fall (e.g., fall while standing, while walking down steps, while walking on uneven surfaces).
Injury related to the fall (e.g., head trauma, bruise, fracture).
Associated symptoms concurrent with a fall should be assessed, including:
Any change in level, or loss, of consciousness.
Cardiovascular symptoms such as chest pain, palpitations, dizziness, vertigo, or lightheadedness.
Symptoms related to a change in position (e.g., supine to sitting or sitting to standing).
Pain or neurologic symptoms (e.g., headache, weakness/tingling/numbness or acute change in mental status), which may indicate an underlying acute condition such as stroke.
Medications should be reviewed (with particular reference to psychotropic medications and opioids;[43] falls with related head injury should prompt a re-evaluation of risk for individuals taking anticoagulants or antiplatelet therapy). A history of comorbidities such as diabetes, Parkinson disease or osteoporosis should be elicited.
Physical exam
The physical exam is focused on factors contributing to a fall, identification of any fall-related injury (e.g., a fracture or subdural hematoma from head trauma), and fall risk factors that can be reduced/modified/corrected to prevent future falls.
Cardiovascular exam
Check rate and rhythm (for tachycardia, bradycardia, or abnormal rhythm contributing to syncope).
Identify and characterize murmurs when structural heart disease (e.g., severe aortic stenosis) is suspected.
Musculoskeletal exam
Identify presence of contractures, joint crepitations.
Identify reductions in range of motion (due to joint injuries or contractures from prolonged immobility), or pain in range of motion (related to osteoarthritis).
Identification of foot-related issues causing pain, balance impairment, and affecting posture and gait.
Evaluate strength in lower-extremity muscle groups; check for specific muscle weakness or pattern (proximal vs. distal) suggesting a potential cause (e.g., proximal lower-extremity weakness may indicate deconditioning; distal lower-extremity weakness could suggest spinal stenosis, amyotrophic lateral sclerosis).
Neurologic exam
Assess mental status, including use of validated scales (e.g., Folstein mini-mental state exam, Montreal Cognitive Assessment, Saint Louis University mental status exam, 4AT tool, Confusion Assessment Method, Geriatric Depression Scale, Cornell Scale for Depression in Dementia), for the evaluation of patients with suspected delirium, depression, or dementia. MoCA Montreal Cognitive Assessment: MoCA test Opens in new window SLU: mental status exam Opens in new window 4AT Rapid Clinical Test for Delirium Opens in new window ACRC: Geriatric Depression Scale Opens in new window
Identify tremors, muscle rigidity, bradykinesia, or shuffling gait, as they suggest the presence of parkinsonism
Coordination and cerebellar function testing is useful when looking for focal deficits related to cerebrovascular disease or neurodegenerative disorders such as corticobasal degeneration.
Consider Romberg sign and tests for proprioception when the patient complains of balance problems or if there are underlying causes of peripheral neuropathy (e.g., diabetes, B12 deficiency).
Consider the Dix-Hallpike maneuver for patients with paroxysmal positional vertigo; alternatively, look for response to Epley's maneuver. To perform the Dix-Hallpike maneuver, the patient sits on the examination table, his or her head is turned 45° to one side, and then the patient is laid back into a supine position, with the head hanging back but supported by the examiner and the neck extended by about 30° (neck extension should be avoided in patients with cervical spondylosis, rheumatoid arthritis, or vascular disease that may limit neck extension or pose a risk for a vascular event). The Dix-Hallpike maneuver is positive when the patient experiences vertigo and nystagmus in the head hanging position. The patient is returned to a seated position and the eyes are again observed for reversal nystagmus.[104][Figure caption and citation for the preceding image starts]: Dix-Hallpike maneuverParnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003 Sep 30;169(7):681-93. Used with permission. [Citation ends].
Vision exam
Visual acuity test, check for abnormalities using Snellen chart, Rosenbaum card.
Tests for nystagmus if the patient has a history of a new vision problem or a history suggestive of vertigo.
Fundoscopic evaluation in patients who have had a fall with head trauma to look for papilledema related to intracranial hemorrhage, and in sudden vision loss.
Consider referral to an ophthalmologist for a more detailed evaluation.
Gait exam
A timed or untimed up-and-go test on all patients as a general evaluation of strength, gait, and balance.[105] CDC: assessment - timed up & go Opens in new window
Full evaluation of gait (stride length, step height, base width, single limb stance time) may also suggest an underlying cause.
Testing and imaging
The following tests may be used in a targeted fashion:
Blood tests: including complete blood count, serum B12, blood glucose (including glycated hemoglobin [HbA1c] to assess level of control in diabetic patients), electrolytes, and thyroid-stimulating hormone are useful in evaluation of peripheral neuropathy or a change in mental status.
X-rays of bones: performed if a patient has persistent pain or is unable to bear weight following a fall.
Computed tomography or magnetic resonance imaging (MRI) of the brain: performed in patients who sustain a head injury (especially if they are on anticoagulation), or in patients with sudden change in mental status (i.e., sudden change in alertness, cognition, or behavior). Neurologic consultation should be considered when stroke or cerebrovascular disease is suspected.
Imaging (MRI) of appropriate spinal locations (e.g., lumbar spine): requested if spinal disease is suspected (e.g., spinal stenosis).
ECG: performed in all patients presenting with syncope.[25][26][106] An event monitor, Holter monitor, or loop recorder may be required, in conjunction with cardiology consultation if cardiovascular causes such as arrhythmia or ischemia are suspected.[106]
Echocardiogram: performed if there is a history of heart disease or ECG data suggestive of structural heart disease.[25][106]
Electroencephalogram: performed if seizure is suspected.
Testing of vision, hearing or vestibular function: carried out if indicated (if a patient confirms upon questioning, or complains of, vision or hearing impairments or vertigo or dizziness).
Electromyography: may be used for evaluation of peripheral neuropathy.
Dual-energy x-ray absorptiometry bone scan: performed on individuals who have fallen, are at risk of future falls, and have not yet been screened for osteoporosis.
Orthostatic challenge (blood pressure and heart rate measurements while lying and during active standing for 3 minutes): recommended as part of the initial evaluation for syncope. A tilt test should be considered if syncope is positional and related to standing.[25]
How to take a venous blood sample from the antecubital fossa using a vacuum needle.
How to record an ECG. Demonstrates placement of chest and limb electrodes.
Demonstration of a standardised method to evaluate a patient for orthostatic hypotension.
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