Evaluation of falls in the elderly

sudden numbness or weakness in the face, arm or leg, especially on one side of the body; confusion, difficulty talking or understanding speech (aphasia); unilateral or bilateral vision loss; difficulty walking, dizziness or loss of balance and coordination; loss of bodily functions

focal hemimotor or hemisensory deficit, somnolence, cranial nerve deficit(s)

stroke symptoms lasting only a few minutes and usually <1 hour: sudden numbness or weakness in the face, arm or leg, especially on one side of the body; confusion, difficulty talking or understanding speech (aphasia); unilateral or bilateral vision loss; difficulty walking, dizziness, or loss of balance and coordination; loss of bodily functions

may be normal outside of attack; focal hemimotor or hemisensory deficit or cranial nerve deficits if acute

previous injury to joint, commonly from past athletic/physical activities

weakness in quadriceps muscles, hip flexors, knee flexors and extensors, dorsi and plantar flexion of the foot; pain in any joints of the lower extremities (including the feet) with movement; crepitus at involved joints; diminished range of motion or pain in range of motion (or excessive range of motion) due to prior injury

lack of regular or adequate exercise; prolonged periods of immobility/sedentary behavior

impaired ability to rise from seated position; decreased flexibility; proximal muscle weakness (quadriceps); flexion contractures at knees (due to prolonged periods of immobility)

high number of falls per year, fracture history, reduced muscle strength

clinical features of osteoporosis (i.e., kyphosis, loss of height due to fractures), and of sarcopenia (i.e., muscle weakness, physical dysfunction, measured by either grip strength or chair stand test)

use of herbal medications/supplements and/or over-the-counter or prescription medications (use of 5 or more of any type of medication is particularly hazardous): benzodiazepines, antidepressants, anxiolytics, antipsychotics, opioids; sedatives and hypnotics (e.g., zolpidem), sildenafil, antihypertensives (specifically beta-blockers and peripheral vasodilators), digoxin, class Ia antiarrhythmics; nonsteroidal anti-inflammatory drugs; diabetes medications (e.g., insulin, thiazolidinediones) and associated hypoglycemia; highly anticholinergic drugs such as first-generation antihistamines (e.g., diphenhydramine), muscle relaxants, antimuscarinic drugs used for treatment of urinary incontinence, and vasodilators

no physical findings; chart review may show use of multiple or high-risk medications

loose rugs or carpets, wires, cords; clutter in home; poor lighting; slippery surfaces; absence of handrails; presence of garage/basement stairs, recent use of a cane or walker, living alone

full assessment beyond the scope of the usual clinic visit

blurred vision, diplopia, complete or partial loss of vision

visual acuity may be impaired according to Snellen chart at 6 m or Rosenbaum card at 36 cm; fundoscopy may show macular degeneration; visual field exam/confrontation may show deficit in peripheral vision

may report a feeling of unsteadiness when walking (especially on uneven surfaces, in poorly lit areas); loss of sensation in feet or hands; history may include diabetes or neurodegenerative disease (e.g., herniated disk); back or neck pain if disk disease present; medications taken may include risk of peripheral neuropathy (B6 supplement; amiodarone; chemotherapy)

Romberg sign; light touch, pinprick, proprioception, vibratory sense in lower extremities may show pattern of distribution of sensory impairment

dizziness, vertigo

nystagmus; signs of otitis media, including bulging tympanic membrane, Dix-Hallpike maneuver

history of disk disease, peripheral neuropathy (proprioceptive abnormality, e.g., secondary to diabetes), arthritis, previous hip or leg fracture, foot problems, joint infection, parkinsonism

type of gait may suggest an underlying disorder (e.g., shuffling gait in Parkinson disease or related disorder, wide-based gait in normal pressure hydrocephalus; steppage gait in foot drop); focused neurologic exam: positive Romberg evaluation may suggest presence of peripheral neuropathy

change in mental status that is typically gradual and is associated with changes in functional status, such as activities of daily living (e.g., using the phone, doing household chores, cooking, shopping for groceries, managing medications or finances, arranging transportation); may have associated changes in mood (apathy, anxiety) or sensorium (visual hallucinations, delusions, paranoia), development of new or inappropriate behaviors, language difficulty; may be accompanied by motor symptoms (gait, balance problems, tremors)

difficulty explaining situations (e.g., daily activity, meal previous night); inability to perform common daily functions (e.g., button shirt, tie shoes, bathe, dress, toilet, personal hygiene, transfer and ambulate, feed self); confusion; inability to recall numbers; physical exam findings of gait and/or balance problems, tremors, bradykinesia, axial muscle rigidity, or focal neurologic abnormalities

acute or subacute time course; febrile illness; vomiting or diarrhea (causing electrolyte disturbance); drug use

fever, orthostasis, waxing/waning change in mental status and confusion

feelings of sadness and/or worthlessness, thoughts of suicide, lack of energy, change in sleep habits (insomnia or excessive sleepiness), constipation, may express anger at family members or friends, change in appetite (weight loss or gain), difficulty with concentration, psychomotor slowing or irritability

subdued or depressive affect, listlessness, shuffling walk

best history is a seizure witnessed by medical personnel

clinical suspicion needed for diagnosis of seizure; a postictal state may be observed if exam closely follows historical event of seizure

fall with associated head trauma with concurrent use of anticoagulation raises risk

sudden altered level of consciousness or mental status following fall or head trauma, with or without focal neurologic signs

loss of consciousness; potentially life-threatening accompanying symptoms include palpitations, chest pain, back pain, hematemesis and melena; history of precipitating factors, e.g., micturition, defecation, coughing, swallowing, hot environment, prolonged standing, severe pain and emotional distress; history of event occurring if wearing a tight collar or while shaving (especially older men; suggests carotid sinus syndrome); prodromal symptoms, e.g., nausea, sweating and lightheadedness; history of underlying heart disease

bradycardia, tachycardia, irregular pulse, cardiac murmur; sensory, motor, visual and speech deficits

lightheadedness, dizziness, loss of consciousness or falls associated with a change in position from supine to seated or seated to standing; history of medications producing orthostatic hypotension (e.g., alpha blockers) or volume depletion (diuretics) may explain symptoms; however, some patients have no symptoms with changes in pulse or blood pressure from supine to standing

changes in blood pressure and pulse within 3 minutes associated with shifts in position from supine to seated or seated to standing; pulse and blood pressure can be checked immediately upon shift in position and within 1 to 3 minutes to identify changes; systolic blood pressure fall >20 mmHg from one position to another or diastolic blood pressure fall >10 mmHg from one position to another or pulse increase of 20 beats per minute with or without symptoms

excess intake of alcohol; use of analgesics (e.g., opioids) and/or recreational drugs; exposure to toxic agents (e.g., paint, paint thinners, wood varnishes), possibly occupation- or hobby-related

findings will depend on substance; nonspecific signs may include poor grooming, depression, malnutrition, bladder and bowel incontinence, recurring falls and head trauma

may be elicited by activities such as facial shaving, turning the head or wearing tight collars

carotid sinus massage produces asystole or reduced systolic blood pressure

event based on history of observed fall coincident with meal times

no physical findings