FALL

Unintentional descent to lower level; leading cause of injury hospitalization in adults ≥65

SYMPTOMS / ASSOCIATED SX

  • Witnessed or unwitnessed fall; may have amnesia for event

  • Head strike, hip/wrist/rib pain; ecchymosis, laceration

  • Fear of falling, reduced mobility, loss of independence

  • Exam: gait instability, orthostatic VS, focal neuro deficits, TUG test ≥12s abnormal

DENIES

  • Chest pain/palpitations before fall (cardiac syncope)

  • Focal weakness/speech difficulty (CVA/TIA)

  • Severe headache (ICH, SAH)

  • Neck pain or paresthesias (C-spine injury)

SOCIAL HISTORY

  • Lives alone vs. with support; home hazards, assistive device use, prior falls in last 12 months

  • Alcohol use; functional baseline (ADLs/IADLs)

MAIN ETIOLOGY

  • Intrinsic: gait/balance disorder, lower extremity weakness, vision impairment, orthostatic hypotension, cognitive impairment, deconditioning

  • Extrinsic: polypharmacy (sedatives, antihypertensives, diuretics, anticholinergics), improper footwear, environmental hazards

  • Acute medical trigger: infection/sepsis, metabolic derangement, arrhythmia, hypoglycemia, AMS, new stroke

MOST COMMON DDX

  • Syncope/presyncope (LOC, prodrome, ECG changes)

  • Seizure (post-ictal, tongue laceration, incontinence, EEG)

  • CVA/TIA (focal neuro deficit, imaging)

  • Hypoglycemia (fingerstick <70)

  • Drop attack (no LOC, sudden leg weakness — vertebrobasilar)

  • Carotid sinus hypersensitivity (carotid massage reproduces sx)

DATA

  • BMP, CBC, fingerstick glucose

  • Orthostatic VS ×3 (SBP drop ≥20 or DBP ≥10 = positive)

  • ECG (arrhythmia, QTc, heart block)

  • CT head without contrast if head strike, anticoagulation, AMS, or focal deficit

  • C-spine imaging if neck pain or midline tenderness

  • Hip/pelvis XR (occult fracture); CXR if aspiration suspected

  • UA + culture (UTI as acute trigger); TSH if not recent

  • TUG test, Romberg; Beers Criteria medication reconciliation

HOME MEDS

  • Benzodiazepines/sedative-hypnotics — hold/taper (Beers)

  • Anticholinergics — discontinue if possible

  • Antihypertensives — hold if orthostatic; reassess BP goals in elderly (SBP 130–150 in frail)

  • Insulin/sulfonylureas — hold if hypoglycemia contributed

  • Diuretics — hold if volume depleted or orthostatic

PLAN

  • Identify and treat acute medical trigger

  • Fall precautions: bed alarm, call light in reach, non-skid footwear, low bed

  • Orthostatic hypotension:

    • Increase fluids/salt if no HF/HTN; compression stockings; abdominal binder

    • Hold/reduce offending antihypertensives

    • Fludrocortisone 0.1 mg PO daily or midodrine 2.5–10 mg PO TID (hold at bedtime)

  • Polypharmacy review: deprescribe Beers Criteria medications

  • Vitamin D 800–1000 IU PO daily (AGS/USPSTF — reduces fall risk)

  • Calcium 1200 mg/day total if osteoporosis risk

  • PT/OT: gait training, balance, assistive device fitting, home safety assessment

  • Social work: safe discharge disposition, home services, rehab placement

  • DISCHARGE:

    • Outpatient fall prevention program (STEADI initiative, CDC)

    • Deprescribing plan documented; PCP follow-up 1–2 weeks

    • DEXA if not recent; bisphosphonate if osteoporosis (alendronate 70 mg PO weekly)

RED FLAGS

  • Head strike + anticoagulation → CT head regardless of GCS; observe ≥24h

  • Focal neurologic deficit → emergent stroke workup

  • Cervical midline tenderness or paresthesias → C-spine precautions, urgent imaging

  • Hip pain + unable to bear weight → occult femur fracture; ortho consult

  • New LOC → full syncope workup; cardiac monitoring

  • Multiple recurrent falls → consider elder abuse/neglect; mandatory reporting if suspected

SENIOR IM RESIDENT PEARLS

  • Single best predictor of future fall: prior fall in past 12 months — always ask

  • TUG test: ≥12s = high fall risk; ≥20s = needs assistive device

  • Beers Criteria 2023 (AGS): highest-risk — sedative-hypnotics, TCAs, antipsychotics, benzodiazepines, anticholinergics, alpha-1 blockers

  • Orthostatic hypotension: measure at 1 AND 3 minutes after standing

  • Common mistake: treating the fall without identifying the underlying medical trigger

  • Common mistake: restarting all home antihypertensives at discharge without reassessing BP goals

  • STEADI algorithm (CDC): Screen → Assess → Intervene — standard of care