Human Development

Geriatric falls: assessment and prevention

Clinical Overview and When to Suspect Geriatric Falls

— ~1 in 4 community-dwelling adults ≥65 falls each year; ~50% of those ≥80

— Falls are the leading cause of injury death and TBI in adults ≥65 in the US

— 20–30% of falls cause moderate-to-severe injury (hip fracture, subdural hematoma, lacerations)

— Hip fracture 1-year mortality approaches 20–30%

— USPSTF/AGS recommendation: Ask all adults ≥65 annually about (1) any fall in the past year, (2) difficulty with walking or balance, (3) fear of falling

— Any "yes" triggers a multifactorial fall risk assessment

— New fall, recurrent falls (≥2/yr), or any fall with injury → mandatory full assessment

— Polypharmacy (≥4 meds, especially psychotropics, antihypertensives, opioids, anticholinergics)

— Recent hospitalization, delirium, or new device (catheter, IV pole)

— Parkinson disease, stroke, peripheral neuropathy, dementia, depression

— Vision impairment (cataracts, macular degeneration), hearing loss

— Orthostatic hypotension, vitamin D deficiency, sarcopenia, frailty

— Home hazards: rugs, poor lighting, stairs without rails, no bathroom grab bars

— Falls embody the outpatient longitudinal model: screen → assess → intervene across visits

— Heavy overlap with deprescribing, Medicare Annual Wellness Visit, and home-safety referrals

— CCS scenarios test recognizing a "mechanical fall" that is actually syncope, medication side effect, or occult infection

Board pearl: A single fall without injury still counts as a screening trigger if the patient reports gait/balance problems or fear of falling — do not dismiss it as "mechanical."

Definition: An unintentional event in which a person comes to rest on the ground, floor, or lower level, not due to an overwhelming external force (e.g., MVC), seizure, or syncope from a primary cardiac arrhythmia (those are classified separately but still trigger fall workup).

Epidemiology:

When to suspect or actively screen:

High-risk clinical contexts:

Why Step 3 cares:

Presentation Patterns and Key History

— Symptoms before the fall (lightheadedness, palpitations, aura, chest pain, dyspnea, vertigo)

— Previous falls (number, frequency, trajectory)

— Location (bathroom at night = nocturia/orthostasis; stairs = vision/proprioception)

— Activity at time (standing up = orthostatic; turning head = vertebrobasilar/BPPV; reaching = balance)

— Time of day (early AM = orthostatic from overnight diuresis or antihypertensives)

— Trauma sustained and post-fall ability to get up

— Syncopal (LOC, no recall, witnessed slump) → cardiac/neurologic workup

— Pre-syncopal (lightheaded but no LOC) → orthostatic, dehydration, meds

— Mechanical/extrinsic (tripped on rug, ice, poor lighting) → environmental focus

— Gait/balance intrinsic (legs "gave out," shuffling, freezing) → neurodegenerative, myelopathy, B12, NPH

— Benzodiazepines, Z-drugs (zolpidem), opioids, TCAs, antipsychotics, anticholinergics

— Antihypertensives (especially α-blockers, loop diuretics), insulin/sulfonylureas (hypoglycemia)

— SSRIs (yes — independently increase fall and fracture risk in elderly)

— ADLs/IADLs, assistive device use (and whether used correctly)

— Alcohol use, footwear, vision/hearing aids, home layout, stairs, caregiver availability

— Fear of falling → activity restriction → deconditioning → more falls (vicious cycle)

— LOC, incontinence, tongue bite (seizure vs. syncope)

— Headache, focal weakness, new confusion (stroke, SDH)

— Fever, dysuria, cough (occult infection presenting as fall)

Step 3 management: In an elderly patient presenting with "a fall," first ask whether they remember hitting the ground — amnesia for the event reframes this as syncope until proven otherwise and changes the entire workup.

Core history framework — the "SPLATT" mnemonic:

Distinguish fall mechanism categories:

Medication review is mandatory (FRIDs = Fall-Risk-Increasing Drugs):

Functional and social history:

Red-flag features suggesting non-mechanical cause:

Physical Exam Findings and Hemodynamic Assessment

— Orthostatic vitals: supine, then standing at 1 and 3 minutes

– Positive: SBP drop ≥20, DBP drop ≥10, or symptoms with HR rise <15 (suggests autonomic failure if blunted HR response)

— Irregular pulse → check for AF (a common syncope-fall driver)

— Resting tachycardia → volume depletion, anemia, sepsis

— Hypoxia → cardiopulmonary cause

— Murmurs (AS classically causes exertional syncope/fall), carotid bruits

— Carotid sinus massage only in monitored setting if carotid hypersensitivity suspected

— Cranial nerves, visual acuity and fields

— Cerebellar: finger-nose, heel-shin, tandem gait

— Lower-extremity strength, proprioception (often impaired from B12, neuropathy)

— Romberg (sensory ataxia); pull test (Parkinson postural instability)

— Cogwheel rigidity, bradykinesia, festinating gait → PD

— Magnetic/apraxic gait + urinary incontinence + cognitive decline → NPH

— Joint exam (knee/hip OA limits proprioception and strength)

— Foot exam: bunions, calluses, ulcers, ill-fitting shoes

— Timed Up and Go (TUG): rise from chair, walk 3 m, turn, return, sit. ≥12 seconds = increased fall risk

— 30-second chair stand: lower-extremity strength

— 4-stage balance test: parallel → semi-tandem → tandem → single-leg

— Gait speed <0.8 m/s: marker of frailty and fall risk

— Mini-Cog or MoCA (dementia roughly doubles fall risk)

— PHQ-9 (depression and its treatment both contribute)

Board pearl: A TUG ≥12 seconds plus any positive screening question is the practical threshold to launch a multifactorial intervention — memorize this cutoff; it shows up verbatim on stems.

Vitals — do these first, always:

Cardiovascular:

Neurologic — high yield:

Musculoskeletal:

Validated bedside tests:

Cognitive and mood:

Vision/hearing: Snellen chart, whisper test or otoscopy for cerumen impaction

Diagnostic Workup — Initial Labs, Imaging, ECG

— CBC (anemia → presyncope, occult GI bleed)

— BMP (hyponatremia from thiazides/SSRIs is a top reversible cause; AKI, hypoglycemia)

— Glucose / HbA1c if diabetic — tight control with insulin/sulfonylureas increases falls

— TSH (both hyper- and hypothyroidism affect gait and cognition)

— B12 (subacute combined degeneration → proprioceptive loss)

— 25-OH vitamin D if deficiency suspected; supplement if <30 ng/mL in fallers

— UA — occult UTI is a classic geriatric fall trigger (though treat only if symptomatic; asymptomatic bacteriuria is not an indication for antibiotics)

— AF, bradyarrhythmia, AV block, prolonged QT (drug-induced), ischemia, LVH (suggests AS)

— Any LOC, new neurologic deficit, severe headache, persistent vomiting

— Anticoagulation or antiplatelet therapy (including DOACs) — low threshold; many institutions mandate CT and observation

— Visible head trauma above clavicles, age >65 with any mechanism uncertainty

— Suspected skull fracture, GCS <15 at 2 hours

— X-ray of injured extremity; hip and pelvis imaging if cannot bear weight or has groin/hip pain (occult femoral neck fracture — MRI if X-ray negative but clinical suspicion remains)

— C-spine imaging per NEXUS/Canadian C-spine if neck pain, distracting injury, or neurologic findings

Step 3 management: An anticoagulated elderly patient who falls and hits the head needs a non-contrast head CT even if asymptomatic, and many guidelines support a delayed CT or extended observation for occult subdural hematoma.

There is no single "fall lab panel" — testing is targeted by history and exam. But a reasonable initial set for the older adult with a new or recurrent fall:

ECG — obtain in essentially every elderly faller with LOC, presyncope, or unexplained mechanism:

Imaging — head CT indications after a fall:

Other imaging:

DEXA scan: Indicated in all women ≥65, men ≥70, and any older adult after a fragility fracture to guide osteoporosis treatment

Diagnostic Workup — Advanced or Confirmatory Studies

— Ambulatory cardiac monitoring:

– 24–48 hr Holter for frequent symptoms

– 14–30 day event monitor for less frequent

– Implantable loop recorder for unexplained recurrent syncope/falls with suspected arrhythmia — high yield in elderly

— Echocardiogram: Suspected structural disease (AS, HCM, severe LV dysfunction)

— Tilt-table testing: Reserved for recurrent unexplained syncope when neurally mediated/orthostatic etiology is unclear after office orthostatics

— Carotid sinus massage in monitored setting if carotid hypersensitivity suspected (pauses >3 sec or BP drop >50)

— MRI brain when stroke, NPH (ventriculomegaly out of proportion to atrophy), tumor, or chronic SDH suspected

— EEG only if seizure suspected (witnessed convulsion, postictal confusion, tongue bite)

— Nerve conduction studies for peripheral neuropathy contributing to gait instability

— Dix-Hallpike for BPPV — positive triggers Epley maneuver (high-yield curative intervention)

— ENT/audiology referral for persistent vertigo, hearing loss

— Comprehensive optometry/ophthalmology exam — cataract extraction has been shown to reduce fall rates

— Avoid bifocals/multifocals outdoors and on stairs

— Comprehensive Geriatric Assessment (CGA) — gold standard for recurrent fallers

— Includes PT/OT home safety eval, pharmacy review (Beers criteria), social work

— After fragility fracture: DEXA, calcium, vitamin D, evaluate secondary causes (PTH, SPEP, TSH, 24-hr urinary calcium)

Key distinction: Syncope (transient global hypoperfusion, prompt full recovery) vs. seizure (postictal state, lateral tongue bite, incontinence, head version) — both can present as "a fall," and Step 3 stems reward identifying which workup pathway to launch.

When initial workup is unrevealing but falls recur or syncope is suspected:

Neurologic studies:

Vestibular evaluation:

Vision:

Multidisciplinary geriatric assessment:

Bone health follow-through:

Risk Stratification and Multifactorial Intervention Logic

— Low risk (no fall in past year, no gait/balance complaint, negative screen): annual screening, general exercise counseling

— Intermediate risk (one fall without injury, mild gait issue, positive screen but no injury): exercise intervention (especially balance/strength), vitamin D if deficient, medication review

— High risk (≥2 falls, fall with injury, gait/balance abnormality, fear of falling limiting activity): full multifactorial assessment and intervention

— Exercise: Tai chi, Otago program, group balance/strength training — single most effective intervention; reduces falls ~25%

— Medication review and deprescribing: Target FRIDs, follow Beers and STOPP criteria

— Vision optimization: Cataract surgery, single-vision lenses outdoors

— Home safety: OT home assessment — remove throw rugs, add grab bars, improve lighting, stair rails, non-slip bath mats

— Footwear: Low-heel, thin hard sole, non-slip; avoid walking in socks/slippers indoors

— Vitamin D 800 IU/day if deficient (current USPSTF: insufficient evidence to recommend universal supplementation in community-dwelling adults without deficiency to prevent falls — nuance)

— Postural hypotension management: Liberalize salt/fluids if not CHF, compression stockings, fludrocortisone or midodrine if needed

— Cardiovascular: Pacemaker for documented bradyarrhythmic syncope, AS valve replacement, AF rate/rhythm control

— Treat osteoporosis: Bisphosphonates after fragility fracture or T-score ≤-2.5

— Hospitalized patients: Bed alarms, scheduled toileting, minimize tethers, avoid restraints (increase falls and injury)

— Long-term care: Multifactorial + staff education + hip protectors in selected patients

Board pearl: The 2024 USPSTF update recommends exercise interventions for community-dwelling adults ≥65 at increased fall risk (Grade B) and selectively offering multifactorial interventions (Grade C) — exercise is the universal answer.

The AGS/BGS fall guideline and USPSTF frame care in three tiers:

Components of the multifactorial intervention (each independently evidence-based):

Setting matters:

Pharmacotherapy — Deprescribing and Targeted Medications

— Benzodiazepines and Z-drugs (zolpidem, eszopiclone): OR for falls ~1.5–2; taper slowly (10–25%/1–2 weeks), substitute non-pharm sleep hygiene/CBT-I

— First-generation antihistamines (diphenhydramine) and other anticholinergics (oxybutynin) — also worsen cognition

— TCAs (amitriptyline) → switch to SSRI/SNRI if needed for neuropathic pain (duloxetine, gabapentin with renal dosing)

— Antipsychotics: Especially in dementia — black box warning, increased mortality and falls; reserve for severe agitation, lowest dose

— Muscle relaxants (cyclobenzaprine, methocarbamol) — anticholinergic load

— Opioids: Use lowest effective dose, avoid combining with benzos

— Antihypertensives causing orthostasis: α-blockers (doxazosin), high-dose loop diuretics — reassess BP targets (SPRINT supports <130 in fit elderly, but individualize)

— Sulfonylureas/insulin with HbA1c <7 in frail elderly — liberalize target to 7.5–8%

— Vitamin D 800 IU/day in deficient patients (25-OH D <20–30)

— Calcium 1000–1200 mg/day from diet preferred; supplement if needed

— Bisphosphonates (alendronate, zoledronate) after fragility fracture or T ≤-2.5 — reduce hip fracture ~40%

— Denosumab if renal impairment precludes bisphosphonates (watch for rebound vertebral fractures if discontinued)

— Romosozumab for very high fracture risk (avoid in recent MI/stroke)

— Midodrine or fludrocortisone for symptomatic orthostatic hypotension refractory to non-pharm measures

— Droxidopa for neurogenic OH (Parkinson, MSA)

— Pyridostigmine as adjunct for neurogenic OH

Step 3 management: Whenever a stem lists a fall risk medication and a fall, the highest-yield action is deprescribe or substitute that medication before adding anything new — even before ordering imaging in stable patients.

Step 3 reality: The most important "drug intervention" for falls is stopping drugs, not starting them.

High-priority deprescribing targets (Beers/STOPP criteria):

Targeted pharmacotherapy that helps:

Procedures and Device-Based Interventions

— Permanent pacemaker: Documented symptomatic bradycardia, high-grade AV block, sick sinus syndrome with pauses, carotid sinus hypersensitivity with cardioinhibitory response causing recurrent syncopal falls

— AS: Severe symptomatic aortic stenosis with syncope → SAVR or TAVR (TAVR preferred in elderly/high-surgical-risk)

— AF: Rate/rhythm control; consider LAA occlusion (Watchman) if anticoagulation contraindicated due to fall-related bleeding risk — but note guidelines still favor anticoagulation in most fallers since stroke risk outweighs ICH risk

— Chronic subdural hematoma evacuation — fall in anticoagulated elder is the classic stem

— VP shunt for NPH (Hakim triad: gait, urinary, cognitive)

— Hip fracture: surgical fixation or arthroplasty within 24–48 hours reduces mortality

— Vertebral compression fracture: conservative initially; kyphoplasty if persistent disabling pain

— Epley/canalith repositioning for BPPV — quick, in-office, highly effective

— Vestibular rehabilitation therapy

— Cataract extraction: first-eye surgery reduces falls ~30%

— Cane: opposite hand of weak side, handle at wrist crease height

— Walker: standard, front-wheeled, or rollator depending on gait/cognition

— Hip protectors: modest benefit in long-term care

— Grab bars in shower/toilet, raised toilet seats, shower chairs

— Stair handrails on both sides, improved lighting, night-lights

— Remove throw rugs, secure carpet edges, reorganize for one-floor living

CCS pearl: In a CCS hip-fracture case, your sequence is: stabilize → analgesia (acetaminophen + low-dose opioid, avoid NSAIDs in elderly) → ortho consult → surgery within 48 hrs → DVT prophylaxis → PT day 1 post-op → DEXA and bisphosphonate before discharge.

Cardiac procedural interventions for fall/syncope:

Neurosurgical:

Orthopedic:

Vestibular:

Ophthalmologic:

Assistive devices (must be properly fitted by PT/OT):

Home modifications (OT prescribed):

Special Populations — Frail Elderly and Renal/Hepatic Impairment

— Frailty phenotype (Fried): weight loss, exhaustion, weak grip, slow gait, low activity (≥3 = frail)

— Clinical Frailty Scale 1–9; ≥5 indicates increased fall, hospitalization, mortality risk

— Frail patients benefit from comprehensive geriatric assessment more than any single intervention

— Standard guideline target <130/80, but individualize

— In frail patients with orthostasis, history of falls, life expectancy <2 years, or dementia: liberalize to <150/90 to prevent falls and AKI

— Always check standing BP before titrating antihypertensives

— HbA1c target 7.5–8.0% (up to 8.5% in very frail or limited life expectancy)

— Avoid sulfonylureas (glyburide especially) and prandial insulin regimens — hypoglycemia drives falls

— Preferred: metformin (if eGFR ≥30), DPP-4 inhibitors, or low-dose basal insulin

— Gabapentin/pregabalin accumulate → sedation and falls; dose by eGFR

— Renally cleared opioids (morphine, codeine) → toxic metabolites → falls/delirium; use hydromorphone or low-dose oxycodone

— Bisphosphonates contraindicated if eGFR <30–35 → switch to denosumab

— DOACs require renal-dose adjustment; apixaban most forgiving in CKD

— NSAIDs: avoid — AKI, hyperkalemia, GI bleed, hypertension

— Avoid lorazepam/oxazepam accumulation; even "safer" benzos remain problematic for falls

— Acetaminophen max 2 g/day in significant liver disease

— ≥5 medications independently increases fall risk; ≥10 (hyperpolypharmacy) markedly so

— Use Beers, STOPP/START at every visit and at transitions of care

Board pearl: In a frail 88-year-old with recurrent falls and SBP 138, the right answer is often to reduce antihypertensives, not intensify — Step 3 rewards recognizing that "tight" control harms this population.

The "oldest old" (≥85) and frail patients:

BP targets in frail elderly:

Diabetes in frail elderly:

Renal impairment considerations:

Hepatic impairment:

Polypharmacy threshold:

Special Populations — Cognitive Impairment, Parkinson Disease, Post-Stroke

— Dementia roughly doubles fall risk; Lewy body dementia particularly high due to autonomic dysfunction and parkinsonism

— Avoid antipsychotics for behavioral symptoms when possible (black box; falls, stroke, mortality)

— If unavoidable, quetiapine or pimavanserin (latter for PD psychosis) preferred over haloperidol/risperidone in PD/LBD

— Cholinesterase inhibitors (donepezil) can cause syncope/bradycardia — check ECG, review for sick sinus

— Postural instability is a cardinal feature emerging in mid-late disease (pull test positive)

— Orthostatic hypotension from disease + dopaminergic meds — manage with hydration, compression, midodrine, droxidopa

— Freezing of gait → cueing strategies (visual lines, metronome), levodopa optimization

— Avoid dopamine antagonists (metoclopramide, prochlorperazine) — worsen parkinsonism and falls

— Hemiparesis, neglect, visual field cuts all increase falls

— Aggressive PT/OT, AFO bracing, properly fitted cane on unaffected side

— Spasticity management (baclofen, botulinum toxin) can improve gait but watch for sedation

— Diabetic, alcoholic, B12, chemo-induced — proprioceptive loss

— Treat B12 if deficient; optimize glycemic control without hypoglycemia

— Balance training, well-lit environment, avoid walking barefoot

— Macular degeneration, glaucoma, diabetic retinopathy — annual ophthalmologic eval

— Cataract surgery reduces falls; address one eye at a time

— Avoid multifocal lenses on stairs and outdoors

— Independently associated with falls — hearing aid use reduces risk

— Treat cerumen impaction

— Shift goals: comfort and dignity over fall prevention; avoid restraints; pad floor; low bed

Step 3 management: In a PD patient with recurrent orthostatic falls, first-line is non-pharm (slow position changes, compression, salt/fluid liberalization, head-of-bed elevation) before adding midodrine or fludrocortisone.

Dementia and falls:

Parkinson disease:

Post-stroke patients:

Peripheral neuropathy:

Visual impairment:

Hearing loss:

End-of-life / hospice:

Complications and Adverse Outcomes

— Hip fracture — most feared; ~250,000/yr in US; 1-yr mortality 20–30%; <50% return to prior functional level

— Vertebral compression fractures — often subtle, progressive kyphosis, pulmonary restriction

— Distal radius (Colles), proximal humerus, pelvic fractures

— Traumatic brain injury — subdural hematoma especially in anticoagulated patients; presents days to weeks later with headache, confusion, focal deficit

— Cervical spine injury — central cord syndrome from hyperextension over osteophytes (upper > lower extremity weakness)

— Soft tissue: lacerations, hematomas, pressure injuries if long lie

— Rhabdomyolysis → AKI, hyperkalemia

— Hypothermia, dehydration

— Pressure ulcers, compartment syndrome

— Aspiration pneumonia

— Pneumonia, DVT/PE from immobility

— Marker of social isolation and need for life-alert/emergency response system

— Post-fall syndrome / ptophobia: fear of falling → activity restriction → deconditioning → sarcopenia → more falls (the vicious cycle)

— Depression, social isolation

— Loss of independence, nursing home placement (often the first fall with injury triggers this)

— Restraint use → paradoxically increases injurious falls and causes delirium, pressure injury, strangulation

— Foley catheters → CAUTI, tethering increases fall risk on ambulation

— Sedating analgesics post-fracture → delirium, more falls

— Anticoagulation reversal in head trauma — balance ICH risk vs. thromboembolism

— Pneumonia and PE post-hip fracture

— Delayed recognition of intracranial hemorrhage

— Functional decline → cachexia → death within 1 year

Board pearl: A patient found on the floor with elevated CK, AKI, and hyperkalemia after an unwitnessed fall has rhabdomyolysis from a long lie — treat with aggressive IV fluids targeting urine output 200–300 mL/hr and search for the cause of the fall (often syncope or stroke).

Acute injuries:

Long lie consequences (>1 hour on floor):

Functional and psychological sequelae:

Iatrogenic complications during workup/management:

Mortality drivers:

When to Escalate Care — ED, Inpatient, ICU, Consults

— Any LOC, head injury on anticoagulation, new focal neurologic deficit

— Suspected fracture (especially hip, spine, pelvis)

— Inability to ambulate or care for self at home after the fall

— Long lie (>1 hour) — rule out rhabdo, AKI, hypothermia, aspiration

— Vital sign instability, suspected sepsis, new arrhythmia

— Severe injury or uncontrolled bleeding

— Concern for elder abuse/neglect (see chunk 17)

— Significant TBI with GCS decline, large/expanding ICH

— Hemodynamic instability from occult internal injury (splenic, retroperitoneal hematoma especially on anticoagulants)

— Severe rhabdomyolysis requiring aggressive resuscitation or RRT

— High-grade AV block or sustained arrhythmia requiring monitoring or pacing

— Orthopedics: Any fracture; hip fracture → surgery within 24–48 hrs

— Neurosurgery: ICH, especially SDH on anticoagulants — reversal protocols (4-factor PCC for warfarin, andexanet/PCC for factor Xa inhibitors, idarucizumab for dabigatran)

— Cardiology: Syncope of suspected cardiac origin, need for monitoring/EP study/pacemaker

— Neurology: Suspected seizure, stroke, NPH

— Geriatrics: Recurrent fallers benefit from CGA

— PT/OT: Inpatient and outpatient; home safety evaluation

— Pharmacy: Polypharmacy/Beers review

— Social work: Discharge planning, abuse evaluation, home support

— Home with services (home health PT/OT, visiting nurse, life-alert device)

— Subacute rehab / SNF for functional rehab post-fracture

— Assisted living vs. nursing home if recurrent unsafe discharges

— Medication reconciliation at every transition (admission, discharge)

— Schedule follow-up within 7–14 days of discharge

— Communicate explicit fall-prevention plan to PCP and caregiver

CCS pearl: For an anticoagulated elder with even minor head trauma, the order set is non-contrast head CT → reverse anticoagulation if ICH → neurosurgery consult → admit for observation — do not discharge home the same day even if initial CT is negative; delayed bleeds occur.

Send to ED / consider admission:

ICU triage:

Specialist consults to deploy:

Disposition decisions:

Transitions of care — high-risk window:

Key Differentials — Causes Within the "Fall" Category

— Orthostatic hypotension: Volume depletion, autonomic failure (PD, diabetes, amyloid), medications (α-blockers, diuretics, vasodilators)

— Vasovagal/neurally mediated: Pain, micturition, defecation, cough syncope

— Cardiac arrhythmia: AF with RVR or pauses, sick sinus, AV block, VT (especially with structural heart disease), long QT

— Structural cardiac: Aortic stenosis (exertional syncope), HCM, severe PH, PE

— Carotid sinus hypersensitivity

— Stroke/TIA: Especially posterior circulation (vertebrobasilar) — vertigo, diplopia, dysarthria, ataxia

— Seizure: Postictal confusion, tongue bite, incontinence

— Parkinson disease: Postural instability, freezing of gait, festination

— Normal pressure hydrocephalus: Magnetic gait + incontinence + cognitive decline

— Cerebellar disease: Wide-based ataxic gait

— Peripheral neuropathy: Loss of proprioception, sensory ataxia

— Vestibular: BPPV (positional), Meniere, vestibular neuritis

— Cervical myelopathy: Hyperreflexia, spasticity, Lhermitte sign

— Severe knee/hip OA — buckling, weakness

— Vertebral compression fractures altering balance

— Sarcopenia, deconditioning

— Hypoglycemia (sulfonylurea, insulin)

— Hyponatremia (thiazides, SSRIs, SIADH)

— Polypharmacy with sedating agents

— Throw rugs, poor lighting, ice, uneven surfaces, pets

— Ill-fitting footwear, missing assistive device

— Bifocals on stairs

Key distinction: Orthostatic hypotension drops BP on standing with symptoms in seconds; postprandial hypotension drops BP 30–60 min after meals (common in elderly); vasovagal has prodrome of nausea/diaphoresis/warmth — all three can present as "a fall," and each has a different intervention.

Syncopal/presyncopal causes (transient global cerebral hypoperfusion):

Neurologic causes:

Musculoskeletal:

Metabolic/medication:

Environmental/mechanical:

Key Differentials — Other-Category Causes Masquerading as Falls

— UTI — classic geriatric stem: "found on floor, mildly confused, low-grade fever" — but treat only if symptomatic; asymptomatic bacteriuria does not warrant antibiotics

— Pneumonia — may present without fever or cough; tachypnea, hypoxia, delirium

— Sepsis — hypotension → fall; SIRS often blunted in elderly

— C. difficile with dehydration

— Silent MI — elderly may present with weakness, dyspnea, syncope rather than chest pain

— Pulmonary embolism — syncope is a presentation; check Wells score, d-dimer

— Acute CHF exacerbation with hypoxia

— Anemia from occult GI bleed (NSAIDs, anticoagulants, malignancy)

— Hypoglycemia, hyperglycemia with dehydration (HHS)

— Adrenal insufficiency (especially after steroid taper)

— Hyper/hypothyroidism

— Hypercalcemia (malignancy, hyperparathyroidism) → confusion, weakness

— Chronic subdural hematoma from a prior unremembered fall — presents with confusion, gait change, headache, hemiparesis

— Brain tumor, abscess

— Wernicke encephalopathy in malnourished/alcoholic elderly (ataxia, ophthalmoplegia, confusion)

— Alcohol use — often underrecognized in elderly; screen with AUDIT-C

— Prescription drug toxicity (digoxin, lithium, phenytoin levels rise with declining renal function)

— CO poisoning in winter

— Depression → psychomotor slowing, poor self-care, falls

— Anxiety → hyperventilation syncope

— Unexplained injuries, pattern inconsistent with history, caregiver answering for patient

— Mandatory reporting in most US states

Board pearl: A vague "found down" or "weakness" presentation in an elderly patient should prompt the trio of ECG + glucose + UA/CBC plus a careful neuro exam — falls in elders are the chief complaint of last resort for many serious diseases.

Infection presenting atypically:

Cardiopulmonary masqueraders:

Endocrine/metabolic:

Neurologic mimics:

Toxicologic:

Psychiatric:

Elder abuse/neglect:

Secondary Prevention and Long-Term Plan

— Medication reconciliation and deprescribing at every visit and transition

— Exercise prescription: Tai chi, Otago, group balance/strength — ≥3×/week, ongoing indefinitely

— Home safety modifications via OT home visit (grab bars, lighting, remove rugs, raised toilet, shower chair)

— Vision: Annual ophthalmology exam; cataract surgery; single-vision distance glasses outdoors

— Hearing: Audiology referral, hearing aids

— Footwear: Low-heel, thin firm sole, non-slip; avoid slippers and socks indoors

— Vitamin D 800 IU/day if deficient; calcium 1000–1200 mg/day (diet preferred)

— Postural BP management: Slow position changes, hydration, compression stockings, head-of-bed elevation, midodrine/fludrocortisone if needed

— Cardiac: Pacemaker for documented bradyarrhythmia, AS intervention, AF management

— Any fragility fracture (hip, vertebral) in an older adult = osteoporosis diagnosis regardless of T-score → start bisphosphonate

— Alendronate 70 mg weekly (PO) or zoledronic acid 5 mg IV yearly

— Adequate vitamin D and calcium before initiation

— Reassess at 3–5 years for drug holiday eligibility

— Denosumab if renal impairment; do not abruptly discontinue (rebound vertebral fractures)

— Falls alone do not outweigh stroke prevention benefit in AF; one analysis estimated a patient would need to fall ~295×/year to offset benefit

— Apixaban often preferred (lowest bleeding profile)

— Consider LAA occlusion only if truly high bleeding risk

— Especially for those living alone; reduces long-lie consequences

— Teach safe transfers, recognize warning signs, when to call

Step 3 management: A 78-year-old woman with a wrist fracture from a ground-level fall meets criteria for osteoporosis treatment without needing a DEXA — start alendronate plus calcium/vitamin D and arrange DEXA for monitoring.

After any fall, build a written, individualized fall-prevention plan with these components:

Osteoporosis treatment (fragility fracture changes the game):

Anticoagulation decisions in fallers:

Personal emergency response system (life-alert):

Caregiver education and support:

Follow-Up, Monitoring, and Rehab/Counseling

— Post-fall (no injury): see in clinic within 1–2 weeks to complete multifactorial assessment

— Post-hospitalization for fall: PCP follow-up within 7 days (transitions-of-care visit)

— Post-hip fracture: PCP within 1–2 weeks, ortho per protocol, geriatrics or fracture liaison service

— Stable elder with prior falls: review fall plan at every visit; formal reassessment at Medicare Annual Wellness Visit

— Standing BP at every visit when on antihypertensives or with prior orthostasis

— Medication list at every visit — flag new FRIDs

— Functional measures: TUG, gait speed, grip strength annually

— Cognitive screen (Mini-Cog) annually

— Mood screen (PHQ-2/9) annually

— Vision and hearing annually

— Weight (sarcopenia, malnutrition)

— Vitamin D level if previously deficient; recheck in 3 months after supplementation

— DEXA every 2 years on therapy until stable

— Post-fracture: inpatient rehab vs. SNF vs. home health PT/OT based on function

— Goal: return to prior baseline; weight-bearing as tolerated typically within 24 hrs post-op for hip fracture

— Continued community exercise program after formal PT ends — critical to prevent decline

— Fall as a "sentinel event" — reframe with patient and family; one fall doubles risk of another

— Address fear of falling directly — CBT, gradual exposure, ongoing balance training reduce ptophobia

— Discuss advance directives, goals of care — falls often herald functional decline trajectory

— Caregiver burden assessment and respite resources

— Medicare covers Annual Wellness Visit with fall screening, home health PT, DME (walkers, grab bars often partially)

— Fracture Liaison Services improve secondary fracture prevention by 30–40%

— Use EHR fall risk flags but pair with intervention, not just labeling

Board pearl: The Medicare Annual Wellness Visit is the Step 3-favored vehicle for fall screening, cognitive screening, advance care planning, and medication review — recognize this visit type in stems and deploy these elements.

Follow-up cadence:

Monitoring parameters:

Rehabilitation:

Counseling content:

Health system tools:

Ethical, Legal, and Patient Safety Considerations

— Physical and chemical restraints increase injurious falls, delirium, pressure injury, and mortality

— Use only as last resort, time-limited, with documented attempts at alternatives (sitter, environmental, family presence, scheduled toileting, delirium prevention)

— Requires order, monitoring, regular reassessment; CMS regulates strictly

— Capacity is decision-specific — a patient may lack capacity for complex finances but retain capacity to refuse a feeding tube

— Patient with mild dementia may still refuse antipsychotics, nursing home placement, or surgery if they understand risks/benefits

— When capacity is lacking → engage healthcare proxy / surrogate per state hierarchy

— "Against medical advice" discharge after a fall requires documented capacity assessment

— Suspicious patterns: injuries inconsistent with history, multiple stages of bruising, malnutrition, pressure ulcers in well-resourced setting, caregiver dominating interview, financial exploitation signs

— Most US states require physicians to report suspected elder abuse to Adult Protective Services — reasonable suspicion suffices; you do not need proof

— Document objectively; preserve evidence; ensure patient safety before discharge

— Falls, dementia, syncope, polypharmacy all impact fitness to drive

— Some states (e.g., California) require physician reporting of conditions affecting driving; others encourage voluntary reporting

— Counsel and document; refer to driving rehabilitation specialist when uncertain

— Hospital discharge is the highest-risk window for falls and adverse drug events

— Mandatory: medication reconciliation, written instructions, scheduled follow-up within 7–14 days, caregiver involvement, DME in place before discharge

— Inpatient falls are "never events" with reporting and root-cause-analysis obligations

— Bed alarms, hourly rounding, scheduled toileting, low beds, non-slip footwear

— Recurrent falls in advanced illness should prompt palliative/hospice discussion — comfort over prevention

Step 3 management: When a hospitalized elder with mild dementia tries to leave AMA after a fall workup, the answer is assess decision-making capacity for this specific decision — if intact, they may leave; if impaired, engage the surrogate and document.

Restraints — both ethically and clinically problematic:

Informed consent and decision-making capacity:

Mandatory reporting — elder abuse and neglect:

Driving safety:

Transition-of-care safety:

Patient safety culture:

Goals of care:

High-Yield Associations and Rapid-Fire Clinical Facts

— 1 in 4 adults ≥65 falls yearly; ~50% ≥80

— Falls = #1 cause of injury death in adults ≥65

— Hip fracture 1-year mortality 20–30%

— TUG ≥12 sec = increased fall risk

— Orthostatic hypotension: SBP drop ≥20 or DBP drop ≥10 at 1 or 3 min standing

— Gait speed <0.8 m/s = frailty marker

— Vitamin D supplementation 800 IU/day in deficient older adults

— Exercise interventions reduce falls ~25%; cataract surgery ~30%

— Benzos, Z-drugs, opioids, TCAs, antipsychotics, anticholinergics, antihistamines, muscle relaxants, α-blockers, loop diuretics, SSRIs, sulfonylureas

— Magnetic gait + urinary incontinence + cognitive decline → NPH (Hakim triad) → MRI → consider VP shunt

— Vertigo with positional change, Dix-Hallpike positive → BPPV → Epley

— Exertional syncope + systolic murmur radiating to carotids → aortic stenosis → echo → TAVR/SAVR

— Elderly faller on warfarin with headache days later → chronic subdural hematoma → non-contrast CT

— Found on floor + AKI + CK >5,000 → rhabdomyolysis from long lie → aggressive IVF

— Confusion + ataxia + ophthalmoplegia in malnourished elder → Wernicke → IV thiamine BEFORE glucose

— Postprandial fall 30–60 min after eating → postprandial hypotension → smaller meals, sit after eating

Board pearl: Any time a stem features an older adult on anticoagulation + fall + headache or confusion, the next step is non-contrast head CT — this is one of the most testable single-best-answer patterns in geriatric Step 3 questions.

The numbers to know:

Drug-fall associations (memorize this list):

Classic syndrome pearls:

Beers criteria highlights: Avoid benzos, first-gen antihistamines (diphenhydramine), TCAs, glyburide, NSAIDs chronically, antipsychotics in dementia, anticholinergics

USPSTF 2024: Exercise interventions Grade B for community-dwelling ≥65 at increased fall risk; multifactorial interventions Grade C (selectively offer)

AGS/BGS: Annually screen all ≥65 with the three questions

Board Question Stem Patterns

— 82-yo found on floor; says she "just tripped" but cannot recall hitting the ground

— Trap: ordering only X-rays. Right answer: workup as syncope (ECG, orthostatics, glucose, neuro exam)

— 78-yo on warfarin/apixaban hits head, GCS 15, asymptomatic

— Answer: non-contrast head CT and observation, even if exam normal

— 80-yo on diphenhydramine for sleep, alprazolam PRN, oxybutynin, and amitriptyline presents with recurrent falls

— Answer: deprescribe sedating/anticholinergic meds before adding anything

— Elderly patient on hydrochlorothiazide and doxazosin falls when standing in morning

— Answer: discontinue α-blocker, reduce diuretic, hydrate, slow position changes

— Elderly woman with groin pain after fall, shortened externally rotated leg

— Answer: hip X-ray → ortho consult → surgery within 24–48 hrs; start DVT ppx; DEXA + bisphosphonate before discharge

— Magnetic gait, urinary incontinence, cognitive slowing, ventriculomegaly on MRI → high-volume LP tap test → VP shunt

— 90-yo with falls, BP 138/76 on three antihypertensives

— Answer: reduce antihypertensives, individualize target

— Elderly faller with positive UA but no urinary symptoms — do not treat with antibiotics; search for real fall cause

— Dix-Hallpike positive → Epley maneuver

— Recurrent falls with poor vision and lens opacity → refer for cataract surgery

— Community-dwelling 70-yo with one fall last year, mildly slow TUG

— Answer: structured exercise program (tai chi, Otago)

— Multiple bruises in various stages, caregiver answers for patient, malnutrition

— Answer: report to Adult Protective Services

Key distinction: Step 3 stems frequently include a "next best step" twist where the workup (e.g., orthostatics, ECG, med review) outranks an intervention — read the stem for what has already been done.

Pattern 1 — "Found down" decoy:

Pattern 2 — Anticoagulated head trauma:

Pattern 3 — Polypharmacy fall:

Pattern 4 — Orthostatic hypotension:

Pattern 5 — Hip fracture management:

Pattern 6 — NPH:

Pattern 7 — Frail elderly BP:

Pattern 8 — Asymptomatic bacteriuria:

Pattern 9 — Vertigo with rolling over in bed:

Pattern 10 — Cataracts:

Pattern 11 — Exercise prevention:

Pattern 12 — Elder abuse:

One-Line Recap

Geriatric falls are a multifactorial syndrome demanding annual screening of all adults ≥65, full multifactorial assessment after any positive screen or fall, and bundled interventions — exercise, deprescribing, vision/home/footwear optimization, postural BP management, and osteoporosis treatment — because the right answer is almost never a single pill.

Board pearl: When in doubt on a Step 3 fall stem, the highest-yield answers are stop a drug, start exercise, and check orthostatics — interventions, not just imaging.

Screen everyone ≥65 annually with three questions: any fall in past year? gait/balance trouble? fear of falling? Any "yes" → full multifactorial assessment with TUG (≥12 sec = high risk), orthostatic vitals, med review, vision/cognition/mood, and home safety eval.

Exercise is the single most effective intervention (tai chi, Otago, balance/strength programs reduce falls ~25%); pair with deprescribing FRIDs (benzos, Z-drugs, anticholinergics, TCAs, α-blockers, sulfonylureas), vitamin D if deficient, cataract surgery, home modifications, and proper footwear/assistive devices.

Any fall with LOC, head trauma on anticoagulation, suspected fracture, or long lie demands ED-level workup — ECG, head CT, orthostatics, glucose, CBC/BMP/UA, and search for occult syncope, stroke, infection, MI, PE, or rhabdomyolysis; reverse anticoagulation for ICH and admit.

After a fragility fracture, diagnose osteoporosis regardless of T-score, start a bisphosphonate (or denosumab if CKD), ensure calcium/vitamin D, arrange PT/OT, deliver a written fall-prevention plan, and schedule PCP follow-up within 7 days — fall + fracture is a sentinel event predicting another within a year.