An 81-year-old man is brought to the physician due to a recent fall. Three days ago, he stumbled on a rug in his living room and fell to the floor. He had no dizziness or loss of consciousness prior to the event and did not hit his head. He says that he only slipped, but his wife is concerned about the possibility of his falling again. The patient's other medical problems include hypertension and a history of stroke 10 years ago. His medications include aspirin, atorvastatin, and lisinopril. He lives independently with his wife. The patient's vital signs, including orthostatics, are within normal limits. Physical examination, including vision, cranial nerves, sensation, and reflexes, shows no abnormalities. No bruises or other superficial lesions are present. After evaluating medication use, alcohol use, appropriate footwear, and home environmental factors, which of the following is the most appropriate next step in management?

Question

An 81-year-old man is brought to the physician due to a recent fall.  Three days ago, he stumbled on a rug in his living room and fell to the floor.  He had no dizziness or loss of consciousness prior to the event and did not hit his head.  He says that he only slipped, but his wife is concerned about the possibility of his falling again.  The patient's other medical problems include hypertension and a history of stroke 10 years ago.  His medications include aspirin, atorvastatin, and lisinopril.  He lives independently with his wife.  The patient's vital signs, including orthostatics, are within normal limits.  Physical examination, including vision, cranial nerves, sensation, and reflexes, shows no abnormalities.  No bruises or other superficial lesions are present.  After evaluating medication use, alcohol use, appropriate footwear, and home environmental factors, which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c18d_5c25_8f63_c395e8650e73_MD0005_00 This 81-year-old man most likely experienced a mechanical fall and has no evidence of trauma. His examination is reassuring without signs of neurologic or cardiac compromise. Approximately 30%−40% of elderly patients living in the community fall each year; those in long-term care facilities have rates almost twice as high. Although it is reasonable to obtain brain imaging studies in elderly patients with evidence of head trauma, ordering imaging on all elderly patients who fall would result in >1/3 of the senior population receiving head CT scans every year. In the absence of trauma, elderly patients who require medical attention and report multiple falls or have gait abnormalities should be evaluated with a comprehensive and multifactorial approach that includes evaluation of medication use, alcohol use, chronic diseases, environmental factors, blood pressure, and postural stability. According to guidelines published by the American Geriatric Society, British Geriatric Society, and American Academy of Orthopedic Surgeons, all elderly patients should be asked annually about any episode of falls. If a patient reports an episode, the evaluation should include at least one postural stability test. Assessment of gait and balance is important as it determines the need for further evaluation and intervention. The "Get Up and Go" test is commonly used to assess postural stability. In this test, the physician instructs the patient to stand up from an armless chair without assistance, walk a short distance, turn around, return, and sit down again. If the patient is unsteady or has difficulties during the test, further evaluation is necessary. (Choice A) Holter monitoring, electrocardiogram (ECG), and echocardiogram are recommended if a cardiac cause (eg, arrhythmias, cardiac syncope, myocardial ischemia) is suspected. (Choice B) The risk of intracranial bleeding due to a fall while on antiplatelet therapy is very low and would not warrant discontinuation of therapy. Even in average-risk patients with atrial fibrillation on anticoagulation for stroke prevention, the risk of intracranial bleeding is so minimal that a patient would need to fall almost 300 times a year to outweigh the benefits of anticoagulation. (Choice C) Serum chemistries or complete blood count are indicated when a systemic condition is suspected. (Choice E) Head imaging is needed when a neurologic problem is suggested by the history or physical examination. If there is evidence of significant head trauma, a head CT scan without contrast should be performed. Educational objective: Elderly patients should be asked annually about a history of falls. Patients who report a fall should undergo a comprehensive evaluation including postural stability (eg, "Get Up and Go" test). Patients who perform poorly or have recurrent falls may need a more extensive workup. References: Falls in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/10779256) Management of falls in older persons: a prescription for prevention. (http://www.ncbi.nlm.nih.gov/pubmed/22150660)

An 81-Year-Old Man Is Brought to the Physician Due to a Recent