If you want to prevent dangerous falls in an aging adult, here’s one of the very best things you can do: be proactive about getting the right kind of medical assessment after a fall.
Why? There are three major reasons for this:
- A fall can be a sign of a new and serious medical problem that needs treatment. For instance, an older person can be weakened and fall because of illnesses such as dehydration, or a serious urinary tract infection.
- Older adults who have fallen are at higher risk for a future fall. Although it’s a good idea for any older person to be proactive about identifying and reducing fall risk factors, it’s vital to do this well after a fall.
- Busy doctors may not be thorough unless caregivers are proactive about asking questions. Most doctors have the best intentions, but studies have shown that older patients often don’t get recommended care. By being politely proactive, you can make sure that certain things aren’t overlooked (such as medications that worsen balance).
All too often, a medical visit after a fall is mainly about addressing any injuries that the older person may have suffered.
Obviously, this is very important; one doesn’t want to miss a fracture or other serious injury in an older person.
However, if you want to help prevent future falls, it’s also important to make sure the doctors have checked on all the things that could have contributed to the fall.
This is really key to preventing falls in an aging adult. Even if you’re pretty sure your loved one just tripped and stumbled, a good evaluation can uncover issues that made those trips and stumbles more likely.
In this article, I’ll list eight key items that you can make sure the doctors check on, after an older person falls. This will help you make sure your loved one has had a thorough work-up, and can reduce the chance of future serious falls.
This list is partly based on the American Geriatrics Society’s Clinical Practice Guidelines on Preventing Falls.
8 Things the Doctors Should Check After a Fall
1. An assessment for an underlying new illness. Doctors almost always do this if an older person has been having generalized weakness, delirium, or other signs of feeling unwell. Be sure to bring up any symptoms you’ve noticed, and let the doctor know how quickly the changes came on.
Just about any new health problem that makes an older person weak can bring on a fall. Some common ones include:
- Urinary tract infection
- Dehydration
- Anemia (low red blood cell count), which can be brought on by bleeding in the bowel or by other causes
- Pneumonia
- Heart problems such as atrial fibrillation
- Strokes, including mini-strokes that don’t cause weakness on one side
2. A blood pressure and pulse reading when sitting, and when standing. This is especially important if you’ve been worried about falls — or near falls — that are associated with light-headedness, or fainting.
If your older relative takes blood pressure medication, you should make sure the doctor confirms that he or she isn’t experiencing a drop in blood pressure with standing. (Note that tamsulosin — brand name Flomax — is a popular prostate medication that also causes drops in blood pressure.)
A 2009 study of Medicare patients coming to the emergency room after fainting found that checking sitting and standing blood pressure was the most useful test. However, it was only done by doctors 1/3 of the time.
For more information, see “6 Steps to Better High Blood Pressure Treatment for Older Adults”.
3. Blood tests. Checking an older person’s blood tests is often a good idea after a fall. Falls can be worsened by problems with an older person’s blood count, or by things like blood sodium getting too high or too low.
Generally, a complete blood cell count (CBC) and a check of electrolytes and kidney function (metabolic panel, or “chem-7”) are a good place to start.
For more on blood tests that are often useful, see Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults.
Be sure to ask the doctor to explain any abnormalities found in the blood work, whether they might be related to falls, and how the doctor plans to address them.
If your loved one has diabetes and takes insulin or other medications to lower blood sugar, be sure to bring in the glucometer or a blood sugar log. Episodes of low blood sugar (hypoglycemia) are an important risk factor for falls, but a laboratory blood test generally doesn’t show moments of low blood sugar.
4. Medications review. Many older adults are taking medications that increase fall risk. These medications can often be reduced, or even eliminated. Be sure to ask the doctor to address the following types of medications:
- Any sedatives, tranquilizers, or sleeping medications. Common examples include zolpidem (Ambien) for sleep, or lorazepam (Ativan) for anxiety. Antipsychotic medications for restless dementia behaviors, such as risperidone or quetiapine, can also increase sedation and fall risk.
- Blood pressure and diabetes medications. As noted above, it’s not unusual for older adults to be “over-treated” for these conditions, meaning they are taking a level of medication that causes the blood pressure (or blood sugar) be lower than is really necessary for ideal health.
- “Anticholinergic” medications. These medications are commonly taken by older adults, who often have no idea that these medications worsen balance and thinking! They include medications for allergies, overactive bladder, vertigo, nausea, and certain types of antidepressants which may also be given for nerve pain. For more on identifying and avoiding anticholinergics, see here.
- Opiate pain medications, especially if they are new.
The Centers for Disease Control recommends that older adults concerned about falls request a medication review. To learn more about which medications should be reviewed, and what should be done about risky drugs, see this article:
“10 Types of Medication to Review if You’re Concerned About Falling.”
5. Gait, balance, and leg strength. At a minimum, a gait assessment means that the doctor carefully watches the way the older person is walking. Asking the older person to stand up from a chair (without using the arms) can help assess leg strength. There are also some simple ways to check balance.
Simple things to do, if gait, balance, or leg strength don’t seem completely fine, are:
- Address any pain or discomfort, if that seems to be a cause of problems. Many older people are reacting to pain in their feet, joints, or back.
- Refer to physical therapy for gait and balance assessment. These assessments will usually include checking the older person’s leg strength. A physical therapist can often recommend suitable strengthening and balance exercises for seniors, and also can help fit the older person for an assistive device (e.g. a walker) if appropriate. For more on the proven Otago physical therapy program to reduce falls — including videos demonstrating the exercises — see “Otago and Proven Exercises for Fall Prevention.”
6. Evaluation for underlying heart conditions or neurological conditions. These chronic conditions are different from the “acute” types of illnesses that we usually look for right after a fall.
In a minority of cases, an older person may be falling because he or she has developed a chronic problem with the heart or blood pressure system. An example of this would be paroxysmal rapid atrial fibrillation, which causes the heart to sometimes race, or sick sinus syndrome, which can cause the heart to beat too slowly.
It’s also possible for older people to develop a new chronic neurological condition, such as Parkinson’s disease.
If you’re worried about these possibilities, ask the doctor “Do you think a heart condition might have caused this fall? Or do you think an underlying neurological condition could have caused this fall?”
It’s particularly useful for you to ask about these kinds of problems if the falls or near-falls keep happening, especially if you’ve already minimized risky medications and over-treatment of high blood pressure.
7. Evaluation for osteoporosis and fracture risk. Many older adults, especially women, develop thinner bones in later life. Osteoporosis isn’t technically a risk factor for falls, but it’s certainly a major risk factor for injury from a fall. In particular, people with osteoporosis are at much higher risk of having a hip fracture or other type of fracture when they fall.
For this reason, after an older person falls, it’s important to check and make sure they’ve been assessed for osteoporosis.
The US Preventive Services Task Force recommends that all women aged 65 or older be screened for osteoporosis., however many older women end up not getting screened.
If they do have osteoporosis, then it should be treated. Treatment with bisphosphonate medications has been proven to reduce fracture risk.
Experts also recommend promptly starting osteoporosis treatment after a fracture, as the research shows this doesn’t interfere with fracture healing and can reduce the risk of a subsequent fracture.
Calcium and vitamin D supplementation may also help, especially in older adults who have low levels of vitamin D. Other lifestyle changes can also help treat osteoporosis; for more on this, see here.
Note: The United States Preventive Services Task Force and other expert groups used to recommend vitamin D supplementation to help prevent falls, because research had initially identified an association between low vitamin D levels and falls. However, randomized trials were not able to show that vitamin D supplementation decreases falls, so vitamin D is no longer recommended for fall prevention.
8. Vision, podiatry, and home safety referrals. Could your loved one be in need of a vision check, podiatry care, or a home safety evaluation? If you’ve brought an older person in after a fall, it’s a good idea to talk to the doctor about whether these services might help.
I especially recommend home safety evaluations, if they are available in your area. Even something as simple as installing grab bars can make a difference, and home safety evaluations often uncover other simple changes that can prevent falls. Vision checks are also an excellent idea if the older person hasn’t had one recently.
How to use this information
Overwhelmed by this list? Here’s an idea for you:
Print out this post — or download our free cheat sheet — and bring it along next time you take an older person to see the doctor after a fall. If the doctor overlooks certain points, don’t be shy about asking why.
For more practical information on why older adults fall and how you can prevent falls, see my article Why Older People Fall & How to Reduce Fall Risk . You can also learn more about clinically proven exercises that reduce falls here.
Mary charles says
HI my dad fell (nobody saw him) and when he came inside the house he had a memory loss which came back later. My step mother said he looked as if he had been running and he was sweating. Coukd this have been signs of his heart? The dr. Did not do ekg but ordered blood work and a scan of t h e brain. Can they tell by these type of exams? Thank you
Leslie Kernisan, MD MPH says
Hm. The tricky thing is that looking sweaty and out of breath could be cardiac (which means “heart-related” but it can also easily be caused by the “fight or flight” stress response, which comes on whenever one is scared or angry or experiencing any kind of situation that provokes a strong emotion. Obviously, falling or experiencing pain can do this to people.
To evaluate an older person after a fall, it’s important to consider their age, their medical history, and also to ask questions about what symptoms the person experienced before the fall, or has been experiencing lately. This helps to determine whether an EKG — or any other test — is likely to be helpful or not, and also helps determine what the doctors can “tell” from the various test results.
I would recommend talking to your father’s doctor about your questions. You can ask if they think it’s possible that your father’s fall could be related to his heart, or if an EKG might help sort things out. Good luck!
Nonye says
Hi Leslie,
Thanks for all your wonderful advice. I just came across this while searching for what could be causing the kind of pain my mother is experiencing following her fall. My mother is 81 years old and fell more than a month ago while taking a walk in park. She fell on the concrete because she was dragging her feet and was not wearing tennis shoes. She has been to the emergency room twice because of the pain and X-rays and CT scans do not show any broken bones yet she continues to have excruciating pains. She has arthritis and it looks like this fall has exaggerated it immensely. Do you know what can help with this? What do you advise?
Greatly appreciate your response.
Leslie Kernisan, MD MPH says
Sorry to hear that your mother has been having all this pain since her fall.
Hm…hard to say what might be causing her continued pain. Sometimes people have hairline fractures that don’t show up on xray, but I would expect those to show up on a follow-up CT. Other possibilities would be a nerve being pinched or aggravated somewhere, or even worsened arthritis.
Pain often gets better with time, but it’s important to keep moving, and the right type of physical therapy can also help. The trouble is that people in pain often don’t want to move…so sometimes judicious use of pain medicine 30 minutes before can make it possible for the person to participate in their therapy and otherwise keep the painful area moving at least a bit. Some older adults also get relief from topical therapies on the painful area, and this can be safer since there are often fewer side effects.
It will also help if you can keep pushing to have her pain carefully assessed and diagnosed. I can’t do that online, but generally, the doctors need to ask detailed questions about where your mom feels it, what brings it on, whether it feels like an ache or a sharper burning feeling, and so forth. These types of questions are supposed to help a doctor figure out where the pain is coming from, and whether it’s more likely to be coming from a pinched nerve versus arthritis inflammation within a joint or the spine.
If you aren’t satisfied with the efforts the doctors are making, consider a second opinion.
Last but not least, once you have made progress addressing the pain issues, you could consider askign the doctors for help assessing her gait (why is she dragging her feet?). Good luck!
Penny says
I like what you’ve mentioned about “make sure the doctors have checked on all the things that could have contributed to the fall”. It is always a great idea to find a top doctor that will truly care about you. A great doctor who uses the leading-edge technology is another factor.
Leslie Kernisan, MD MPH says
Everyone wants a “top doctor” but if you can’t find one, learning to work well with the doctors that are available is the next best thing. I also encourage people to consider health clinics that are specially designed for older adults, because they often have trained their staff and clinicians to help people with falls.
Sher says
We are having problems with my mother shaking to the point of falling. She is on three blood pressure medications – Metaprolol, Losartan and Amilopidine and is also taking Mitrazapine to help her gain weight. She has already fell two times – ended up in ER the other week. She has neuropathy and dementia.
When she first gets up, it’s worse, but she also fell outside when she said she started shaking and went over with her walker. Her BP is normally 145/ 79. Was taken off blood thinners due to falling.
Would any medicines be causing this? Her walking has gotten much worse and she has foot pain – was taken off Gapabentin about two years ago.
We changed doctors because the previous one seemed to not want to deal with someone in nineties, and new doctor said she could take Ativan but afraid it might make her worse. She seems sleepy all of the time, anyway. Thank you
Leslie Kernisan, MD MPH says
Sorry to hear about this. If your mom is in her 90s and taking mirtazapine “to gain weight,” then I’m guessing she might be kind of frail.
Usually, in people like her, the falls are “multifactorial,” meaning there are several factors contributing to her falls.
I would recommend you read this article, which goes into more details: Why Older People Fall & How to Reduce Fall Risk. I list several common contributors to falls in the slideshow.
I also list specific medications associated with falls here: 10 Types of Medication to Review if You’re Concerned About Falling.
If she’s on Ativan now, you should know that this is a medication that associated with increased fall risk. But again, she’s probably experiencing several other problems that are increasing her fall risk.
Re her blood pressure, it’s important to check it sitting and then standing.
Keep researching as you are doing, and then keep communicating with her doctors. You want to keep letting them know of the falls, and it often helps to keep asking questions. Good luck!
Sher says
Thank you for your response – was considering asking doctor if the beta blocker could be both affecting her weight loss and the weakness? This problem seems to be getting worse really quickly – having problems even getting her out of bed these days – and her leg muscles are very weak. The Mitrazapine has helped her appetite some, but she has lost thirty pounds and gained about seven back.
Have already hurt my back one time trying to get her up, so I really hope there’s a way to get her steady on her feet again. I think I may hold off on the Ativan for the time being. I’m definitely printing the article on falling, to keep.
Leslie Kernisan, MD MPH says
That amount of weight loss is pretty concerning. Beta-blockers make some people feel lousy, but it would be unusual for it to cause that much weight loss or that much weakness.
I would encourage you to ask the doctor to explain what he/she thinks is causing the weight loss. It could well be the same thing that is making her weak and causing weight loss, and that weakness may well be the main driving factor with her falls. I have an article on this topic here, which lists common causes
Q&A: What to Do About Unintentional Weight Loss.
Re Ativan, in people who take it daily, it’s important to be very careful about stopping or reducing the dose too quickly. See How You Can Help Someone Stop Ativan. Good luck and take care!
James Pepoon says
Dr. Kenison, I am an 83 year old male. I am suffering aftereffects from a fall 1 1/2 years ago. Bad nausea and severe constipation. I also get very little physical exercise. I have three blocked (80%) coronary arteries treated with metropolal,isosorbide, amlodiipine. Also type 2 diabetes and take insulin/metformin. I believe I am dying but my cardiologist refuses to give me a time table. Please help me. Thank you!
Leslie Kernisan, MD MPH says
So sorry to hear of your difficulties and your symptoms. I cannot say whether you are gravely ill and likely to die within the next few months or not, but you certainly sound distressed and you must be feeling quite unwell.
It sounds like you are trying to learn more about your prognosis and what to expect. It also sounds like you feel things are pretty dire. To get advice regarding this, you’ll need to work with a health provider who is able to interview you, examine you, and review your medical records.
Rather than ask your cardiologist for a time table, you might want to try saying that you feel really unwell and are worried that you might continue to decline and/or have a serious health crisis. Ask your cardiologist to help you understand what to plan for. You can also say you want to discuss goals of care.
You can even ask your health providers if they think you are now within the “six month life expectancy” window that makes people eligible for hospice. (You don’t have to want to sign up for hospice, to want to understand what they think your prognosis is. That said, hospice is GREAT at helping people with distressing symptoms and also emotional fears at the end of life.)
Another option for you would be to ask to speak with a palliative care provider; they are trained to discuss prognosis and life expectancy. See here: Get Palliative Care.
Last but not least, I have an article about constipation here, it should be possible to relieve your constipation: How to Evaluate, Prevent & Manage Constipation in Aging. Good luck and take care!
Karen says
My 82 year old mother is passing out. Those are her words, for an hour or 2 at a time. She wakes up and does not know what has happened or what she was doing before she passed out. She is not big on doctors or medication or therapy but feels she’ll know when she needs help. She has fallen a number of times over the past few years and usually hits her face and has bruises. We question her doctor but he says let her do what she wants, she won’t listen to any advice I have. What questions should we be asking or what kinds of tests might she need?
Leslie Kernisan, MD MPH says
Yikes, this sounds scary for your mom and for your family.
Generally, you should consider asking the doctor about all 8 things mentioned in the post. That said, if an older person complained of “passing out” and it had been going on for weeks-to-months, I would be especially considering the possibility of underlying cardiac and/or neurological problems. I would also want to check blood pressure sitting/standing and it can help to review several home BP readings.
Occasionally problems with heart rhythm can cause passing out and/or falls. Usually doctors start by checking an ECG in the office, and they might also consider monitoring over a several days, using a Zio patch or other ambulatory monitor.
As for the doctor, it might help for you to ask more questions about what he thinks is causing your mother’s falls. Even if she has refused to follow his advice in the past, for such a potentially significant problem, she might be willing to follow medical advice, especially if it’s framed as a way to help her attain her goals (e.g. a way for her to be able to live independently for longer; a severe fall can force a move, which most older people don’t want). Also, whether or not your mother wants to follow the doctor’s advice, it’s usually reasonable to push for evaluation and better understanding of what is causing such “passing out” falls.
If you try to ask extra questions and the doctor is still not very helpful, you might consider getting a second opinion. Good luck!
Ridley Fitzgerald says
These are definitely things that the elderly should have checked. My mom is getting pretty old, and I have noticed that she walks slower than you used to. She should probably get her gait and balance checked, like you said.
Azarine Alderson says
Thank you
Azarine Alderson says
My Mom is 82, she’s been falling against things that actually catch her fall, she’s been tired lately she gets around with her cane, she had a stroke in 2013, her doctor said it might has something to do with her nerves
Leslie Kernisan, MD MPH says
It might be something with her nerves, but generally it’s best to ask the doctor to do a comprehensive evaluation because often there are multiple causes for falls. For more about this, see:
Why Older People Fall & How to Reduce Fall Risk
10 Types of Medications to Review if You’re Concerned About Falling
If no particular cause for falling is found, then she might still benefit from a structured program to improve strength and balance, such as Otago
Interview: Otago & Proven Exercises for Fall Prevention.
Good luck!
Cynthia Schuetz says
You are providing such a wonderful service, Dr. Kernisan. Seniors, people who love them and professionals who work with them can learn so much from your blog, articles and podcasts. I headed up a falls prevention coalition for 10 years (it’s still going, but with a new coordinator; I’ve turned her on to your website) and have always been looking for info to use. Our focus is educational…getting the word out in as many ways as are possible…about risk factors, reducing risk and behavior change.
Our challenges? Denial in seniors, frustration in loved ones, a medical community that does not see falls as a priority, given all they have to address in so little time. We have been working on empowering seniors to request an annual wellness visit, but that’s also a challenge, both in getting physicians to offer them and seniors to ask for them.
Keep up your important work!! And PS: Both my husband and I have MPHs and doctorates in health ed. (his from Berkeley). So happy to see that MPH after your name!
Leslie Kernisan, MD MPH says
Thank you for so much commenting and for sharing these fascinating insights regarding your experience in fall prevention. I completely agree, denial among older adults is often a hurdle, and yes, it can be hard to get clinicians to devote enough attention to falls. Education and empowerment of seniors and families is necessary, but probably not sufficient…we also need to change the health system so that it becomes easier for seniors and clinicians to do the right things to prevent falls and otherwise improve the wellbeing of aging adults. Thank you for having worked in this important area! And of course a very big thank you for appreciating the site and sharing it with others!
Rochelle says
What about an assessment for stroke? A month ago, my 81-year old mother fell, seemingly for no reason. She arrived at the hospital within an hour, with slurred speech, face drooping on one side, and weakness on one side, and inability to walk. She had been completely independent before.
She was not evaluated for stroke (incredibly!). She was therefore not given TPA during the “golden” 3-4 hour window. She is now completely bed-ridden, can not walk or take care of herself. She is having physical therapy and rehab, but because of the ER’s failure to recognize her stroke until the next day, she will never be independent again.
Leslie Kernisan, MD MPH says
Wow, what a tragic story. You are describing pretty classic stroke symptoms (weakness on one side, facial droop on one side, slurred speech), so that is very surprising if the emergency room didn’t think to evaluate and treat her for stroke. (What DID they think she had??)
I’m sorry to hear that she’s lost so much function. Hopefully she will regain some of her abilities with time and rehab.
Regarding this article, I do list stroke under item 1, “An assessment for underlying new illness.”