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.
Diane says
This is insulting to older adults most of whom are quite able to speak for themselves. I have balance issues so I use a wheeled walker and I am very careful. I do NOT need a caregiver to attend every doctor visit and speak for me. I have had my sister with me at times because I want another perspective on the doc;s statements and because she is younger I have had to tell the doctor that I am able to speak for myself. I have many friends who are also quite able to handle their own lives even after seventy. I will not allow myself to be treated like a child.
Leslie Kernisan, MD MPH says
Sorry if you found the article “insulting,” it was certainly not meant to offend. This is one of my older articles, written a few years ago when the site was called Geriatrics for Caregivers and all articles were quite explicitly addressed to people who were caring for an aging parent, or otherwise helping an older person with health concerns.
Now speaking of “showing some respect” (part of your words which I am removing): I am willing to approve your comment complaining about the article but I am removing one of your sentences, because it felt discourteous to me and unhelpful to the audience.
I agree it’s important to point out that many older adults can manage their health and affairs just fine. Also very useful to remind everyone that even if an older person is accompanied to a visit by a family member or friend, that doesn’t mean the older person can’t speak for himself/herself.
Nancy B says
I’ve been left to be the caregiver for my 92 yr old MIL. She’s had congestive heart failure and AFib dx 8 years. In Sept ’17, medications were adjusted and added. Prior to mu intervention, she was only taking the Metoprolol. That has been doubled, and she also started taking diltiazem, famatodine, eliquis, and pravastatin. Since then her cognition has been declining. Then she fell and hurt her head 6 weeks ago. CtScan fine. The past three weeks she has been hallucinating nearly daily. In her mind, the people.she sees are real. Could one of the meds that shes now taking regularly cause this, or more likely the fall? Prior to around October she did very well on her own. Its been a steady decline, but more so the last several weeks.
Leslie Kernisan, MD MPH says
Sorry to hear of your situation, I can see why you are concerned.
Medications do sometimes cause psychosis symptoms (which include hallucinations) or cognitive decline, but there are many other potential causes, so you really have to work with a clinician in person and get her evaluated. I cover the most common causes of psychosis symptoms here: 6 Causes of Paranoia in Aging & What to Do
I will say that it seems unusual to me that she’s on both metoprolol and diltiazem, as those both slow the heart rate down, sometimes excessively. I wouldn’t expect this to cause hallucinations, but it could contribute to falls. In general in geriatrics, we try to use the least amount of medication necessary. You may want to ask her doctors if it’s possible to reduce her medications or at least the doses. This is called deprescribing, you can learn more here: Deprescribing: How to Be on Less Medication for Healthier Aging
Occasionally people who fall and hit their head initially have a negative head CT but later develop a bruise in or on the brain. One study I saw found that this happened in 6% of cases, so again, not likely but a possibility.
Good luck, I hope you can get a careful evaluation and some answers from her health providers.
Ethan says
Hi!
My mom fell last October, she refused to be rushed in the hospital. She hit her head but she didn’t go unconscious nor did it bleed. She had bruises on her arm and was complaining how painful her left shoulder was. She was able to bear with it for a week but after then she was already trembling when she walks and lost her appetite. We rushed her to the hospital and underwent few testings. The doctor told us that there was no dislocated bone are breaks on her shoulder or head. We were discharged after a week. Her condition improved to say the least. However, after 3 months, she can hardly walk again and she is shaking uncontrollably. She also gets fever everyday and would subside either at night or early morning . She seems to be having hard time breathing as well.We haven’t seen a doctor though. Any idea what she might be the problem? She’s 68.
Leslie Kernisan, MD MPH says
I can’t say what might be the program, but I will say that it all sounds extremely concerning. Especially if someone is having difficulty breathing, it’s essential to contact a health provider right away to get help.
You cannot solve a problem like this online, she needs to be seen by a health provider and you need to ask what they think might be going on. Good luck and please get her to see a health provider soon. If she doesn’t have a regular doctor, you can still take her to an urgent care center or even to an emergency room.
Jennifer says
Hi Dr. Kernisan,
My Mom is 70 years old and has been diagnosed with Dementia and has had a few “mini strokes” that even she wasn’t aware of. Over the last 2 years she has had a rapid decline. 2 years ago she was “normall” and now she can’t walk without a walker, is unable to get up from the couch on her own, she’s unable to get in and out of the tub without assistance, I have to wash her hair, she no longer uses the shower because she falls constantly. We’ve had numerous trips to the ER for various falls that resulted in stitches, loss of consciousness, various strains and sprains. We’ve been going to PT 3 times a week with no improvement. I guess I’m trying to understand why this is happening? Is this because of Alzheimer’s? Or is this something else entirely? We’ve seen her PCP, neuro, cardio but no one has told me WHY the falls and physical decline is happening? She doesn’t talk much which I can understand, it’s the physical part I’m totally confused about? At this rate I feel like she will be in a wheelchair soon. I worry I’m missing something and I have no idea how to help her.
She does have a history of alcoholism and stopped completely about 6-7 years ago. Could that be a contributing factor? I’m not sure if her Dr’s even know that?
Leslie Kernisan, MD MPH says
Oh, I’m sorry to hear of your mom’s decline, it must be very hard for both her and you.
Falls in older adults are almost always due to multiple factors at the same time. Her dementia (having both vascular dementia and Alzheimer’s is not uncommon) is almost certainly contributing to falls, but she may well have other issues as well.
A good PT evaluation should be able to tell a person’s doctor — as well as the patient and family — if an older person is showing signs of decreased strength and/or poor balance. Exercises and physical therapy can help counter these problems, but they have to be the right kind of exercises, and generally getting someone with dementia to cooperate with the exercises takes effort, persistence, and perhaps a little extra skill.
It absolutely is important for healthcare providers to assess an older person for fall risks beyond a PT eval. I cover some of the most common causes of falls in this article: Why Older People Fall & How to Reduce Fall Risk.
I also explain how falls should be evaluated in this mini-course: How to Personalize Your Fall Prevention Plan.
Regarding past alcoholism, it is associated with chronic damage to the brain (thought to be mainly due to associated poor nutrition) and part of the brain’s balance system. It can also affect the peripheral nerves. So it’s quite possible that her past alcoholism is a contributor to her current difficulties. You may want to mention it to her doctors, but as she has been sober for a few years, this is probably not a modifiable contributor to her falls (meaning, there’s not something the doctors or you can do differently regarding past alcohol abuse as a contributor to current falls).
Her overall physical decline does sound worrisome. Whether or not it can be stabilized or reversed, the doctors should be able to do a better job of explaining the likely causes. I would encourage you to keep asking them questions, and they aren’t helpful, consider a second opinion. Some people are able to get a geriatric consultation at an academic medical center near them.
You can also learn more about cerebral small vessel disease (which is closely related to “mini-strokes” that people aren’t aware of) here: Cerebral Small Vessel Disease: What to Know & What to Do.
good luck, I hope you get some better answers soon!
W.U.G. says
I fell yesterday and got a cut on my wrist while I got up to go to the bathroom. I fell right in front of my bed, but didn’t blackout. My wife yelled for my sons and they put me back in bed, and I went to sleep. I felt better today, so I may not ever fall again, but if I do than I’ll go visit my doctor for sure.
Leslie Kernisan, MD MPH says
Yikes. You don’t say how old you are, but in general, an older person who falls is at fairly high risk of falling again. I would recommend bringing up the fall with your doctor and considering further evaluation to identify and address fall risk factors.
I do have a fall prevention mini-course designed to help older adults figure out what to discuss with their doctor, you can learn more here: How to Personalize Your Fall Prevention Plan.
Good luck and take care!
a Daughter says
My mom had a fall last May. She fell against her dining room china cabinet (handle) and punctured her arm ( about 1/2 way between her elbow and wrist) and head. We rushed her to the hospital and lucky nothing broken. She recovered well from her head wound but her arm wound(it was deep) became infected and took a long time to heal. She has since had continuous pain in her arm that is now starting at her shoulder and shoots down her arm to the point that it wakes her ! she has gone to her GP and he sent her to a dermatologist?! What type of doctor should she see for this pain ? they have taken xrays and ultrasounds and there is nothing broken and the infection did not penetrate further than the top layer of her skin. Thank you !
Leslie Kernisan, MD MPH says
Sorry that your mother has developed frequent pain in her arm. Hard to say just what might be causing it. Pain that shoots down a limb can be caused by damage or pressure to a nerve. Sometimes people get shoulder or arm pain due to a nerve in the neck being squeezed, but nerves can also be injured or squeezed in the shoulder or upper arm. I’m not an expert on upper extremity nerves, so I’m not sure if the injury she experienced would be likely to cause this or not.
Generally, the experts in nerves are neurologists. Xrays and ultrasounds can be reasonable tests to make sure there’s no fracture or fluid collection pressing on things in her arm, but they don’t particularly test nerves or nerve function. The Mayo Clinic has a page on pain due to pinched nerves here: Pinched nerve.
Many medications to treat nerve pain can affect an older person’s balance, or sometimes their thinking. If this is the cause of your mother’s pain, you may want to ask about non-drug methods to manage the pain, or perhaps something like physical therapy might be able to relieve the pressure on the nerve. Good luck, I hope your mother finds some relief soon!
Renee says
Hi Dr. My Mom 72, fell and fractured 2 vertebrae in her back T8 and T9. She lived with the pain for 2 weeks until the pain became too much to handle. We rushed her to the hospital. Due to the pain meds, no bowel program, and a host of other pre-existing issues, we have now been here for 16 days. She has 10 specialist treating their specific area, but her health is deteriorating daily. Her primary care physician does not have privileges at the hospital, so we are assigned a hospitalist, who changes daily. I need to find a doctor to take over and coordinate all of the specialists, but I have no idea who I am looking for. She has diabetes, COPD, low functioning 1 kidney, High Blood Pressure. Am I looking for a Geriatric Specialist? An Internist? Any help would be greatly appreciated.
Leslie Kernisan, MD MPH says
So sorry to hear of your situation, sounds very difficult.
16 days is a long time to be in the hospital. It’s hard to say what kind of doctor would be best without knowing more about why she is still requiring hospital care. You could see if there is a geriatric consult service available. A palliative care service might be able to advise re managing her pain, bowels, or other uncomfortable symptoms. Palliative care specialists are also good at grasping the “big picture,” which might be very helpful in your mom’s situation.
She does have a lot of internal medicine problems and internists are used to taking care of people like your mom. But if they are busy or just not attuned to the geriatric angle on things…well, I have described many hospitalists there (they are usually internists).
If you need help getting things coordinated and back on track, you could look into hiring a professional patient advocate. Some of them are even medical doctors, but I think most are nurses or have other healthcare backgrounds. A good one will have experience navigating the usual hospital mayhem.
Good luck, I hope you find a way to make progress soon.
J Wilkinson says
Hi, my 80 year old mum lost her balance today, I was kneeling on the floor & she somehow lost her balance falling onto me, her side hitting my side, I managed to grab her braking her fall before she landed on the floor. I checked her ribs/ stomach which showed no sign of bruising or pain when gently pressed & again 1 hr later. She did say she had a some pain when breathing but she has had this for a while as she has a cute COPD.
I have advised her to take some pain relief can you please advise as she refuses to go to the Dr’s as my father went into hospital 2 years ago & never came out
Leslie Kernisan, MD MPH says
I can never advise online as to what someone should do. If she has recently fallen and you are concerned, you need to seek medical advice from someone close to you. In the US, most primary care doctors’ offices have advice lines, I would recommend calling something similar.
What is most worrisome, in terms of acute injury, is worsening pain, worsening shortness of breath or chest pain, or the person becoming very weak or very confused. If any doubt, try to get her to a medical professional.
In terms of her refusing to go to a doctor: she’s perhaps feeling scared and emotional, and it’s hard to reason with people at a time like this. Try to reassure her and speak to her fears. Perhaps she might agree if you remind her that this is not a hospitalization, it is just an urgent care check up. Also point out how this can help her reach some of her goals, like continuing to live at home. I have tips on talking to resistant parents here: 4 Things to Do When an Older Person Resists Help.
Good luck!
Chris Sigerist says
I am presently 84 yrs old and don’t have any health problems except for COPD. I’ve never fallen – so far- but I am very careful when walking in the house or outside. It appears to me that the feet don’t get the message from the
brain fast enough to move in concert with the upper body. E.G. if you are
walking and decide to turn around, the feet don’t ‘keep up’ so you have to slow the body down till they do. Does any of this make sense.
Thank you for your comments.
Chris
Leslie Kernisan, MD MPH says
Terrific that you haven’t fallen and that you are being careful and attentive regarding your fall risk.
Yes, as people age, all kinds of reflexes and physical abilities can slow down. There are many possible reasons for this; in most older people, it’s due to a combination of factors.
If you have noticed this for yourself, I would recommend bringing it up to your doctor, so that you can be evaluated for treatable issues that might be making it harder for your feet to keep up. The right kinds of exercises can also help improve mobility and balance. Good luck!
Sharon Bagwell says
My father is 86 and lives with my husband and I in our finished basement. I work at home so can check on him throughout the day. He has shown signs of severe memory loss and other symptoms of what I think could be dementia, but when I shared this with his doctor, he didn’t seem concerned or prescribe any testing. Yesterday dad fell getting out of the shower. I did not see him fall, but heard the shower curtain rod fall so ran down to see if he was OK. He said he was ok, got up on his own, got dressed and even walked up & down the basement steps a couple of times. I am use to his strange sleep patterns, however, last night he went to bed at 8:15 pm, woke up at 5:30 am and at some point went back to bed because he is still sleeping at 3:15 pm (cst). Should I be concerned? If he wakes up and still says he’s fine, shouldn’t I get him checked out even though he will probably resist? Men are so stubborn.
Leslie Kernisan, MD MPH says
This sounds like an urgent concern. As a matter of principle, if you ever have an urgent concern regarding possible illness or injury, you must contact your usual doctors, or even consider the emergency room. Primary care doctors in the US have answering services, and should be able to let you know fairly quickly whether they’d recommend urgent care, the ER, or an ambulance.
Urgency aside, you are raising a couple of important issues. One is that you’ve noticed worrisome symptoms, but it’s not clear that your father’s doctor has done much of an evaluation or proposed a diagnosis. Another is that your dad fell recently, and what would warrant further evaluation.
In terms of the fall, it’s reassuring that he was able to get up afterwards and walk the stairs. If after a fall an older person seems sleepier or more tired:
– Could an illness or physical abnormality have caused or contributed to his fall? Older adults sometimes fall because they are feeling weak due to some new or worsened health issue. This could be an infection, anemia, basically the things I mention under item 1 in the article. If an older person continues to seem weaker or sleepier after a fall, it’s certainly best to get them evaluated.
– In terms of injuries caused by falls, it is possible for older adults to hit their head and develop bleeding in the brain over the next few hours, especially if the older adult has been taking a blood-thinner such as warfarin. For this reason, if an older person falls and you think he may have hit his head, you’ll want to monitor over the next 12-24 hours, and if they develop worrisome symptoms or just seem weaker or more confused than usual, it’s best to get further evaluation.
So, you basically need to watch after a fall and see whether you notice any other signs that something may be amiss. If you do, you need an urgent evaluation. If not, then you should still consider an evaluation to assess the fall and address fall prevention, but it’s a little less urgent.
In terms of your father’s memory symptoms: it’s common for doctors to not address this, often because they are busy and sometimes because they may not be entirely sure how to go about the assessment. Some doctors also believe there’s not much point in assessing memory symptoms, because many forms of dementia — such as Alzheimer’s disease — can’t technically be cured or reversed.
But in fact, older adults with signs of memory or thinking problems SHOULD be evaluated. There often are ways to at least improve their thinking, if not reverse an underlying disease, plus some of them are actually suffering from a treatable non-dementia problem that scrambles thinking. These two articles explain why it’s important to push for evaluation, and what the evaluation should include:
Q&A: What to do if your aging parent becomes rude & resistant
How We Diagnose Dementia: The Practical Basics to Know
Lastly: yes, lots of older adults seem quite stubborn, and will resist or decline further evaluation. Using better communication strategies sometimes helps, but generally it’s a tough situation.
4 Things to Do When an Older Person Resists Help
If his memory is really bad, I recommend learning more about decision-making capacity, because it’s possible that he has lost the capacity to correctly decide whether or not he needs evaluation.
Incompetence & Losing Capacity: Answers to 7 FAQs
Hope he is feeling ok, and good luck with your next steps!