Data gathering and assessment for an elderly patient with recent fall

Data Gathering and Assessment Procedures for an Elderly Patient After a Recent Fall

• Ask the patient about any falls in the last 12 months, including frequency, circumstances (place, time, activity), and any preceding symptoms such as light-headedness or loss of consciousness to distinguish between a simple fall and a collapse.
• Obtain an eyewitness account if possible to clarify the nature of the fall.
• Assess risk factors including cognitive impairment, visual impairment, mobility or balance conditions (e.g., arthritis, diabetes, stroke, Parkinson's disease), medication use (especially psychoactive drugs and those causing postural hypotension), fear of falling, frailty, and other factors like alcohol misuse or depression.
• Perform gait and balance assessments using pragmatic tools such as the Timed Up & Go test and/or the Turn 180° test, observing postural stability, gait, stride length, and sway. Use clinical judgment interpreting these tests, considering factors like walking aid use and footwear.
• Offer a multifactorial falls risk assessment by a skilled clinician (usually in a specialist falls service) if the patient has had two or more falls in the last year, presents for medical attention after a fall, or performs poorly on gait and balance tests.
• The multifactorial assessment should include: history of falls; assessment of gait, balance, mobility, and muscle strength; osteoporosis risk; perceived functional ability and fear of falling; visual and cognitive impairments; neurological and cardiovascular examination; urinary incontinence; home hazards; and medication review focusing on polypharmacy and drugs increasing fall risk.
• Review medications, especially psychotropic drugs, with specialist input to discontinue if possible to reduce fall risk.
• Provide verbal and written information on reducing fall risk and consider annual reassessment if no indication for multifactorial assessment.

These procedures ensure a comprehensive understanding of the patient's fall risk and guide individualized interventions to prevent future falls.

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