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geriatrics.falls.core.v1

Falls in older adults

general_internal_medicinechronicsubacutegeriatricadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Falls in older adults — assessment + multifactorial prevention dossier. Manifest points at the real existing placeholder prisma/seed/manifests/symptom.falls.v1.ts (a stub); a dedicated geriatrics.falls.core.v1 manifest + atoms + problem-package are deferred to the deepening pass. Regimen axis is almost entirely non-pharmacologic (exercise/PT-OT/home-hazard/vision/footwear/pacing/deprescribing) — every RegimenDrug carries non_pharm:true and NO rxcui; pharmacologic vitamin D / midodrine / osteoporosis agents are intentionally modeled as referral/supplement actions, not RxCUI-bound drugs, pending RxNav validation. calc.clinical_frailty_scale reused (shared with geriatrics.frailty-polypharmacy.core.v1) for frailty contextualisation; calc.qsofa/news2 used as generic post-fall deterioration screens since dedicated gait-balance calculators (TUG, gait speed, Berg, 30-s chair stand) are not yet in clinical-tools-registry.ts. Bayesian likelihood ratios for syncope-vs-mechanical-fall discrimination deferred (see design brief Open gaps). Sibling pivots authored per §5.5.2 vs geriatrics.frailty-polypharmacy.core.v1 (FRID deprescribing pivot) and a syncope engine (witnessed-LOC/cardiac pivot).

Entry points (5)

  • history
    >=1 fall in the past 12 months — positive annual falls screen (World Falls Guidelines 2022)
    fall_in_past_year
  • symptom
    Self-reported or observed gait/balance difficulty or unsteadiness (AGS/BGS)
    gait_or_balance_problem
  • symptom
    Fear of falling / activity restriction — 3rd screening question (World Falls Guidelines 2022)
    fear_of_falling
  • demographic
    Age >=65 presenting for routine visit — opportunistic annual screen (USPSTF 2024)
    age_65_plus
  • symptom
    Acute presentation after a fall — ED/inpatient post-fall workup trigger (AGS/BGS)
    post_fall_presentation

Required inputs (12)

  • agerequired
    demographic • used at FRAME
    Falls screening threshold >=65; injury and intervention thresholds age-stratified (USPSTF 2024)
  • falls_historyrequired
    history • used at ENTRY
    Number, circumstances, injuries, witnessed/unwitnessed; >=1 fall/year or recurrent (>=2) drives stratification (World Falls Guidelines 2022)
  • fall_circumstancesrequired
    history • used at CONTEXT
    Mechanical (trip/slip) vs unexplained vs syncopal (LOC, prodrome, witness account) — pivots syncope workup (AGS/BGS)
  • current_medsrequired
    medication • used at CONTEXT
    Fall-risk-increasing drugs (FRIDs): psychotropics, benzodiazepines, antihypertensives, anticholinergics, hypoglycemics, anticoagulants (World Falls Guidelines 2022)
  • orthostatic_bprequired
    vital • used at INITIAL_WORKUP
    Orthostatic hypotension (>=20 mmHg SBP or >=10 mmHg DBP drop at 1 and 3 min) is a core treatable contributor (AGS/BGS)
  • gait_balance_assessmentrequired
    history • used at RISK_STRATIFICATION
    TUG, gait speed, 30-s chair stand, Berg balance — defines low/intermediate/high risk (World Falls Guidelines 2022)
  • anticoagulant_userequired
    history • used at RED_FLAGS
    Head injury on DOAC/warfarin/antiplatelet → low threshold non-contrast CT head; delayed subdural risk (AGS/BGS)
  • vision_status
    history • used at INITIAL_WORKUP
    Visual acuity, cataract, bifocal/multifocal lens use on stairs — modifiable contributor (World Falls Guidelines 2022)
  • cognitive_status
    history • used at INITIAL_WORKUP
    Cognitive impairment increases falls risk and modifies exercise/home-hazard plan (AGS/BGS)
  • environmental_hazards
    history • used at INITIAL_WORKUP
    Home hazard exposure (rugs, lighting, stairs, footwear) — OT home-hazard intervention target (World Falls Guidelines 2022)
  • heart_rate_rhythm
    vital • used at BRANCHING_WORKUP
    Arrhythmia / carotid sinus hypersensitivity as syncopal-fall cause; cardioinhibitory CSS may warrant pacing (AGS/BGS)
  • vitamin_d_25oh
    lab • used at INITIAL_WORKUP
    Vitamin D supplementation indicated only if deficient; routine supplementation NOT recommended (USPSTF 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm scope: community-dwelling or inpatient adult >=65 (or younger high-risk) for falls assessment + multifactorial prevention; exclude isolated acute injury management without falls workup (USPSTF 2024)
    inputs: age
    advance: Patient in scope for annual falls screening or post-fall multifactorial assessment (World Falls Guidelines 2022)
  2. 2ENTRY
    Annual falls screen — three questions: >=1 fall in past year? gait/balance problem? fear of falling? OR acute post-fall presentation (World Falls Guidelines 2022)
    inputs: falls_history
    advance: Positive screen (any of 3) or post-fall trigger documented; negative screen → reassess in 1 year (World Falls Guidelines 2022)
  3. 3CONTEXT
    Characterise fall(s): number, circumstances (mechanical vs unexplained vs syncopal — LOC, prodrome, witness), injuries, FRID medication reconciliation, comorbidity, social/caregiver support, prior fracture (AGS/BGS)
    inputs: fall_circumstances, current_meds, falls_history
    advance: Fall mechanism characterised and FRID list reconciled (World Falls Guidelines 2022)
  4. 4RED_FLAGS
    Exclude acute precipitant/injury: syncope/cardiac cause (LOC, arrhythmia, chest pain), head injury on anticoagulant (low-threshold CT head; delayed subdural), hip/long-bone fracture, spinal cord injury, long-lie with rhabdomyolysis, recurrent unexplained falls (AGS/BGS)
    inputs: anticoagulant_use, fall_circumstances
    actions: calc.news2
    advance: Acute precipitant/injury excluded or escalated and addressed (AGS/BGS)
  5. 5INITIAL_WORKUP
    Multifactorial assessment ("I HATE FALLING"): orthostatic vitals, medication/FRID review, vision, feet/footwear, vitamin D/nutrition, cognition, mood, continence, environmental hazards; basic labs to exclude reversible contributors (World Falls Guidelines 2022)
    inputs: orthostatic_bp, vision_status, cognitive_status, environmental_hazards, vitamin_d_25oh
    actions: workup.falls, workup.cga, panel.metabolic, panel.cbc, panel.vitamin_d
    advance: Multifactorial domains assessed; treatable contributors catalogued (World Falls Guidelines 2022)
  6. 6BRANCHING_WORKUP
    Targeted by finding: syncopal/unexplained → ECG, orthostatic challenge, carotid sinus massage (if no carotid bruit/recent stroke), ambulatory ECG, echo; head injury on anticoagulant → CT head; suspected fracture → plain films/CT; long-lie → CK/CMP/UA for rhabdo + AKI; peripheral neuropathy/vestibular → focused exam (AGS/BGS)
    inputs: heart_rate_rhythm, anticoagulant_use
    actions: workup.delirium, panel.cmp, panel.ua
    advance: Branch-specific diagnostics queued and resulted (AGS/BGS)
  7. 7DIFFERENTIAL
    Classify fall etiology: mechanical/extrinsic, multifactorial intrinsic (gait-balance + FRID + orthostatic + sensory), syncopal (cardiac arrhythmia, orthostatic, reflex/carotid sinus, structural), neurologic (Parkinsonism, neuropathy, cerebellar, NPH, post-stroke), MSK/sarcopenia, vestibular; exclude masquerading seizure/TIA (World Falls Guidelines 2022)
    advance: Dominant etiology(ies) assigned; reversible contributors prioritised (World Falls Guidelines 2022)
  8. 8RISK_STRATIFICATION
    Stratify low / intermediate / high risk by gait-balance performance (TUG >=12 s, gait speed <0.8 m/s, reduced 30-s chair stand, Berg <45) plus falls history and injurious/recurrent/unexplained falls; frailty amplifies falls + fracture risk (World Falls Guidelines 2022)
    inputs: gait_balance_assessment, falls_history
    actions: calc.clinical_frailty_scale, calc.qsofa
    advance: Risk tier assigned (low → education; intermediate → exercise + targeted; high → multifactorial individualized program) (World Falls Guidelines 2022)
  9. 9TREATMENT
    Evidence-based bundle: structured strength + balance exercise (Otago/Tai Chi) as cornerstone (strongest evidence); deprescribe FRIDs; manage orthostatic hypotension; vision correction (cataract surgery; avoid bifocals on stairs); home-hazard modification by OT; footwear/podiatry; vitamin D only if deficient; cardiac pacing for cardioinhibitory carotid sinus syndrome; bone-health/osteoporosis treatment to reduce fracture; individualized multicomponent program for high risk (World Falls Guidelines 2022)
    inputs: gait_balance_assessment, current_meds, orthostatic_bp
    advance: Risk-tiered intervention plan agreed with patient/caregiver and initiated (World Falls Guidelines 2022)
  10. 10DISPOSITION
    Discharge with falls-prevention plan vs admit (significant injury, syncope requiring monitored workup, unsafe home, social failure-to-cope); referrals: PT/OT, falls clinic, fracture-liaison/bone-health service, cardiology if syncopal/pacing (AGS/BGS)
    advance: Care setting confirmed and multidisciplinary referrals placed (AGS/BGS)
  11. 11MONITORING
    Falls diary; exercise adherence; reassess gait-balance (TUG/gait speed) and orthostatics at 3-6 months; recheck after each FRID change; bone-health and vitamin D follow-up if treated (World Falls Guidelines 2022)
    inputs: orthostatic_bp, gait_balance_assessment
    actions: calc.clinical_frailty_scale
    advance: Monitoring schedule set; falls rate stable or decreasing; no FRID-withdrawal syndromes (World Falls Guidelines 2022)
  12. 12FOLLOWUP
    Reassessment cadence (annual screen if low risk; 3-6 monthly if high risk or post-intervention); fracture-liaison/bone-health linkage; reinforce exercise; caregiver/home support; advance care discussion if recurrent injurious falls in frail patient (USPSTF 2024)
    advance: Next reassessment scheduled and bone-health/PT-OT loop closed (World Falls Guidelines 2022)