Clinical Commander

All dossiers
symptom.falls.v1

Falls and fall risk (older adult)

symptomchronicsubacuteundifferentiatedadultgeriatricoutpatientacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym deepening pass (2026-05-14) — full §5.5 contract depth. Pattern peers: symptom.vertigo.v1 (04bf795f) + neuro.ischaemic-stroke.v1 (a738ab2a). Engine scope: older-adult fall / fall-risk triage + multifactor evaluation + deprescribing across home / outpatient / ED / inpatient / ICU. Downstream confirmed mechanisms route to symptom.vertigo.v1 (vestibular cause), symptom.dementia.v1 (cognitive impairment co-route), and neuro.ischaemic-stroke.v1 (focal neuro deficit / posterior-circulation TIA). Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors by setting) and STOPP-START deprescribing detail live in companion depth bundle _briefs/symptom.falls.v1.depth.md — schema has no first-class likelihood-ratio field. 5 setting playbooks (home, ed, icu, inpatient, outpatient). 13 severity triggers (≥6 per spec): head_injury_on_anticoagulation + unexplained_syncopal_fall + recurrent_2plus_in_12mo + injurious_fall + anticoagulant_post_fall_ich_rule_out + orthostatic_hypotension_severe + medication_induced_fall + severe_hypoglycemia_in_diabetes + frailty_phenotype_or_sarcopenia + cognitive_impairment_concurrent + vision_impairment_severe + fragility_fracture_post_fall + elder_abuse_or_neglect_concern. 3 sibling differentiation rows (symptom.vertigo.v1 + symptom.dementia.v1 + neuro.ischaemic-stroke.v1) — all verified to exist in ALL_DOSSIERS registry. Additional look-alikes (syncope/presyncope, hypoglycemia, MSK osteoarthritis) captured as pivots in depth bundle. Schema-blocked items surfaced: Tinetti POMA, Berg Balance, TUG codifier, STEADI three-question screen codifier, Hendrich-II inpatient fall risk, Morse Fall Scale, Fried frailty index — none in clinical-tools-registry.ts; cross-shard tickets emitted to shard-0. Modern view captured: deprescribing is HIGHEST-YIELD single intervention (STOPP/START v3 — O'Mahony 2023 PMID 37256475). USPSTF 2024 endorses exercise (Otago / tai chi / FaME) as first-line primary prevention. Multifactor evaluation reserved for ≥2 falls in 12 mo OR injurious fall (AGS/BGS 2010 PMID 21226685). Vitamin D modestly reduces falls only in the deficient (Bischoff-Ferrari 2009 PMID 19797342); USPSTF 2024 recommends AGAINST universal supplementation. PMIDs (8): USPSTF Falls 2024 (38833246 verify), AGS/BGS 2010 (21226685), Campbell Otago 1997 (9366737), Sherrington Cochrane 2019 (30703272), Bischoff-Ferrari vit D 2009 (19797342), O'Mahony STOPP/START v3 2023 (37256475 verify), AGS Beers 2023 (37139824), HORIZON-PFT zoledronic 2007 (17878149). PMIDs marked "verify" flagged NEEDS_SOURCE_REVIEW per shard convention.

Entry points (6)

  • history
    ≥1 fall in last 12 months — STEADI screen positive (CDC STEADI 2017; USPSTF 2024 PMID 38833246)
    fall_in_last_12_months
  • symptom
    Gait or balance complaint, fear of falling (AGS/BGS 2010 PMID 21226685)
    gait_balance_complaint
  • symptom
    Post-fall ED visit (with or without injury) — Canadian CT Head Rule applies if anticoag / AMS (AGS 2024)
    post_fall_ed_visit
  • symptom
    Recurrent unexplained falls — full multifactor evaluation (USPSTF 2024; AGS/BGS 2010 PMID 21226685)
    recurrent_unexplained_falls
  • symptom
    Injurious fall (fracture / head injury / laceration requiring repair) — full multifactor evaluation (AGS 2024)
    injurious_fall
  • symptom
    Fried frailty phenotype ≥3/5 (weight loss + exhaustion + slow gait + weakness + low activity) (Fried 2001)
    frailty_screen_positive

Required inputs (26)

  • agerequired
    demographic • used at CONTEXT
    ≥65 = STEADI target population; ≥85 highest risk; risk doubles per decade after 65 (USPSTF 2024)
  • sbprequired
    vital • used at INITIAL_WORKUP
    Orthostatic vitals (supine, 1 and 3 min standing) — drop ≥20 mmHg systolic OR ≥10 mmHg diastolic = orthostatic hypotension (AAN/AAS 2015)
  • hrrequired
    vital • used at INITIAL_WORKUP
    Orthostatic HR change >30 bpm = POTS; bradyarrhythmia / AF screen (AAN/AAS 2015)
  • fall_circumstancesrequired
    symptom • used at CONTEXT
    Mechanical vs medical; loss of consciousness suggests syncope; positional/rotational suggests vertigo
  • injuries_sustainedrequired
    symptom • used at RED_FLAGS
    Fracture, head injury especially on anticoag — CCHR for elderly applies (CDC STEADI 2017)
  • pre_syncopal_featuresrequired
    symptom • used at RED_FLAGS
    Syncope route to symptom.syncope / cardio.neurally-mediated-reflex-syncope.v1 (AGS 2024)
  • prior_falls_countrequired
    history • used at RISK_STRATIFICATION
    ≥2 falls in past 12 mo = STEADI high-risk tier = full multifactor evaluation (USPSTF 2024; AGS/BGS 2010 PMID 21226685)
  • fear_of_falling
    history • used at CONTEXT
    FES-I scale; activity restriction worsens deconditioning (USPSTF 2024)
  • home_environmentrequired
    history • used at CONTEXT
    Stairs, rugs, lighting, bathroom safety, bedside rails — OT home safety assessment (AGS/BGS 2010 PMID 21226685)
  • current_medsrequired
    medication • used at CONTEXT
    STOPP/START v3 + Beers — psychotropic, opioid, anticholinergic, antihypertensive, hypoglycemic, anticoag (O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)
  • vision_impairmentrequired
    history • used at CONTEXT
    Cataract, AMD, glaucoma, refractive error, multifocal lenses on stairs — ophthalmology referral (AGS/BGS 2010)
  • hearing_impairment
    history • used at CONTEXT
    Hearing loss linked to falls + cognitive load — audiology referral (AGS 2024)
  • cognitive_statusrequired
    history • used at CONTEXT
    Dementia/MCI raises risk; co-route symptom.dementia.v1 (AGS 2024)
  • urinary_incontinence
    history • used at CONTEXT
    Nocturia + urgency = bathroom falls — treat underlying (AGS/BGS 2010)
  • footwear_assistive_devicerequired
    history • used at CONTEXT
    Improperly fitted device, slippers, multifocal lenses on stairs (AGS/BGS 2010)
  • vertigo_symptoms
    history • used at CONTEXT
    Spinning / positional vertigo → route to symptom.vertigo.v1 for HINTS+ / Dix-Hallpike workup (AAO-HNS 2017)
  • alcohol_use
    history • used at CONTEXT
    AUDIT-C; even moderate alcohol increases fall risk in elderly (AGS/BGS 2010)
  • vitamin_drequired
    lab • used at INITIAL_WORKUP
    <20 ng/mL deficient = supplement 800 IU; modest fall reduction in deficient only (Bischoff-Ferrari 2009 PMID 19797342)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hypothyroid causes weakness, slowness, hyporeflexia
  • b12
    lab • used at INITIAL_WORKUP
    B12 deficiency → peripheral neuropathy → sensory ataxia
  • a1c
    lab • used at INITIAL_WORKUP
    Hypoglycemia from tight control with sulfonylurea/insulin — relax target to 7.5-8% if severe hypos (ADA 2026; AGS Beers 2023)
  • cbc_renalrequired
    lab • used at INITIAL_WORKUP
    Anemia + AKI shift gait and increase fatigue / orthostatic burden
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Bradyarrhythmia / AV block / AF / long QT — pacemaker candidate if cardio-neurogenic syncope (AGS 2024)
  • ct_head_post_fall
    imaging • used at RED_FLAGS
    Canadian CT Head Rule for elderly — anticoag, AMS, basal skull fracture signs, vomiting, age ≥65 with mechanism — STAT non-contrast CT (AGS 2024)
  • pelvis_hip_xray
    imaging • used at RED_FLAGS
    STAT pelvis / hip XR if hip pain + inability to bear weight after fall (AGS 2024)
  • dxa_bone_density
    imaging • used at BRANCHING_WORKUP
    Osteoporosis → bisphosphonate / denosumab indication; post-fragility fracture pathway (AACE/ACE 2020; USPSTF 2018)

12-phase flow (12)

  1. 1FRAME
    Distinguish fall from near-fall / fear of falling / syncope (route cardio) / vertigo (route symptom.vertigo.v1) / drop attack — latter route to specific engines (USPSTF 2024 PMID 38833246; AGS/BGS 2010 PMID 21226685)
    inputs: fall_circumstances, pre_syncopal_features, vertigo_symptoms
    advance: Event categorized and downstream routes decided
  2. 2ENTRY
    STEADI screen positive, ≥1 fall in past 12 mo, gait/balance complaint, post-fall ED visit, injurious fall, frailty (CDC STEADI 2017; USPSTF 2024; AGS/BGS 2010 PMID 21226685)
    inputs: age
    advance: Entry trigger captured
  3. 3CONTEXT
    Detailed fall history, meds (STOPP/START v3 + Beers), vision/hearing, cognition, footwear, home environment, alcohol, caregiver, urinary symptoms (USPSTF 2024; AGS/BGS 2010 PMID 21226685; O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)
    inputs: current_meds, vision_impairment, cognitive_status, footwear_assistive_device, home_environment, prior_falls_count
    advance: Multifactorial context complete
  4. 4RED_FLAGS
    Head injury on anticoag (CCHR-elderly STAT CT, reverse anticoag if ICH per AHA 2022), fracture (STAT pelvis/hip XR if hip pain), syncope, focal neuro deficit, abuse/neglect, severe orthostatic drop (AGS/BGS 2010 PMID 21226685; AHA 2022 ICH; NICE CG161 2024)
    inputs: injuries_sustained, pre_syncopal_features, ct_head_post_fall, pelvis_hip_xray
    actions: workup.acute_stroke, workup.first_seizure, workup.delirium
    advance: Acute injuries managed; cardiogenic / neurologic mimics excluded
  5. 5INITIAL_WORKUP
    Orthostatic vitals (supine + 1 + 3 min standing), TUG, gait observation, 30-s chair stand, vision (Snellen), cognitive screen (Mini-Cog), CBC/BMP/TSH/B12/vitamin D/A1c, ECG (CDC STEADI 2017; AGS/BGS 2010 PMID 21226685; USPSTF 2024)
    inputs: sbp, hr, vitamin_d, tsh, ecg, cbc_renal
    actions: panel.cbc, panel.renal, panel.thyroid, panel.cardiac, workup.falls
    advance: Multifactorial assessment complete
  6. 6BRANCHING_WORKUP
    DXA if osteoporosis suspected (post-fragility fracture), Holter / tilt table for unexplained syncope, MRI if focal / cervical myelopathy / NPH concern, urodynamics, podiatry, formal PT functional eval, audiometry, ophthalmology (USPSTF 2024; AACE/ACE 2020; AGS/BGS 2010 PMID 21226685)
    inputs: dxa_bone_density
    advance: Selective workup completed
  7. 7DIFFERENTIAL
    Etiology categories: postural/orthostatic hypotension / syncope (cardiac vs reflex vs orthostatic) / gait + balance disorder (neuropathy, PD, NPH, cerebellar) / medication-induced (STOPP/START) / vestibular (route vertigo) / visual impairment / sarcopenia + frailty (Fried) / environmental / cognitive impairment / recurrent ≥2 in 12 mo (USPSTF 2024; AGS/BGS 2010 PMID 21226685)
    advance: Multifactorial drivers identified and categorized
  8. 8RISK_STRATIFICATION
    STEADI tier (low/mod/high); Morse Fall Scale (inpatient — not yet in registry); Hendrich-II (inpatient — not yet in registry); Fried frailty phenotype (≥3/5 = frail); CHA2DS2-VASc + HAS-BLED if anticoag question (CDC STEADI 2017; Fried 2001; AGS/BGS 2010 PMID 21226685)
    inputs: prior_falls_count
    actions: workup.falls
    advance: Risk tier documented
  9. 9TREATMENT
    STOPP/START + Beers deprescribe (HIGHEST-YIELD single intervention); vitamin D 800 IU if deficient (Bischoff-Ferrari 2009 PMID 19797342); PT Otago / tai chi / FaME multicomponent balance + strength (Sherrington Cochrane 2019 PMID 30703272; Campbell BMJ 1997 PMID 9366737); home safety OT; vision correction (cataract surgery, avoid multifocal on stairs); audiology; footwear; treat osteoporosis (DXA → bisphosphonate / denosumab); pacemaker for cardio-neurogenic syncope; midodrine / fludrocortisone for OH; relax glycemic + BP targets (ADA 2026; ACC/AHA HTN 2025; AGS/BGS 2010 PMID 21226685; USPSTF 2024)
    inputs: current_meds, vitamin_d
    advance: Multifactorial intervention plan documented
  10. 10DISPOSITION
    Outpatient PT vs admit if fracture / head injury / unexplained syncope / unable to ambulate / social failure; ICU rare (TBI, hip-fx sepsis) (AGS/BGS 2010 PMID 21226685; NICE CG161 2024)
    advance: Disposition documented
  11. 11MONITORING
    Fall diary; repeat STEADI annually; repeat TUG q6 mo with PT; orthostatic vitals after each antihypertensive change; A1c q3 mo if loosening DM target (CDC STEADI 2017; AGS/BGS 2010 PMID 21226685; ADA 2026)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Multifactorial intervention review at 3 mo; caregiver education; advance care planning if frail; geriatrics co-management if available (AGS/BGS 2010 PMID 21226685; USPSTF 2024)
    advance: Follow-up scheduled