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geriatrics.falls.core.v1PRODUCTION
geriatrics.falls.core.v1

Falls in older adults

general_internal_medicinechronicsubacutegeriatricadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
1
Actions
0
Advance rule
Set
Advance when

Patient in scope for annual falls screening or post-fall multifactorial assessment (World Falls Guidelines 2022)

Patient inputs (12)

Mechanical (trip/slip) vs unexplained vs syncopal (LOC, prodrome, witness account) — pivots syncope workup (AGS/BGS)

Fall-risk-increasing drugs (FRIDs): psychotropics, benzodiazepines, antihypertensives, anticholinergics, hypoglycemics, anticoagulants (World Falls Guidelines 2022)

Number, circumstances, injuries, witnessed/unwitnessed; >=1 fall/year or recurrent (>=2) drives stratification (World Falls Guidelines 2022)

Falls screening threshold >=65; injury and intervention thresholds age-stratified (USPSTF 2024)

Orthostatic hypotension (>=20 mmHg SBP or >=10 mmHg DBP drop at 1 and 3 min) is a core treatable contributor (AGS/BGS)

Head injury on DOAC/warfarin/antiplatelet → low threshold non-contrast CT head; delayed subdural risk (AGS/BGS)

TUG, gait speed, 30-s chair stand, Berg balance — defines low/intermediate/high risk (World Falls Guidelines 2022)

Arrhythmia / carotid sinus hypersensitivity as syncopal-fall cause; cardioinhibitory CSS may warrant pacing (AGS/BGS)

Visual acuity, cataract, bifocal/multifocal lens use on stairs — modifiable contributor (World Falls Guidelines 2022)

Cognitive impairment increases falls risk and modifies exercise/home-hazard plan (AGS/BGS)

Home hazard exposure (rugs, lighting, stairs, footwear) — OT home-hazard intervention target (World Falls Guidelines 2022)

Vitamin D supplementation indicated only if deficient; routine supplementation NOT recommended (USPSTF 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningsyncopal_cardiac_fall
    Fall with witnessed loss of consciousness, no prodrome/recall, or with arrhythmia/structural cardiac suspicion — syncope, not a mechanical fall (AGS/BGS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghead_injury_on_anticoagulant
    Head strike or unwitnessed fall in patient on DOAC, warfarin, or antiplatelet — risk of intracranial / delayed subdural hemorrhage (AGS/BGS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningspinal_cord_injury_post_fall
    Post-fall neck/back pain with neurologic deficit, urinary retention, or saddle anesthesia — spinal cord / cauda equina injury (AGS/BGS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehip_or_long_bone_fracture
    Suspected hip or long-bone fracture after a fall — inability to bear weight, deformity, shortening/external rotation (World Falls Guidelines 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelong_lie_rhabdomyolysis
    Prolonged lie after fall (>1 h on floor) with elevated CK, AKI, hyperkalemia, pressure injury, or hypothermia (AGS/BGS)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_unexplained_falls
    Two or more falls in 12 months without clear mechanical cause, or any unexplained fall (no recalled trip/slip and no witnessed precipitant) (World Falls Guidelines 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Multifactorial falls prevention — exercise-cornerstone bundle (World Falls Guidelines 2022)
axis: falls_multifactorial_preventionstep 1 - Step 1 — Screen + stratify
Selected step "Step 1 — Screen + stratify" — Annual screen positive (>=1 fall/year, gait-balance problem, or fear of falling) or post-fall
  • three_question_falls_screen
    first line
    screening_action
    triggers: age_>=65, routine_visit, post_fall
    World Falls Guidelines 2022 — annual screen: fall in past year, gait/balance problem, fear of falling; any positive → multifactorial assessment
  • gait_balance_performance_testing
    first line
    assessment_action
    triggers: positive_screen, recurrent_falls
    TUG, gait speed, 30-s chair stand, Berg balance stratify low/intermediate/high risk (World Falls Guidelines 2022)

outpatient playbook — drug actions (3)

  1. 1. structured strength + balance exercise (Otago/Tai Chi)
    progressive program 3x/week, ongoing • non-pharmacologic • ongoing
    trigger: Intermediate/high risk able to participate
    Cornerstone — strongest evidence (World Falls Guidelines 2022)
  2. 2. FRID deprescribing
    gradual taper of psychotropics/benzodiazepines; review antihypertensives/anticholinergics/hypoglycemics • non-pharmacologic • staged
    trigger: FRIDs present
    Withdraw/limit psychotropics (World Falls Guidelines 2022)
  3. 3. vitamin D repletion
    replete only if 25-OHD deficient • PO • per deficiency protocol
    trigger: Documented deficiency
    NOT routine — USPSTF 2024 recommends against routine supplementation for falls prevention

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: >=1 fall in the past 12 months — positive annual falls screen (World Falls Guidelines 2022); Self-reported or observed gait/balance difficulty or unsteadiness (AGS/BGS); Fear of falling / activity restriction — 3rd screening question (World Falls Guidelines 2022).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Falls in older adults** (geriatrics.falls.core.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Multifactorial falls prevention — exercise-cornerstone bundle (World Falls Guidelines 2022)** — step "Step 1 — Screen + stratify".
1. three_question_falls_screen (screening_action, first line) — World Falls Guidelines 2022 — annual screen: fall in past year, gait/balance problem, fear of falling; any positive → multifactorial assessment
2. gait_balance_performance_testing (assessment_action, first line) — TUG, gait speed, 30-s chair stand, Berg balance stratify low/intermediate/high risk (World Falls Guidelines 2022)

Setting playbook (outpatient) — Annual screen, multifactorial assessment, and risk-tiered prevention bundle with exercise as the cornerstone
3. structured strength + balance exercise (Otago/Tai Chi) progressive program 3x/week, ongoing non-pharmacologic ongoing — Intermediate/high risk able to participate (Cornerstone — strongest evidence (World Falls Guidelines 2022))
4. FRID deprescribing gradual taper of psychotropics/benzodiazepines; review antihypertensives/anticholinergics/hypoglycemics non-pharmacologic staged — FRIDs present (Withdraw/limit psychotropics (World Falls Guidelines 2022))
5. vitamin D repletion replete only if 25-OHD deficient PO per deficiency protocol — Documented deficiency (NOT routine — USPSTF 2024 recommends against routine supplementation for falls prevention)

Non-pharmacologic actions:
- OT home-hazard assessment + modification
- Vision correction / expedited cataract surgery; avoid bifocals on stairs
- Footwear advice + podiatry referral
- Orthostatic hypotension non-pharmacologic measures
- Refer to bone-health/fracture-liaison service if fracture risk
- Falls/exercise education + falls diary

AVOID / contraindication checks:
- Routine_vitamin_D_without_documented_deficiency_not_recommended_for_falls_prevention (USPSTF 2024)
- Avoid_bifocal_multifocal_lenses_on_stairs_increases_falls (World Falls Guidelines 2022)
- Abrupt_benzodiazepine_or_psychotropic_withdrawal_seizure_rebound_risk_taper_gradually (World Falls Guidelines 2022)
- Carotid_sinus_massage_contraindicated_if_carotid_bruit_or_recent_stroke_MI (AGS/BGS)
- Unsupervised_assistive_device_handout_without_PT_fitting_may_increase_falls (AGS/BGS)

Monitoring

Regimen monitoring:
- falls diary continuous (World Falls Guidelines 2022)
- TUG and gait speed reassessment q3-6mo (World Falls Guidelines 2022)
- orthostatic BP recheck after each antihypertensive change (AGS/BGS)
- exercise adherence review q1-3mo (Cochrane)
- bone health DXA and vitamin D followup if treated (World Falls Guidelines 2022)
- FRID reconciliation at every visit and care transition (World Falls Guidelines 2022)

Setting (outpatient) monitoring:
- Falls diary review each visit (World Falls Guidelines 2022)
- TUG/gait speed reassessment q3-6mo (World Falls Guidelines 2022)
- Orthostatic BP recheck after antihypertensive change (AGS/BGS)
- Exercise adherence q1-3mo (Cochrane)

Follow-up plan: 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)
- Close-out criterion: Next reassessment scheduled and bone-health/PT-OT loop closed (World Falls Guidelines 2022)

Monitoring phase: 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)

Disposition

Current setting: outpatient — Annual screen, multifactorial assessment, and risk-tiered prevention bundle with exercise as the cornerstone

Disposition criteria:
- Low risk: reassess annually with education (USPSTF 2024)
- Intermediate/high risk: enrolled in exercise + targeted interventions, reassess 3-6 months (World Falls Guidelines 2022)
- Refer high-risk/complex to multidisciplinary falls service (AGS/BGS)

Escalation triggers (move to higher acuity):
- Syncope/cardiac cause suspected → cardiology + monitored workup (AGS/BGS)
- Injurious fall (fracture/head injury) → ED for imaging (AGS/BGS)
- Recurrent unexplained falls despite intervention → specialist falls clinic (World Falls Guidelines 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Fall with witnessed loss of consciousness, no prodrome/recall, or with arrhythmia/structural cardiac suspicion — syncope, not a mechanical fall (AGS/BGS)
- [LIFE_THREATENING] Head strike or unwitnessed fall in patient on DOAC, warfarin, or antiplatelet — risk of intracranial / delayed subdural hemorrhage (AGS/BGS)
- [LIFE_THREATENING] Post-fall neck/back pain with neurologic deficit, urinary retention, or saddle anesthesia — spinal cord / cauda equina injury (AGS/BGS)

Citations

- World Falls Guidelines 2022 (Montero-Odasso) + 2024 USPSTF falls prevention + AGS/BGS [PMID:36178003](https://pubmed.ncbi.nlm.nih.gov/36178003/)
- Cited evidence (PMID 38805261) [PMID:38805261](https://pubmed.ncbi.nlm.nih.gov/38805261/)
- Cited evidence (PMID 22972103) [PMID:22972103](https://pubmed.ncbi.nlm.nih.gov/22972103/)
- Cited evidence (PMID 31808787) [PMID:31808787](https://pubmed.ncbi.nlm.nih.gov/31808787/)
- Cited evidence (PMID 38805262) [PMID:38805262](https://pubmed.ncbi.nlm.nih.gov/38805262/)

Last reconciled with current guidelines: 2026-05-16.
References