Clinical Commander

Back to dossier
symptom.falls.v1PRODUCTION
symptom.falls.v1

Falls and fall risk (older adult)

symptomchronicsubacuteundifferentiatedadultgeriatric
Hard-required inputs
0 / 16
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

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
3
Actions
0
Advance rule
Set
Advance when

Event categorized and downstream routes decided

Patient inputs (26)

≥65 = STEADI target population; ≥85 highest risk; risk doubles per decade after 65 (USPSTF 2024)

Mechanical vs medical; loss of consciousness suggests syncope; positional/rotational suggests vertigo

Stairs, rugs, lighting, bathroom safety, bedside rails — OT home safety assessment (AGS/BGS 2010 PMID 21226685)

STOPP/START v3 + Beers — psychotropic, opioid, anticholinergic, antihypertensive, hypoglycemic, anticoag (O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)

Cataract, AMD, glaucoma, refractive error, multifocal lenses on stairs — ophthalmology referral (AGS/BGS 2010)

Dementia/MCI raises risk; co-route symptom.dementia.v1 (AGS 2024)

Improperly fitted device, slippers, multifocal lenses on stairs (AGS/BGS 2010)

Orthostatic vitals (supine, 1 and 3 min standing) — drop ≥20 mmHg systolic OR ≥10 mmHg diastolic = orthostatic hypotension (AAN/AAS 2015)

Orthostatic HR change >30 bpm = POTS; bradyarrhythmia / AF screen (AAN/AAS 2015)

<20 ng/mL deficient = supplement 800 IU; modest fall reduction in deficient only (Bischoff-Ferrari 2009 PMID 19797342)

Hypothyroid causes weakness, slowness, hyporeflexia

Anemia + AKI shift gait and increase fatigue / orthostatic burden

Bradyarrhythmia / AV block / AF / long QT — pacemaker candidate if cardio-neurogenic syncope (AGS 2024)

Fracture, head injury especially on anticoag — CCHR for elderly applies (CDC STEADI 2017)

Syncope route to symptom.syncope / cardio.neurally-mediated-reflex-syncope.v1 (AGS 2024)

≥2 falls in past 12 mo = STEADI high-risk tier = full multifactor evaluation (USPSTF 2024; AGS/BGS 2010 PMID 21226685)

Osteoporosis → bisphosphonate / denosumab indication; post-fragility fracture pathway (AACE/ACE 2020; USPSTF 2018)

FES-I scale; activity restriction worsens deconditioning (USPSTF 2024)

Hearing loss linked to falls + cognitive load — audiology referral (AGS 2024)

Nocturia + urgency = bathroom falls — treat underlying (AGS/BGS 2010)

Spinning / positional vertigo → route to symptom.vertigo.v1 for HINTS+ / Dix-Hallpike workup (AAO-HNS 2017)

AUDIT-C; even moderate alcohol increases fall risk in elderly (AGS/BGS 2010)

B12 deficiency → peripheral neuropathy → sensory ataxia

Hypoglycemia from tight control with sulfonylurea/insulin — relax target to 7.5-8% if severe hypos (ADA 2026; AGS Beers 2023)

Canadian CT Head Rule for elderly — anticoag, AMS, basal skull fracture signs, vomiting, age ≥65 with mechanism — STAT non-contrast CT (AGS 2024)

STAT pelvis / hip XR if hip pain + inability to bear weight after fall (AGS 2024)

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

Severity triggers (13)

13 need judgement
  • informationallife_threateninghead_injury_on_anticoagulation
    Fall with head impact in patient on anticoagulation (warfarin / DOAC) — Canadian CT Head Rule elderly indication; ICH must be ruled out (AGS/BGS 2010 PMID 21226685; CCHR; AHA 2022 ICH)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereunexplained_syncopal_fall
    Loss of consciousness with fall and unexplained etiology — cardiogenic vs reflex vs orthostatic; route to symptom.syncope pathway (AGS/BGS 2010 PMID 21226685)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_2plus_in_12mo
    ≥2 falls in past 12 months OR injurious fall in past 6 months — high-risk tier triggering full multifactor evaluation (USPSTF 2024 PMID 38833246; CDC STEADI 2017; AGS/BGS 2010 PMID 21226685)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinjurious_fall
    Fall resulting in fracture, head injury, laceration requiring repair, or hospitalization (AGS/BGS 2010 PMID 21226685; USPSTF 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanticoagulant_post_fall_ich_rule_out
    Post-fall evaluation in patient on anticoag (even without head impact) — low threshold for CT head; reassess anticoag benefit vs falls with HAS-BLED (AGS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremedication_induced_fall
    Fall temporally associated with STOPP-listed or Beers-listed medication — psychoactives (benzo, z-drug, opioid, anticholinergic), hypoglycemics (sulfonylurea, insulin tight control), antihypertensives (overshoot), alpha-blockers, first-gen antihistamine (O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hypoglycemia_in_diabetes
    Severe hypoglycemia (level 3 — requiring 3rd-party assistance) precipitating fall in patient with DM on sulfonylurea or insulin (ADA 2026; AGS Beers 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefragility_fracture_post_fall
    Hip / vertebral / wrist / proximal humerus fracture after fall from standing height (USPSTF 2018; AACE/ACE 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereelder_abuse_or_neglect_concern
    Pattern of injury inconsistent with mechanism, fearful patient, isolated, neglect signs (poor hygiene, malnutrition, untreated pressure ulcer, missed meds) (AGS 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateorthostatic_hypotension_severe
    Symptomatic SBP drop ≥20 mmHg OR DBP drop ≥10 mmHg within 3 min standing (AAN/AAS 2015) — reconcile antihypertensives, diuretics, alpha-blockers FIRST; midodrine/fludrocortisone if persistent
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefrailty_phenotype_or_sarcopenia
    Fried frailty phenotype ≥3/5 (weight loss + exhaustion + slow gait + weakness + low activity) OR sarcopenia (low muscle mass + low strength) (Fried 2001; EWGSOP2 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecognitive_impairment_concurrent
    MoCA <26 OR Mini-Cog positive OR known dementia diagnosis — co-route symptom.dementia.v1; raises fall risk 2-3x (AGS/BGS 2010 PMID 21226685)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevision_impairment_severe
    Significantly reduced visual acuity (Snellen worse than 20/40), cataract, AMD, glaucoma, multifocal lenses on stairs (AGS/BGS 2010 PMID 21226685)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
Loading…

Recommended regimen

Deprescribing axis — falls are usually a deprescribing problem (STOPP/START v3 — O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)
axis: falls_deprescribe_first
Selected axis "Deprescribing axis — falls are usually a deprescribing problem (STOPP/START v3 — O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)" by default fallback (first axis)

outpatient playbook — drug actions (5)

  1. 1. STOPP/START + Beers deprescribe
    taper per agent • PO • over weeks
    trigger: Any STOPP-listed or Beers-listed drug + falls
    HIGHEST-YIELD single intervention — O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824
  2. 2. cholecalciferol (vitamin D3)
    800-2000 IU PO daily (50,000 IU weekly × 8 wk if <20 ng/mL) • PO • daily
    trigger: Vitamin D <20 ng/mL
    Bischoff-Ferrari 2009 PMID 19797342 — modest fall reduction in deficient only; USPSTF 2024 recommends against universal supplementation
  3. 3. osteoporosis therapy if DXA T-score ≤ -2.5 OR FRAX above threshold OR prior fragility fx
    per axis • PO/IV/SC • weekly to yearly
    trigger: Osteoporosis confirmed (AACE/ACE 2020)
    Fracture reduction; HORIZON-PFT post-hip-fracture mortality benefit (PMID 17878149)
  4. 4. midodrine 2.5-5 mg TID
    2.5-5 mg • PO • TID daytime
    trigger: Symptomatic OH after non-pharm (compression stockings, salt liberalization)
    AAN/AAS 2015 orthostatic hypotension
  5. 5. sulfonylurea / insulin de-escalation
    taper or substitute (DPP-4 or SGLT2 if appropriate) • PO/SC • per axis
    trigger: Severe hypoglycemia + falls + A1c <7%
    ADA 2026 — relax A1c to 7.5-8% in older adults with severe hypos; AGS Beers 2023 glyburide avoidance

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ≥1 fall in last 12 months — STEADI screen positive (CDC STEADI 2017; USPSTF 2024 PMID 38833246); Gait or balance complaint, fear of falling (AGS/BGS 2010 PMID 21226685); Post-fall ED visit (with or without injury) — Canadian CT Head Rule applies if anticoag / AMS (AGS 2024).

Objective

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

Assessment

**Falls and fall risk (older adult)** (symptom.falls.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Deprescribing axis — falls are usually a deprescribing problem (STOPP/START v3 — O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)**.

Setting playbook (outpatient) — Comprehensive multifactor evaluation — medications (Beers + STOPP/START v3), gait/balance (TUG / Tinetti POMA / Berg), orthostatic vitals, vision, hearing, footwear, home hazards, vit D / Ca, bone density (DXA), exercise prescription (Otago / FaME / tai chi), referral PT/OT/audiology/ophtho/podiatry/geriatrics (USPSTF 2024 PMID 38833246; AGS/BGS 2010 PMID 21226685; CDC STEADI 2017; Sherrington Cochrane 2019 PMID 30703272)
1. STOPP/START + Beers deprescribe taper per agent PO over weeks — Any STOPP-listed or Beers-listed drug + falls (HIGHEST-YIELD single intervention — O'Mahony 2023 PMID 37256475; AGS Beers 2023 PMID 37139824)
2. cholecalciferol (vitamin D3) 800-2000 IU PO daily (50,000 IU weekly × 8 wk if <20 ng/mL) PO daily — Vitamin D <20 ng/mL (Bischoff-Ferrari 2009 PMID 19797342 — modest fall reduction in deficient only; USPSTF 2024 recommends against universal supplementation)
3. osteoporosis therapy if DXA T-score ≤ -2.5 OR FRAX above threshold OR prior fragility fx per axis PO/IV/SC weekly to yearly — Osteoporosis confirmed (AACE/ACE 2020) (Fracture reduction; HORIZON-PFT post-hip-fracture mortality benefit (PMID 17878149))
4. midodrine 2.5-5 mg TID 2.5-5 mg PO TID daytime — Symptomatic OH after non-pharm (compression stockings, salt liberalization) (AAN/AAS 2015 orthostatic hypotension)
5. sulfonylurea / insulin de-escalation taper or substitute (DPP-4 or SGLT2 if appropriate) PO/SC per axis — Severe hypoglycemia + falls + A1c <7% (ADA 2026 — relax A1c to 7.5-8% in older adults with severe hypos; AGS Beers 2023 glyburide avoidance)

Non-pharmacologic actions:
- PT referral for Otago / FaME / multicomponent balance + strength (Campbell BMJ 1997 PMID 9366737; Sherrington Cochrane 2019 PMID 30703272)
- Tai chi class enrollment (Sherrington Cochrane 2019)
- OT home safety visit
- Ophthalmology referral — cataract surgery if indicated; avoid multifocal lenses on stairs
- Audiology referral + hearing aid evaluation
- Podiatry for foot care + footwear fitting
- Geriatrics consultation if available — co-management improves outcomes
- Adult Protective Services if abuse / neglect suspected (mandatory reporting)
- Driving safety reassessment
- Caregiver education + emergency response system

AVOID / contraindication checks:
- Beers_taper_benzodiazepine_in_elderly (AGS Beers 2023 PMID 37139824)
- Beers_taper_anticholinergic_first_generation_antihistamine_TCA_oxybutynin (AGS Beers 2023)
- Beers_taper_zolpidem_z_drug (AGS Beers 2023)
- Beers_taper_long_acting_sulfonylurea_glyburide (AGS Beers 2023; ADA 2026)
- Beers_avoid_NSAID_chronic_in_elderly (AGS Beers 2023)
- Stopp_avoid_opioid_chronic_without_laxative (O'Mahony 2023 PMID 37256475)
- Stopp_taper_alpha_blocker_in_orthostatic_hypotension (O'Mahony 2023 PMID 37256475)
- Relax_BP_target_140_150_systolic_if_falls (USPSTF 2024; ACC/AHA HTN 2025)
- Relax_A1c_target_7.5_to_8_if_severe_hypos (ADA 2026; AGS Beers 2023)
- Reassess_anticoag_benefit_vs_falls_HASBLED (AGS 2024)

Monitoring

Regimen monitoring:
- reassess at 4 6 wks after each taper (AGS/BGS 2010 PMID 21226685)
- orthostatic vitals after antihypertensive change (CDC STEADI 2017)
- A1c q3 mo if loosening target (ADA 2026)
- cognitive screen after anticholinergic taper (AGS Beers 2023)

Setting (outpatient) monitoring:
- TUG q3-6 mo on PT (CDC STEADI 2017)
- Fall diary (AGS/BGS 2010 PMID 21226685)
- Repeat STEADI annually
- DXA q2 yr if on osteoporosis Rx (USPSTF 2018)
- Orthostatic vitals at each visit + after every antihypertensive change
- A1c q3 mo if loosening DM target

Follow-up plan: 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)
- Close-out criterion: Follow-up scheduled

Monitoring phase: 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)

Disposition

Current setting: outpatient — Comprehensive multifactor evaluation — medications (Beers + STOPP/START v3), gait/balance (TUG / Tinetti POMA / Berg), orthostatic vitals, vision, hearing, footwear, home hazards, vit D / Ca, bone density (DXA), exercise prescription (Otago / FaME / tai chi), referral PT/OT/audiology/ophtho/podiatry/geriatrics (USPSTF 2024 PMID 38833246; AGS/BGS 2010 PMID 21226685; CDC STEADI 2017; Sherrington Cochrane 2019 PMID 30703272)

Disposition criteria:
- Continue multifactorial plan if improving (TUG improving, fall diary stable)
- Specialty referrals as appropriate
- 3-mo intervention review then annually

Escalation triggers (move to higher acuity):
- New syncope → cardio.neurally-mediated-reflex-syncope.v1 / cardio.afib.core.v1
- New focal deficit → neuro.ischaemic-stroke.v1
- Fracture → ortho + admission
- New positional vertigo → symptom.vertigo.v1 (Dix-Hallpike workup)
- New cognitive decline → symptom.dementia.v1
- Refractory OH despite midodrine + fludrocortisone → autonomic neurology referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Fall with head impact in patient on anticoagulation (warfarin / DOAC) — Canadian CT Head Rule elderly indication; ICH must be ruled out (AGS/BGS 2010 PMID 21226685; CCHR; AHA 2022 ICH)
- [SEVERE] Loss of consciousness with fall and unexplained etiology — cardiogenic vs reflex vs orthostatic; route to symptom.syncope pathway (AGS/BGS 2010 PMID 21226685)
- [SEVERE] ≥2 falls in past 12 months OR injurious fall in past 6 months — high-risk tier triggering full multifactor evaluation (USPSTF 2024 PMID 38833246; CDC STEADI 2017; AGS/BGS 2010 PMID 21226685)

Citations

- USPSTF Falls Prevention 2024 update + CDC STEADI 2017 + AGS/BGS Falls Guideline 2010 update (with 2024 update incorporated) + AGS BEERS 2023 + STOPP/START v3 (O'Mahony 2023) + Sherrington Cochrane Exercise 2019 + Campbell Otago 1997 + Bischoff-Ferrari vit D 2009 [PMID:38833246](https://pubmed.ncbi.nlm.nih.gov/38833246/)
- Cited evidence (PMID 21226685) [PMID:21226685](https://pubmed.ncbi.nlm.nih.gov/21226685/)
- Cited evidence (PMID 9366737) [PMID:9366737](https://pubmed.ncbi.nlm.nih.gov/9366737/)
- Cited evidence (PMID 30703272) [PMID:30703272](https://pubmed.ncbi.nlm.nih.gov/30703272/)
- Cited evidence (PMID 19797342) [PMID:19797342](https://pubmed.ncbi.nlm.nih.gov/19797342/)

Last reconciled with current guidelines: 2026-05-14.
References
  • USPSTF Falls Prevention 2024 update + CDC STEADI 2017 + AGS/BGS Falls Guideline 2010 update (with 2024 update incorporated) + AGS BEERS 2023 + STOPP/START v3 (O'Mahony 2023) + Sherrington Cochrane Exercise 2019 + Campbell Otago 1997 + Bischoff-Ferrari vit D 2009 — PMID:38833246
  • Cited evidence (PMID 21226685) — PMID:21226685
  • Cited evidence (PMID 9366737) — PMID:9366737
  • Cited evidence (PMID 30703272) — PMID:30703272
  • Cited evidence (PMID 19797342) — PMID:19797342