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Geriatric EM: Falls Can Be Sentinel Events

Phraewa Thatphet, MD |



A 72-year-old woman is brought to your Emergency Department (ED) after falling while rushing to the toilet. She has no visible deformity on examination and is discharged with pain medications. Two weeks later, EMS transports her to the ED after a loss of consciousness. Computed tomography (CT) of the head at that time shows a subdural hematoma.

Unfortunately, this scenario is common. Given time constraints in the ED, management plans often miss opportunities to assess a patient’s risk for falling and may not be compliant with recommendations [1, 2]. However, falling can be a sentinel event for older adult patients [3].

Falls can be sentinel events

While emergency physicians may focus on trauma burden or concern for cardiac arrhythmia acutely, falls have a surprisingly high one-year mortality rate at 21.9% [4]. Falling causes up to 12% of deaths in the geriatric population [5]. They can lead to both serious and non-serious complications, for example, fractures and intracranial injury, a decline in health and function, social isolation, increased risk of nursing home admission, and loss of confidence [6-11]. Providers in the ED can begin the process of detecting who is at high-risk for falling in the future to prevent such high morbidity and mortality.

Quick assessment in the ED

Unfortunately, while there are many tools to screen for fall risk, none have been validated in the ED. Below are some tools that can be used as part of a more complete clinical assessment.

The STEADI Algorithm [12, 13] comprises various components, including:

  1. Screening questions
    • Have you fallen in the past year? If so, how many?
    • Do you feel unsteady when standing or walking?
    • Do you worry about falling?
  2. Timed Up and Go (TUG) test [12, 14, 15]
    • The patient sits in a standard armchair. When the provider says “Go,” the patient stands up from the chair, walks 3 meters (10 feet), turn, and walk back to sit at the chair. The provider records the time.
  3. Observe the patient for gait/balance instability.

If “Yes” to any question, a TUG ≥12 seconds, or gait or balance instability, the patient may be at risk of fall and further assessment should be considered.


Tiedemann’s Brief Performance-Based Fall Risk assessment tool [16]

  1. History taking
    • Previous fall? (Y/N)
    • Medication review
      • Four or more (excluding vitamins)? (Y/N)
      • Any psychotropic? (Y/N)
  1. Visual acuity test – Unable to see all of line 16 on a low contrast visual acuity test (Y/N)
  2. Peripheral sensation test – Unable to feel 2 out of 3 trials (Y/N)
  3. Balance/Coordinated Stepping/Strength
    • Near tandem stand test (balance)- Unable to stand for 10 secs (Y/N)
    • Alternate step test (coordinated stepping)- Unable to complete in 10 secs (Y/N)
    • Sit to stand test (strength)- Unable to complete in 12 secs (Y/N)

Each “Yes” gets 1 score. We can compare the score(s) with the probability of falling.

Number of risk factors Probability of falling
0-1 7%
2-3 13%
4-5 27%
6+ 49%


Carpenter’s ED fall risk questions [6]

  1. Presence of non-healing foot sore?
  2. Any fall in the past 12 months?
  3. Inability to cut his/her own toenails?
  4. Self-reported depression?

If there is more than 1 factor present, the patient is at increased risk for a fall in 6 months. If you are unable to use one of these screening tools, it may be most useful to review high-risk medications and observe them walk.


High-risk medications [17]

  • Sedative-hypnotic and anxiolytic drugs (especially long-acting benzodiazepines)
  • Tricyclic antidepressants
  • Major tranquilizers (phenothiazines and butyrophenones)
  • Antihypertensive drugs
  • Cardiac medications
  • Corticosteroids
  • Nonsteroidal anti-inflammatory drugs
  • Anticholinergic drugs
  • Hypoglycemic agents
  • Any medication that is likely to affect balance


Educate the patient

An important consideration is to educate the patient on fall prevention. The American College of Emergency Physicians sponsored the creation of a video, the 7 Step Challenge to Prevent Falls, that you can include in your patient’s discharge summary or have them watch prior to discharge.

Take Home Points

  • Falls can be sentinel events and represent a high risk for morbidity and mortality for older adult patients.
  • Emergency physicians can play a crucial role in identifying patients at risk and preventing future injury.



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Author information

Phraewa Thatphet, MD

Phraewa Thatphet, MD

Research Fellow
Division of Geriatric Emergency Medicine
Department of Emergency Medicine
Massachusetts General Hospital
Emergency Physician
Department of Emergency Medicine
Khon Kaen University

The post Geriatric EM: Falls Can Be Sentinel Events appeared first on ALiEM.

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