Gait

Gait should be assessed with the help of physiotherapy (PT) and occupational therapy (OT), to ensure that discharge is safe. They will help assess her movement as well as making sure that her home is manageable. OT help with key areas, stairs and Package of Care (PoC) assessment are two very important examples.

Additional consideration should be made for footwear - poorly fitting or high heels carry a higher risk of falling.

Neuro

Muscle strength and Mrs Howells' new unilateral weakness also increases falls risk, but we also need to remember to take into account peripheral sensation too.

Vision

Although it is not addressed in this scenario, it should be considered in her overall management. As presbyopia and macular degeneration are not uncommon in older patients, tripping hazards increase - more so due to mobility and gait issues. Vision assessment, acuity and fields,  should form part of your assessment

Polypharmacy

In its own right, it is a risk factor for falls. However literature also concludes that the link between certain types of medications is stronger overall - we briefly discussed this under medications and confusion. Consider reducing medications that are non-essential. Statins are a good example - in younger patients the benefit outweighs the risk of developing complications of high cholesterol, however in older patients the benefit of this is less obvious (in say a 90 year old). Each patient should be considered individually.

Postural hypotension

Older patients with multiple comorbidities are high risk for postural hypotension. Causes fall under:

Dehydration, Medications, Cardiac, Endocrine, Nervous system and Postprandial.

Cardiac - bradycardia, heart failure and valvular dysfunction

Endocrine - Diabetes, thyroid disease and Addison's disease

Nervous - Parkinson's, Lewy body dementia, Multiple system atrophy (MSA) and amyloidosis.

Cognitive impairment

Wandering, orthostatic hypotension, gait decline are valid things you would consider. However, the purpose here is more to assess the usefulness of their falls history and if recommendations will be complied with.

Continence

As mentioned earlier, LUTS are common in older patients alongside other urological problems. UTIs and urgency are related to falls as - in their crudest form - they cause patients to get up and rush to the toilet. Combined with poor gait, vision, postural hypotension it can therefore cause falls. Not your essential part of the falls assessment, but she did mention that she had urinary symptoms - making this a valid consideration.

ECG

While it does not fit Mrs Howells' history and Normal Sinus Rhythm (NSR) ECG, a patient with a history of unexplained falls should trigger you to consider arrhythmogenic syncopy. Longer ECG tapes or reveal devices are additional investigations alongside ECGs if this is the case.