14.2 Falls, Gait Assessment & Polypharmacy

ABIM Internal Medicine Exam

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2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

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2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

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14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

14.2 Falls, Gait Assessment & Polypharmacy

Key Takeaways Explain This Topic AI

Falls and clinical pharmacology and aging are enumerated under other primary geriatric topics.

All adults 65 and older should be asked annually about falls, and a positive answer triggers a multifactorial assessment.

Psychotropic medications, including benzodiazepines, antipsychotics, sedative hypnotics and antidepressants, are among the strongest modifiable fall risk factors.

The AGS Beers Criteria identify potentially inappropriate medications in older adults and are a starting point for judgment rather than a prohibition list.

Deprescribing should be prioritized by harm potential and aligned with the patient goals of care and estimated time to benefit.

Last updated: August 2026

1. Fall Risk Stratification & Gait Assessment

Falls are the leading cause of fatal and non-fatal injury in adults aged >=65 years. More than 95% of hip fractures result from falls, carrying a 1-year mortality of 20-30%.

CDC STEADI (Stopping Elderly Accidents, Deaths, & Injuries) Algorithm

Every older adult should be screened annually with the 3 STEADI Screening Questions :

Have you fallen in the past year? (If yes, how many times and were you injured?)

Do you feel unsteady when standing or walking?

Do you worry about falling?

If the patient answers YES to any question, they are at elevated fall risk and require objective gait, balance, and strength testing.

Objective Bedside Physical Assessments

Assessment Test Procedure & Measurement Clinical Thresholds & Interpretation

Timed Up and Go (TUG) Test Patient rises from a standard arm chair, walks 3 meters (10 feet) at a comfortable pace, turns around, walks back, and sits down. < 10 seconds: Normal mobility, low fall risk.; > 12 seconds: High fall risk ; mandates multifactorial fall evaluation and physical therapy referral.

4-Stage Balance Test Patient attempts to hold 4 progressively challenging foot positions for 10 seconds each without support:; 1. Side-by-side stance; 2. Semi-tandem stance (heel of one foot beside big toe of other); 3. Tandem stance (heel directly touching toes of other foot); 4. Single-leg stance Inability to hold the tandem stance for a full 10 seconds indicates significant balance impairment and high fall risk.

30-Second Chair Stand Test Patient sits with arms crossed across chest; counts number of full stands achieved in 30 seconds. Evaluates proximal lower extremity muscle strength.; Scores below age- and sex-adjusted normative values (<10-12 stands) indicate sarcopenia and high fall propensity.

Orthostatic Blood Pressure Measurement Measure BP and HR after lying supine for 5 minutes, then repeat at 1 minute and 3 minutes after standing. Positive Orthostatic Hypotension: Drop in SBP >= 20 mmHg OR drop in DBP >= 10 mmHg within 3 minutes of standing.; - Neurogenic Orthostasis: HR fails to increase by >10 bpm (autonomic failure, Parkinson disease, diabetic autonomic neuropathy).; - Non-Neurogenic Orthostasis: HR increases by >15-20 bpm (volume depletion, vasodilatory antihypertensives).

Loading diagram... CDC STEADI Fall Risk Assessment and Multifactorial Intervention Algorithm

• 2. Polypharmacy & The 2023 AGS Beers Criteria
• Definitions and Prescribing Cascades

Polypharmacy: The concurrent use of >=5 medications (Hyper-polypharmacy: >=10 medications).

Prescribing Cascade: An adverse drug reaction (ADR) is misinterpreted as a new medical condition, prompting the initiation of an additional drug, which causes secondary ADRs. Classic examples:

Amlodipine (Dihydropyridine CCB) -> causes peripheral ankle edema -> misdiagnosed as heart failure -> Furosemide started -> causes hypokalemia, orthostasis, and urinary frequency -> Oxybutynin started -> causes acute delirium and constipation.

NSAID -> causes systemic hypertension -> Lisinopril started -> causes bradykinin dry cough -> Dextromethorphan / Codeine started -> causes sedation and falls.

2023 American Geriatrics Society (AGS) Beers Criteria

The Beers Criteria categorize medications that are potentially inappropriate in most older adults due to an unfavorable risk-to-benefit profile.

Medication Class & Specific Agents Primary Clinical Risks & Adverse Sequelae Mechanistic Rationale & Deprescribing Actions

Anticholinergics (Strong) ; Diphenhydramine, Hydroxyzine, Oxybutynin, Chlorpheniramine, Amitriptyline, Paroxetine Acute delirium, cognitive impairment, memory decline, urinary retention, severe constipation, dry mouth, blurred vision, falls/fractures Competitively blocks central and peripheral muscarinic ( M 1 − M 5 M_1-M_5 M 1 ​ − M 5 ​ ) receptors. Avoid completely. Substitute non-pharmacologic sleep hygiene or second-generation antihistamines (Cetirizine, Fexofenadine).

Benzodiazepines & Z-Drugs ; Diazepam, Lorazepam, Alprazolam, Clonazepam, Zolpidem, Eszopiclone, Zaleplon Acute delirium, ataxia, psychomotor slowing, motor vehicle collisions, falls, hip fractures Positive allosteric modulators of G A B A A GABA_A G A B A A ​ receptors. Age-related reduction in hepatic oxidation and increased central sensitivity. Avoid in all older adults. Reserve exclusively for alcohol withdrawal, severe generalized seizure disorders, or severe REM sleep behavior disorder.

Antipsychotics (Typical & Atypical) ; Haloperidol, Olanzapine, Quetiapine, Risperidone, Aripiprazole FDA Black Box Warning: Significantly increased mortality (cardiac sudden death, aspiration pneumonia) and ischemic stroke in dementia-related psychosis Avoid for behavioral and psychological symptoms of dementia (BPSD) unless non-pharmacologic interventions fail AND patient exhibits severe, dangerous physical aggression threatening immediate harm to self/others. If used, titrate to lowest effective dose and taper rapidly.

NSAIDs (Non-COX-selective & COX-2 selective) ; Ibuprofen, Naproxen, Meloxicam, Ketorolac, Indomethacin, Celecoxib Gastrointestinal ulceration/bleeding, acute kidney injury (inhibition of afferent arteriolar prostacyclin vasodilation), worsening hypertension, fluid retention, heart failure exacerbations Avoid chronic scheduled use. If unavoidable for severe osteoarthritis, co-prescribe a Proton Pump Inhibitor (PPI) or misoprostol; prefer topical NSAIDs (Diclofenac gel) or Acetaminophen. Indomethacin and Ketorolac carry the highest CNS and GI toxicity and should be completely avoided.

Skeletal Muscle Relaxants ; Cyclobenzaprine, Methocarbamol, Carisoprodol, Metaxalone, Baclofen Sedation, dizziness, confusion, strong anticholinergic toxicity, fracture risk Poorly tolerated in older adults with minimal evidence of efficacy for chronic musculoskeletal spasms. Avoid entirely.

Sulfonylureas (Long-Acting) ; Glyburide, Glimepiride Prolonged, severe, life-threatening hypoglycemia (due to active metabolites cleared renally) Glyburide is strongly contraindicated due to extreme risk of sustained hypoglycemia. Glimepiride also carries elevated risk. If a sulfonylurea must be used, Glipizide is preferred (shorter duration, inactive metabolites). First-line alternatives: Metformin, SGLT2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors.

Sliding-Scale Regular Insulin (SSI) Higher risk of hypoglycemia without improvement in glycemic control; creates erratic glycemic swings Avoid reactive sliding-scale regular insulin monotherapy without basal insulin. Use scheduled basal insulin (Glargine/Degludec) with fixed prandial insulin if intensive glycemic therapy is clinically indicated.

Proton Pump Inhibitors (PPIs) ; Omeprazole, Pantoprazole, Esomeprazole, Lansoprazole Clostridioides difficile colitis, osteoporotic hip/spine fractures, hypomagnesemia, vitamin B12 deficiency, community-acquired pneumonia, acute interstitial nephritis Avoid scheduled use > 8 weeks unless high-risk compelling indications exist (e.g., severe erosive esophagitis LA Grade C/D, Barrett esophagus, chronic daily oral NSAID/corticosteroid therapy, Zollinger-Ellison syndrome). Taper and discontinue or switch to H2-receptor antagonists (Famotidine).

STOPP / START Criteria for Systematic Deprescribing

STOPP (Screening Tool of Older Persons' Prescriptions): Identifies clinically inappropriate medications (e.g., duplicate drug classes, loop diuretics for ankle edema without heart failure, aspirin for primary prevention in adults >70 without clinical ASCVD).

START (Screening Tool to Alert to Right Treatment): Identifies evidence-based clinical omissions (e.g., statin for secondary prevention of stroke/CAD, ACE inhibitor/ARB in heart failure with reduced ejection fraction or chronic kidney disease with albuminuria, bone protection in osteoporosis).