Fall History Taking – OSCE Guide

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Taking a comprehensive fall history is an important skill often assessed in OSCEs. This guide provides a structured framework for taking a history from a patient following a fall in an OSCE setting.


Background

Falls are common in older people, with around 50% of patients over 80 having at least one fall a year.Falls are a significant cause of trauma and disability in older people and a common presentation in emergency departments. 

Falls are often multifactorial, and many risk factors can contribute to someone having a fall.A thorough fall history is vital to identify risk factors and help manage and prevent future falls. 

Risk factors for falls are split into activity (what the person is doing), environment (where the person is, are there any safety risks), and person (history of falls, advanced age, visual problems, muscle weakness, abnormal gait, impaired balance).

These risks can be managed by treating any underlying cause, making reasonable environmental adaptations, and encouraging strength and balance training to prevent further falls.

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Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient, including your name and role.

Confirm the patient’s name and date of birth.

Explain that you’d like to take a history from the patient.

Gain consent to proceed with history taking.

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

  • Demonstrating empathy in response to patient cues: both verbal and non-verbal.
  • Active listening: through body language and your verbal responses to what the patient has said.
  • An appropriate level of eye contact throughout the consultation.
  • Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
  • Making sure not to interrupt the patient throughout the consultation.
  • Establishing rapport (e.g. asking the patient how they are and offering them a seat).
  • Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
  • Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about the fall?”
Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.


History of presenting complaint

The purpose of a fall history is to find out:

  • What happened to cause the fall?
  • What are the consequences of the fall?
  • Is there anything we could do to prevent further falls?

Covering these points will allow you to assess the fall fully. The best way to do this is to assess events before, during and after the fall systematically.

Before the fall

Clarify when the fall occurred:

  • “When did you fall? Do you remember the time?”

It is important to clarify when the fall happened, so we can determine a time scale for how long they were on the floor if they could not get up. 

Ask about activities before the fall:

  • “What were you doing just before you fell?”
  • “Talk me through what you were doing before you fell”

Falls may be related to the activity (e.g. gardening, exercising, carrying shopping). It may also indicate underlying pathology (e.g. standing up, suggesting postural hypotension)

Ask about warning signs and physical symptoms before the fall:

  • “Did you think you were going to fall over?”
  • “Did anything feel different this time compared to times when you haven’t fallen?”
  • “Did you have any symptoms such as dizziness or palpitations before the fall?”

This is important for ascertaining any underlying pathology, which will be screened in more detail later in the consultation.

During the fall

Ask about the nature of the fall. This is an opportunity for the patient to describe the act of falling in as much detail as possible. However, some patients may not be able to recall all the information, so closed questions can act as prompts:

  • “How did you fall?”
  • “Did you trip over, or did you just fall?”
  • “Can you remember what direction you fell?”
  • “Did anything break your fall?”
  • “Did you hit your head or any other part of your body?”

Clarify how the patient landed (if they remember):

  • “What did you fall onto?”
  • “What position were you in when you landed”

Ask about loss of consciousness:

  • “Did you black out at any point? Either before, during, or after you had fallen?”
  • “Do you remember falling? What about hitting the ground?”

This question is particularly important as it can indicate the underlying pathology and the patient’s recollection of the events. If they did lose consciousness, the patient may be unable to remember falling. Instead, they will remember finding themselves on the floor.

Loss of consciousness can help distinguish a fall from an episode of transient loss of consciousness (TLOC). Loss of consciousness is usually associated with hypotension, syncopal symptoms, cardiac causes, and neurological causes.

Ask what the patient did when they started to fall:

  • “What did you do when you felt yourself falling?”
  • “Did you try and break your fall?”

Some patients try to re-position themselves as a natural reflex to falling. Other patients may try to reach out and grab something nearby. 

After the fall

Clarify how long the patient was on the ground:

  • “How long were you lying on the floor?”

This is a key question because it can give us a lot of information, both physically and from a social perspective. A fall with a prolonged period lying on the ground (‘fall with a long lie’) is associated with complications, including rhabdomyolysis, pressure damage and neurovascular compromise. 

Asking this question may identify social or safeguarding issues (e.g. if the patient lives with people, was there a delay in helping them up?). 

Ask if the patient was able to get up by themselves:

  • “Did you manage to get up yourself?”

If the patient was unable to get up, ask how they sought help and who came to help:

  • “Did someone come to help you?”
  • “Did you call someone? Who?”
  • “Was it a family member, neighbour, or carer?”

This can tell us a lot about the patient’s social background and support networks.

Explore how the patient felt after the fall:

  • “How did you feel right after the fall?”
  • “Did you have any pain?”
  • “Did you have any other symptoms such as feeling sick, vomiting or feeling dizzy?”

These symptoms can tell us about the consequences of the fall. 

Now

Ask how the patient feels now:

  • “How are you feeling at the moment?”

Ask directly about specific symptoms which may indicate injuries following the fall:

  • “Do you have any pain anywhere?”
  • “Do you have any bruising or swelling?”
  • “Do you have any weakness?”

This is a key screening question to identify injuries caused by the fall.

Ask about further falls since the original fall. Depending on the setting of the consultation, the patient may have had further falls since the main episode:

  • “Have you had any further falls since then? If so, how many?”

Explore how the fall is affecting the patient:

  • “How have things been since the fall?”
  • “Have you been worried about falling again?”
  • “Have you stopped doing any activities you used to do?”

This is important when thinking about the risk of further falls. Fear of falling is important to identify as it can lead to a hesitant gait, leading to muscle loss and an abnormal walking pattern, leading to further falls.

The patient may have lost confidence or developed an acute stress reaction following the fall. 

Risk of future falls

The FRAT score can indicate an individual’s risk of falling and guide management.2 Some of these questions will be covered later on in the history.

FRAT Score

This determines the relative risk that a patient has of recurrent falls. There are specific questions that form the assessment:

  • “Have you had any falls in the last year?”
  • “Are you on 4 or more medications per day?”
  • “Do you have a diagnosis of stroke or Parkinson’s disease”
  • “Do you have any problems with your balance?”
  • “Are you able to get up from a chair without using your arms?”

A patient gets a point for each question answered with “yes”. Interpretation:

  • Less than 3 points: lower risk
    3-5 points: higher falls risk

Previous falls

It may be appropriate to ask the patient if they have ever fallen before this episode, how that fall compares to this one, and how often they fall if they have done so in the past.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideasconcerns, and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.

The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more naturalpatient-centred, and not overly formulaic.

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Ideas

Explore the patient’s ideas about the current issue:

  • “Why do you think you fell?”
  • “What do you think caused the fall?”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.

Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far“Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next“Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”


Systemic enquiry

systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

In a fall history, screening for any preceding illnesses that may have caused the fall is important (e.g. urinary tract infection or chest infection). 

Some examples of symptoms you could screen for in each system include:

  • Systemic: fever, night sweats, unintentional weight loss (infection or other systemic illness)
  • Cardiovascular: chest pain, palpitations (cardiac syncope)
  • Respiratory: productive cough, shortness of breath, pleuritic chest pain (chest infection)
  • Gastrointestinal: diarrhoea, vomiting, abdominal pain (gastroenteritis, colitis)
  • Urinary: dysuria, frequency, incontinence, haematuria (urinary tract infection, urinary retention)
  • Neurological: confusion, abnormal movements (dementia, Parkinson’s disease)

Assessing fracture risk

Depending on the context, it may be important to assess fracture risk.3 The Fracture Risk Assessment Tool (FRAX®) tells us the ten-year probability of having a major osteoporotic fracture and can guide treatment in high-risk patients.

Asking about the following can help determine the relative risk of osteoporotic fractures:

  • Age
  • Sex: women are more prone to osteoporosis and fractures
  • BMI: a low BMI is associated with increased risk of fractures
  • Any previous fractures
  • Family history of fractures (in particular, a fractured hip)
  • Smoking status: smoking is a risk factor for osteoporosis
  • Steroid use: this is a risk factor for osteoporosis
  • Rheumatoid arthritis
  • Conditions that can lead to secondary osteoporosis (type 1 diabetes, hyperthyroidism, premature menopause, chronic malnutrition, or malabsorption)
  • Alcohol use (3 or more units per day)

Past medical history

Establishing a patient’s medical history is particularly important when assessing falls. This may help identify why the patient has fallen and identify risk factors for injuries (e.g. osteoporosis increasing the risk of fractures). 

Ask if the patient has any medical conditions: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”

Ask if the patient has previously undergone any surgery (e.g. lower limb surgery, pelvic surgery, cancer surgery):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure, and why was it performed?”

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Examples of relevant medical conditions

Relevant medical conditions in the context of a fall include:

  • Conditions that affect mobility, strength, or balance: benign paroxysmal positional vertigo, Parkinson’s disease, orthostatic hypotension, arthritis syndromes and sarcopenia
  • Conditions that affect cognition: dementia syndromes and other neurological conditions
  • Conditions that affect sensory elements: visual impairment, peripheral neuropathy
    Conditions that affect bone health: osteoporosis (increased fracture risk)
  • Conditions that can lead to urgent movement (making it more likely for someone to fall): urinary conditions, including urinary tract infection, incontinence and overactive bladder
  • Cardiovascular conditions: aortic stenosis, atrial fibrillation, pacemakers, other arrhythmias

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).


Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over the counter medications, document the medication namedosefrequencyform and route.

Ask the patient if they’re currently experiencing any side effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
  • “Do you think your falls started after you began taking any of your current medications?”
Polypharmacy

Polypharmacy, defined as using five or more medications, increases the risk of adverse drug reactions and falls.

Medications to be aware of include:

  • Antihypertensives (e.g. amlodipine, ramipril): multiple antihypertensives increase the risk of hypotension 
  • Sedating drugs (e.g. benzodiazepines, antipsychotics, opioid analgesics, antihistamines and anti-epileptics) increase the risk of falls
  • Diuretics (e.g. indapamide, furosemide): increase the risk of hypotension and electrolyte disturbances
  • Antidepressants (e.g. SSRIs): increase the risk of postural hypotension, sedation and electrolyte disturbances (e.g. hyponatraemia)
Anticholinergic burden

Anticholinergic burden refers to drugs that decrease the action of the parasympathetic nervous system, particularly acetylcholine.

A high anticholinergic burden can lead to adverse effects such as confusion, dizziness, and falls

The mnemonic PC SOAP can be used to remember drugs with a high anticholinergic burden:

  • Promethazine (antihistamine)
  • Cetirizine (antihistamine)
  • Solifenacin (used for overactive bladder)
  • Oxybutynin (used for overactive bladder)
  • Amitriptyline (used for depression and pain)
  • Prochlorperazine (antiemetic)

Family history

Ask the patient if there is any family history of relevant medical conditions:

  • “Do any of your parents or siblings have any medical conditions?” 

Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic factors).

Examples of conditions with a genetic component which may increase the risk of falls include cardiovascular disease and autoimmune conditions (particularly those affecting the nervous system). 


Social history

General social context

Explore the patient’s general social context including:

  • the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)
  • who else the patient lives with and their personal support network
  • what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
  • if they have any carer input (e.g. twice daily carer visits)

If relevant, identifying any home hazards, such as upturned carpets, wires and cables, and furniture, is important. These hazards may indicate a safeguarding concern and require referral to the adult safeguarding team

Smoking

Record the patient’s smoking history, including the type and amount of tobacco used.

Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk profile:

  • pack-years = [number of years smoked] x [average number of packs smoked per day]
  • one pack is equal to 20 cigarettes

See our smoking cessation guide for more details.

Alcohol

Record the frequencytype and volume of alcohol consumed on a weekly basis.

See our alcohol history taking guide for more information.

Excess alcohol consumption increases the risk of falls.

Fluid intake

Dehydration can lead to electrolyte imbalance, confusion, and falls. Quantifying how much fluid a patient drinks daily and if this has changed recently is important.


Closing the consultation

Summarise the key points back to the patient.

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Reviewer

Dr Rachel Murdoch

Consultant in Older Persons’ Medicine


References

  1. NICE CKS. Falls risk assessment. Available from: [LINK]
  2. HCPA StopFalls Campaign. FRAT Score. Published in 2018. Available from: [LINK]
  3. Centre for Metabolic Bone Diseases, University of Sheffield. FRAX tool. Available from: [LINK]

 

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