Those over 65 have the highest risk of falling with 30% of those over 65 and 50% of those over 80 falling at least once a year. Falls can have a profoundly negative impact on the quality of life of the elderly and their carers. The physical distress, pain and injury is also associated with loss of confidence and independence. This negatively affects morbidity and mortality with associated financial implications to the NHS.
History of presenting complaint
|WHO:||Who has seen you fall?||Ensure adequate collateral history including addressing the when, where, what and why.|
|WHEN:||When did you fall?||What time of day?
What were they doing at the time?
|WHERE:||Where did you fall?||In the house? Outside?|
|WHAT:||What happened before/during and after the fall?||Before:
|WHY:||Why do you think you fell?||May have tripped over a rug or started a new medication.|
|HOW:||How many times have you fallen over the last 6 months?||Allows you to gauge the severity of the problem.|
|General||Fatigue / Weight loss|
|Cardiovascular||Chest pain / Palpitations|
|Respiratory||SOB / Cough|
|Neurological||Loss of consciousness / Seizures / Motor or sensory disturbance|
|Genitourinary||Incontinence / Urgency / Dysuria|
|Gastrointestinal||Abdominal pain / Diarrhoea / Constipation|
|Musculoskeletal||Joint pain / Muscle weakness|
Past Medical History
|General||Visual/hearing impairment, Diabetes, Anaemia|
|Cardiovascular||Angina/Cardiovascular disease, Arrhythmias|
|Neurological||Parkinson’s disease, Peripheral neuropathy, Stroke, Dementia|
|Genitourinary||Urinary tract infection, incontinence|
|Gastrointestinal||Diverticulitis/Chronic diarrhoea, Alcoholic liver disease|
|Musculoskeletal||Arthritis, Chronic pain, Fractures|
Support at home – friends/family and carers
Mobility – use of aids and when e.g. zimmer frame downstairs only
Diabetic medications (hypoglycaemia)
Antibiotics (intercurrent infection)
Note: Polypharmacy itself is a risk factor for falls!
|General||Is the patient alert and orientated?
Are they able to perform the timed “up and go” test?
|Cardiovascular||Pulse- may have irregularities such as AF or bradycardia
Blood pressure – Hypotension
Bruits over carotid arteries
Murmurs: Aortic stenosis/Aortic Regurgitation/Mitral stenosis
|Neurological||Cranial nerve examination- stroke or visual impairment
Power- weakness e.g. disuse atrophy
Tone- evidence of neurological disease
Sensation- peripheral neuropathy due to diabetes
Co-ordination- chronic alcohol misuse leading to cerebellar degeneration.
|Musculoskeletal||Check for injuries associated with falls (head and fractured neck of femur) and examine carefully the point of contact with the floor|
|ENT||Is there any evidence of ear wax?
Are the tympanic membranes intact?
|CATEGORY||TEST||CAUSE OF FALL|
|Bedside||Observations (BP/HR/RR/Sats/Temp)||Sepsis / Bradycardia|
|Lying and standing blood pressure||Orthostatic hypotension|
|Urine dipstick||Infection / Rhabdomyolysis (blood in urine)|
|ECG||Bradycardia / Arrhythmias / Heart block|
|Cognitive screening e.g. AMT||Cognitive impairment|
|Blood glucose||Hypoglycaemia secondary to poor intake|
|Bloods||Full Blood Count||Anaemia / Infection|
|Urea and Electrolytes||Dehydration / Electrolyte abnormalitiesRhabdomyolysis|
|Liver function tests||Chronic alcohol use|
|Bone profile||Calcium abnormalities in malignancy or over supplementation|
|CT head||Chronic or acute subdural / Stroke|
|Echo||Valvular heart disease e.g aortic stenosis|
|Specialist||Tilt table test|
|Epleys manoeuvre||Benign Paroxysmal Positional Vertigo|
|Cardiac monitoring e.g. 48hr tape||If no symptoms during monitoring episode in hospital|
The differential diagnosis of falls is very wide. A detailed history and examination will lead to the eventual diagnosis.
Possible causes include:
|General||Mechanical (always give a reason e.g. secondary to poor footwear/visual difficulties- see falls assessment) / Polypharmacy|
|Cardiovascular||Arrhythmias / Orthostatic hypotension / Bradycardia / Valvular heart disease|
|Neurological||Stroke / Peripheral neuropathy|
|Genitourinary||Incontinence / Urinary tract infection|
|Musculoskeletal||Arthritis / Disuse atrophy|
|ENT||Benign Paroxysmal Positional vertigo / Ear wax|
It is important to complete a full falls risk assessment to identify any causative features as falls are commonly multifactorial. Although priority should be to treat any underlying medical cause (e.g. pacemaker if complete heart block), all causes should be addressed where possible. Due to the complex aetiology, it is important to continue to search for possible risk factors and causes of falls even when one has been found.
|Mechanical falls assessment||Possible intervention|
|2||Visual problems||Eye test and ensure wears glasses|
|3||Hearing difficulties||Remove wax / Hearing assessment|
|4||Medications review||Reduce unnecessary meds|
|5||Alcohol intake||Alcohol cessation advice / Services|
|6||Cognitive impairment||Referral to psychiatric team|
|7||Postural hypotension||Review meds / Keep hydrated|
|8||Continence||Treat infections / Continence assessment|
|9||Footwear||Ensure good fitting footwear|
|10||Environmental hazards||Turn on lights / Take up rugs|