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Background

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?

  • Looking upwards (vertebrobasilar insufficiency)
  • Getting up from bed (postural hypotension)
WHERE:Where did you fall?In the house? Outside?
WHAT:What happened before/during and after the fall?Before:

  • Is there any warning?
  • Is there any dizziness/chest pain or palpitations? (helping to identify the cause)

 

During:

  • Is there any incontinence or tongue biting (indicating seizure activity).
  • Was there any loss of consciousness?
  • Is the patient pale/flushed (may indicate vasovagal attack)?
  • Did they injure themselves?
  • What part of the body had first contact with the floor?

After:

  • What happens after the fall?
  • Is the patient able to get themselves up?
  • How long does it take them?
  • Are they able to resume normal activities afterwards?
  • Was there any confusion after the event? (head injury)
  • Was there any weakness or speech difficulty after the event? (Stroke/TIA)
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.

Systems Enquiry

GeneralFatigue / Weight loss
CardiovascularChest pain / Palpitations
Respiratory SOB / Cough
NeurologicalLoss of consciousness / Seizures / Motor or sensory disturbance
GenitourinaryIncontinence / Urgency / Dysuria
GastrointestinalAbdominal pain / Diarrhoea / Constipation
MusculoskeletalJoint pain / Muscle weakness

Past Medical History

GeneralVisual/hearing impairment, Diabetes, Anaemia
CardiovascularAngina/Cardiovascular disease, Arrhythmias
RespiratoryCOPD
NeurologicalParkinson’s disease, Peripheral neuropathy, Stroke, Dementia
GenitourinaryUrinary tract infection, incontinence
GastrointestinalDiverticulitis/Chronic diarrhoea, Alcoholic liver disease
MusculoskeletalArthritis, Chronic pain, Fractures

Social History

Alcohol intake

Support at home – friends/family and carers

Mobility – use of aids and when e.g. zimmer frame downstairs only


Medication review

Beta-blockers (bradycardia)

Diabetic medications (hypoglycaemia)

Antihypertensives (hypotension)

Benzodiazepines (sedation)

Antibiotics (intercurrent infection)

Note: Polypharmacy itself is a risk factor for falls!


Examination

GeneralIs the patient alert and orientated?

Are they able to perform the timed “up and go” test?

CardiovascularPulse- may have irregularities such as AF or bradycardia

Blood pressure – Hypotension

Bruits over carotid arteries

Murmurs: Aortic stenosis/Aortic Regurgitation/Mitral stenosis

RespiratoryInfection
NeurologicalCranial nerve examination- stroke or visual impairment

Power- weakness e.g. disuse atrophy

Tone- evidence of neurological disease

Reflexes

Sensation- peripheral neuropathy due to diabetes

Co-ordination- chronic alcohol misuse leading to cerebellar degeneration.

GastrointestinalAbdominal tenderness

Organomegaly

MusculoskeletalCheck for injuries associated with falls (head and fractured neck of femur) and examine carefully the point of contact with the floor
ENTIs there any evidence of ear wax?

Are the tympanic membranes intact?


Investigations

CATEGORYTESTCAUSE OF FALL
BedsideObservations (BP/HR/RR/Sats/Temp)Sepsis / Bradycardia
Lying and standing blood pressureOrthostatic hypotension
Urine dipstickInfection / Rhabdomyolysis (blood in urine)
ECGBradycardia / Arrhythmias / Heart block
Cognitive screening e.g. AMTCognitive impairment
Blood glucoseHypoglycaemia secondary to poor intake
BloodsFull Blood CountAnaemia / Infection
Urea and ElectrolytesDehydration / Electrolyte abnormalitiesRhabdomyolysis
Liver function testsChronic alcohol use
Bone profileCalcium abnormalities in malignancy or over supplementation
ImagingChest X-rayPneumonia
CT headChronic or acute subdural / Stroke
EchoValvular heart disease e.g aortic stenosis
SpecialistTilt table test
Epleys manoeuvreBenign Paroxysmal Positional Vertigo
Cardiac monitoring e.g. 48hr tapeIf no symptoms during monitoring episode in hospital

Differential diagnosis

The differential diagnosis of falls is very wide. A detailed history and examination will lead to the eventual diagnosis.

Possible causes include:

GeneralMechanical (always give a reason e.g. secondary to poor footwear/visual difficulties- see falls assessment) / Polypharmacy
CardiovascularArrhythmias / Orthostatic hypotension / Bradycardia / Valvular heart disease
NeurologicalStroke / Peripheral neuropathy
GenitourinaryIncontinence / Urinary tract infection
EndocrineHypoglycaemia
MusculoskeletalArthritis / Disuse atrophy
ENTBenign Paroxysmal Positional vertigo / Ear wax

Management

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 assessmentPossible intervention
1GaitPhysiotherapy
2Visual problemsEye test and ensure wears glasses
3Hearing difficultiesRemove wax / Hearing assessment
4Medications reviewReduce unnecessary meds
5Alcohol intakeAlcohol cessation advice / Services
6Cognitive impairmentReferral to psychiatric team
7Postural hypotensionReview meds / Keep hydrated
8ContinenceTreat infections / Continence assessment
9FootwearEnsure good fitting footwear
10Environmental hazardsTurn on lights / Take up rugs
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