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. ¹ Falls can have a profoundly negative impact on the quality of life of the elderly and their carers. The physical distress, pain and injury are also associated with loss of confidence and independence. This negatively affects morbidity and mortality with associated financial implications for the NHS.
History of presenting complaint
A detailed history is essential in determining the cause of falls. The table below highlights key information that should be gathered when taking a history.
|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, or 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.|
Be cautious in cases where the patient is unable to recall events clearly, as this may indicate new confusion associated with a head injury.
A systems enquiry may identify other relevant information that may relate to the falls.
Past Medical History
- Alcohol intake
- Support at home – friends/family and carers
- Mobility – use of aids and when (e.g. zimmer frame downstairs only)
Most medications have side effects which could cause falls. Polypharmacy itself is a risk factor for falls. It is good practice to review medications and de-prescribe those which are no-longer indicated.
- Beta-blockers (bradycardia)
- Diabetic medications (hypoglycaemia)
- Antihypertensives (hypotension)
- Benzodiazepines (sedation)
- Antibiotics (intercurrent infection)
Timed up and go test:
- Ask the patient to get up from the chair/bed and walk three metres then turn around and sit down again. The patient should be permitted to use their walking aid.
Investigations are based on your history and examination but could include some of those mentioned below.
|CATEGORY||TEST||POSSIBLE CAUSE OF FALL|
|Lying and standing blood pressure|
|Cognitive screening e.g. AMT|
|Bloods||Full Blood Count|
|Urea and Electrolytes|
|Liver function tests|
|Specialist||Tilt table test|
|Cardiac monitoring (e.g. 48hr tape)|
The differential diagnosis of falls is very wide. A detailed history and examination will lead to the eventual diagnosis. It is important to determine whether the patient has suffered a transient loss of consciousness or a simple mechanical fall.
Some possible causes of falls are shown in the table below.
Once a transient loss of consciousness event has been ruled out, it is important to complete a full falls risk assessment. This is indicated in order to identify any causative features especially as older people are likely to have multiple co-existing factors causing a fall. 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.
The table below includes some of the key components of a full falls risk assessment.
1. Falls in older people: assessing risk and prevention. Clinical guideline [CG161]. Published date: