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Background

Those over 65 have the highest risk of falling with 30% >65s and 50% >80s 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? e.g. rushing to toilet or 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

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
Respiratory COPD
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

Social History

Alcohol intake

Support at home – friends/family and carers

Mobility – use of aids and when e.g. zimmer 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

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 bradycardiaBlood pressure – HypotensionBruits over carotid arteriesMurmurs: Aortic stenosis/Aortic Regurgitation/Mitral stenosis
Respiratory Infection
Neurological Cranial nerve examination- stroke or visual impairmentPower- weakness e.g. disuse atrophyTone- evidence of neurological diseaseReflexesSensation- peripheral neuropathy due to diabetes

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

Gastrointestinal Abdominal tenderness, Organomegaly
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?

Investigations

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
Imaging Chest X-ray Pneumonia
CT head Chronic or acute subdural / Stroke
Echo Valvular heart disease e.g aortic stenosis
Specialist Tilt table test
Epleys Manouvre Benign Paroxysmal Positional Vertigo
Cardiac monitoring e.g. 48hr tape If 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:

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
Endocrine Hypoglycaemia
Musculoskeletal Arthritis / Disuse atrophy
ENT Benign 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 assessment Possible intervention
1 Gait Physiotherapy
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