Those over the age of 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 detailedhistory is essential in determining the cause of falls. The table below highlights key information that should be gathered when taking a history.
Who has seen you fall?
Ensure adequate collateral history including addressing the when, where, what and why.
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 did you fall?
In the house, or outside?
What happened before/during and after the fall?
Was there any warning?
Was there any dizziness/chest pain or palpitations?
Was there any incontinence or tongue biting (indicating seizure activity).
Was there any loss of consciousness?
Was the patient pale/flushed (may indicate vasovagal attack)?
Did the patient injure themselves?
What part of the body had the first contact with the floor?
What happened after the fall?
Was the patient able to get themselves up off the floor?
How long did it take them?
Was the patient 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? (e.g. stroke/TIA)
Why do you think you fell?
May have tripped over a rug or started a new medication.
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 systemsenquiry may identify other relevant information that may relate to falls.
Shortness of breath
Loss of consciousness
Motor or sensory disturbance
Past Medical History
Recurrent urinary tract infection
Alcoholic liver disease
Support at home – friends/family and carers
Mobility – use of mobility aids and when (e.g. zimmer frame downstairs only)
Most medications have side effects which can increase the likelihood of 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.
Diabetic medications (hypoglycaemia)
Antibiotics (intercurrent infection)
Is the patient alert and orientated?
Are they able to perform the 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.
Pulse: may have irregularities such as AF or bradycardia
Sensation: may be reduced secondary to upper or lower motor neuron pathology
Co-ordination: may be impaired (e.g. chronic alcohol misuse leading to cerebellar degeneration)
Check for injuries associated with falls and examine carefully the point of contact with the floor
Is there any evidence of ear wax?
Are the tympanic membranes intact?
Investigations are based on your history and examination but could include some of those mentioned below.
POSSIBLE CAUSE OF FALL
Lying and standing blood pressure
Rhabdomyolysis (blood in urine)
Cognitive screening (e.g. AMT)
Hypoglycaemia secondary to poor oral intake
Full blood count
Infection (raised white cells)
Urea and electrolytes
Liver function tests
Chronic alcohol use
Calcium abnormalities in malignancy
Over-supplementation of calcium
Chronic or acute subdural
Valvular heart disease (e.g aortic stenosis)
Tilt table test
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 broad. 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.
Mechanical (e.g. poor footwear/visual impairment)
Valvular heart disease
Urinary tract infection
Benign paroxysmal positional vertigo
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 risk factors. 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.
Eye test and ensure wears glasses
Reduce unnecessary medication
Alcohol cessation advice
Alcohol service referral
Referral to a psychiatric team
Treat or rule out infections
Ensure good fitting footwear
Turn on lights
Take up rugs
Falls in older people: assessing risk and prevention. Clinical guideline [CG161]. Published date: