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Falls in the Elderly: History Taking and Differential Diagnoses

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Overview

Falls are common in older people (>65 years old) and prevalence increases with age. Falls are multifactorial and their causes may be inter-related.

Risk Factors

  • General:
    • Previous falls
    • The fear of falling itself
  • Cardiovascular:
  • Neurological:
  • Musculoskeletal causes:
    • Joint instability/deformities
    • Deconditioning – reduced muscle tone and function due to prolonged immobility
    • Obesity
  • Pharmacological:
    • Polypharmacy
    • Drugs associated with falls are alpha-blockers, antihypertensives, diuretics, beta-blockers, benzodiazepines, Z-drugs, antidepressants, dopamine agonists, levodopa, NSAIDs, opioids, tricyclic antidepressants, antidiabetic medications associated with hypoglycaemia (e.g. sulfonylureas), and first-generation antihistamines.
  • Environmental:
    • Using a cane/walker
    • Living alone
    • Loose rugs
    • Poor lighting
    • Uneven floors
    • Clutter

History Taking

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

The fall

  • Where did they fall?
  • What did they do when falling?
    • E.g. walking down stairs/walking on uneven surfaces
    • Did they fall while standing?
  • Did they hurt themselves falling?
  • Did they hit their head falling?
  • Is there any pain now?
  • Have they ever fallen before? – the strongest risk factor
  • Did anyone see the fall?
  • How is their health generally?

Before the fall

  • Were there any warning symptoms?
    • Dizziness?
    • Light-headedness?
    • Chest pain?
    • Palpitations?
    • Vision changes?
      • Did these symptoms occur when standing or sitting up?
  • Are there any stroke symptoms or other red-flags (FAST)?
    • Facial drooping
    • Arm drooping
    • Speech slurring?
    • Weakness?
    • Numbness?
    • Tingling?
  • Do they take blood-thinners or have a bleeding disorder?
  • Were there any triggers?
    • Any strong emotions/having blood taken etc.?

During the fall

  • Was there any loss of consciousness?
  • Was there any incontinence?
  • Was there any tongue-biting?
  • Did they look pale? – suggests vasovagal syncope
  • Was anyone with them? Did anyone see it?

After the fall

  • Could they get up after falling?
  • How long did it take to get up?
  • How long did they lie there?
  • Did they feel confused after the fall?
  • Did they feel ill/groggy after falling?
  • Could they continue what they were doing after?

Functional level

  • Do they walk independently?
  • Do they live alone?
  • Do they have any care input?
  • Does falling stop them from being able to carry out their normal activities?
  • Can they dress, get around the house, and go to the shop?

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?

Physical Examinations

Overview

Physical examinations may include:

  • A cardiovascular examination:
    • May identify arrhythmia and/or murmurs that can predispose to syncope
  • A neurological examination:
    • May identify features of Parkinsonism, ataxia, muscle weakness/wasting
    • May identify altered mental status
  • A musculoskeletal examination:
    • May identify joint problems (such as deformities, locking, or other features of impaired function), gait problems, and muscle weakness
  • An assessment of gait:
    • Timed Up & Go test
    • Turn 180° test
  • Other tests:

Investigations

Overview

When suggesting investigations in an OSCE, the BOXES (Blood tests, orifice tests, x-rays, ECGs, special tests) mnemonic is useful for deciding the order of investigations:

  • Blood tests:
    • Full blood count (FBC):
      • May identify anaemia
      • May identify bleeding diathesis (e.g. thrombocytopenia)
      • May identify leukocytosis suggesting infection
    • Blood glucose and HbA1c:
      • May identify hypoglycaemia
      • May identify diabetes mellitus
    • Urea and electrolytes (U&Es):
      • May identify renal disease
      • May identify electrolyte abnormalities
    • Liver function tests (LFTs):
      • May identify liver disease
    • Creatine kinase (CK):
    • Thyroid function tests (TFTs):
  • X-rays:
    • X-rays of bones:
      • May identify fractures
      • Considered in patients with persisting pain and/or an inability to weight bear
  • ECGs:
    • ECG:
      • In all patients with syncope, chest pain, and/or palpitations
      • May identify arrhythmia
    • Ambulatory ECG monitoring:
      • If the initial ECG did not identify arrhythmia but suspicion remains
  • Special tests:
    • Lying and standing blood pressure:
      • May identify orthostatic hypotension
    • CT head:
      • If a head injury has occurred
      • May identify acute intracranial bleeds (e.g. extradural haematoma due to the fall) or chronic intracranial bleeds that may have caused the fall (e.g. chronic subdural haematoma)
    • Dual-energy X-ray absorptiometry (DEXA) scan:
    • MRI head:
      • May identify structural abnormalities such as tumours
    • MRI of spine:
      • May identify spinal disorders
    • Echocardiogram:
      • May identify structural heart disease
    • Tilt-table testing:
      • May identify orthostatic hypotension
    • Vision testing:
      • If vision is suspected to be impaired
    • Electroencephalogram (EEG):
      • If seizures are suspected

Differential Diagnoses

Stroke and transient ischaemic attack (TIA)

  • A history and physical exam may reveal:
    • FAST features – facial drooping, arm/leg weakness, speech problems
    • Numbness, tingling, vision loss, loss of coordination, loss of balance
    • In TIA, symptoms usually last a few minutes and <1 hour
  • Investigations may reveal:

Deconditioning

  • A history and physical exam may reveal:
    • Prolonged periods of immobility and inadequate exercise
    • Weakness, an inability or difficulties with standing up from sitting without help
  • Investigations may reveal:
    • Timed Up & Go test:
      • Evidence of weakness when trying to stand

Joint instability

  • A history may reveal:
    • Previous joint injuries or arthritis
  • A physical exam may reveal:
    • Weakness, joint crepitus, reduced range of motion, pain when moving the affected joint
  • Investigations may reveal:
    • Timed Up & Go test:
      • Evidence of weakness when trying to stand

Environment hazards

  • A history may reveal:
    • Loose carpets, wires, clutters, poor lighting, no handrails
  • Occupational therapists carry out home visits to identify the causes of falls

Polypharmacy

  • A history may reveal:
  • The use of drugs associated with falls or multiple drugs (see Polypharmacy)
  • Drugs associated with falls are alpha-blockers, antihypertensives, diuretics, beta-blockers, benzodiazepines, Z-drugs, antidepressants, dopamine agonists, levodopa, NSAIDs, opioids, tricyclic antidepressants, antidiabetic medications associated with hypoglycaemia (e.g. sulfonylureas), and first-generation antihistamines.

Visual impairment

  • A history may reveal:
    • A known history of or new episodes of visual impairment
  • A physical exam may reveal:
    • Visual acuity – impaired vision
    • Fundoscopy – may show retinal pathology
  • Investigations may reveal:
    • Refer to ophthalmology:
      • Refer urgently for sudden loss of vision

Labyrinthitis/vestibular neuronitis

  • A history may reveal:
    • Acute vertigo with nausea and vomiting:
    • Symptoms are worsened with changes in head position
    • There may be a history of a recent upper respiratory tract infection
  • Diagnosis is generally clinical

Benign paroxysmal positional vertigo

  • A history may reveal:
    • Usually seen in older patients (>50 years)
    • Vertigo triggered by changes in head position, such as rolling over in bed or gazing upwards
    • Vertigo lasts around 10-20 seconds
  • A physical exam may reveal:
    • Dix-Hallpike test is diagnostic – shows rotatory nystagmus that lasts around 30 seconds

Dementia

  • A history may reveal:
    • Slow, gradual decline in cognitive function, impairment in activities of daily living (e.g. household tasks, cooking, shopping) and associated features (e.g. hallucinations and motor symptoms) depending on the subtype 
  • A physical exam may reveal:
    • Cognitive screening tests may show impairment
  • Investigations may reveal:
    • Routine laboratory tests (e.g. full blood count, urea and electrolytes, thyroid function tests, B12 and folate etc.):
      • To look for reversible causes
    • CT/MRI head:
      • To screen for other pathologies such as tumours and intracranial bleeds
      • May show atrophy of different areas of the brain depending on the dementia subtype
    • See Dementia

Delirium

  • A history may reveal:
    • Acute, fluctuating consciousness, cognition, and perception developing over hours to days
    • Behavioural disturbances, disorganised thinking, paranoia, hallucinations, and emotional disturbances may be present
    • There may be a trigger (e.g. pain, infection, nutritional problems or dehydration, constipation or urinary retention etc.)
  • Investigations may reveal:
    • Cognitive assessment:
      • Delirium can be diagnosed with CAM, DSM-V, or 4AT
    • Further investigations are to identify an underlying cause, see Delirium.

Seizure

  • A history may reveal:
    • Loss of consciousness with jerking, stiffening of limbs, or atony
    • Focal seizures may have a prodromal aura (e.g. déjà vu, epigastric rising)
    • Post-ictal drowsiness and disorientation may be present
    • Tongue biting and incontinence suggest seizures
  • Investigations may reveal:
    • Oxygen saturations:
      • To screen for hypoxia
    • Blood glucose:
      • To screen for hypoglycaemia
    • Urea and electrolytes (U&Es):
    • Neuroimaging (CT/MRI head):
      • To screen for tumours or structural abnormalities
    • Electroencephalogram (EEG):
      • May show epileptiform changes

Parkinson’s disease

  • A history and physical exam may reveal:
    • TRAP features:
      • Tremors
      • Rigidity
      • Akinesia/bradykinesia
      • Postural instability
  • Parkinson’s disease is clinically diagnosed by a specialist

Subdural haematoma

  • A history may reveal:
    • May be chronic – weeks to months of confusion, reduced consciousness, or neurological defects, or acute – symptoms present more acutely
    • There may be a history of head trauma in the fall and/or anticoagulant use
  • A physical exam may reveal:
    • Reduced consciousness following the fall or head trauma, focal neurological signs depending on where the haematoma is
  • Investigations may reveal:
    • CT head:
      • Shows a crescenteric collection that is not limited by the suture lines
        • If acute, it is hyperdense, if chronic, it is hypodense

Syncope

  • A history reveals a loss of consciousness triggered by different causes:
    • Neurally-mediated syncope:
      • Vasovagal syncope – after exposure to blood/unpleasant sight, strong emotion, pain, stress
      • Situational syncope – after certain behaviours (e.g. urination, vomiting, coughing)
      • Carotid sinus syncope – after applying pressure to the carotid sinus (e.g. tight shirts, shaving)
    • Orthostatic syncope – after standing up from sitting down
    • Cardiogenic syncope – associated with chest pain, palpitations, shortness of breath
  • Investigations may reveal:
    • Lying-standing blood pressure:
      • Orthostatic hypotension is defined as a drop in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.
    • ECG:
      • May identify arrhythmia
    • Tilt-table testing:
      • If blood pressure measurements are inconclusive, a tilt-table test may be considered.
    • 24-hour ECG monitoring:
      • May identify arrhythmia

Orthostatic hypotension

  • A history may reveal:
    • Dizziness and syncope following prolonged standing, dehydration and its causes
    • Parkinson’s disease or multiple system atrophy
  • Investigations may reveal:
    • Lying and standing blood pressure:
      • Orthostatic hypotension, decrease of at least 20 mmHg systolic or at least 10 mmHg within 3 minutes of standing up after lying/sitting

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