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:
- Syncope
- Postural hypotension
- Carotid sinus hypersensitivity
- Post-prandial hypotension – falls after eating meals
- Neurological:
- Peripheral neuropathy (e.g. diabetes mellitus)
- Visual impairment
- Hearing impairment
- Vestibular dysfunction (e.g. benign paroxysmal position vertigo)
- Gait disturbance (e.g. Parkinsonism, arthritis, peripheral neuropathy)
- Cognitive/mood disorders (e.g. dementia, delirium, depression)
- Epilepsy
- Subdural haematoma
- Stroke or transient ischaemic attack
- 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:
- Dix-Hallpike manoeuvre – may identify benign paroxysmal positional vertigo
- Visual acuity
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):
- May be elevated if rhabdomyolysis has occurred due to a long lie
- Thyroid function tests (TFTs):
- May identify hypo/hyperthyroidism
- Full blood count (FBC):
- X-rays:
- X-rays of bones:
- May identify fractures
- Considered in patients with persisting pain and/or an inability to weight bear
- X-rays of bones:
- 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
- ECG:
- 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:
- To evaluate the risk of osteoporosis
- 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
- Lying and standing blood pressure:
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:
- Blood glucose:
- To rule out hypoglycaemia
- Non-contrast CT head:
- Rules out haemorrhagic stroke
- Blood glucose:
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
- Timed Up & Go test:
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
- Timed Up & Go test:
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
- Refer to ophthalmology:
Labyrinthitis/vestibular neuronitis
- A history may reveal:
- Acute vertigo with nausea and vomiting:
- The presence of hearing loss makes labyrinthitis more likely
- The absence of hearing loss makes vestibular neuronitis more likely
- Symptoms are worsened with changes in head position
- There may be a history of a recent upper respiratory tract infection
- Acute vertigo with nausea and vomiting:
- 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
- Routine laboratory tests (e.g. full blood count, urea and electrolytes, thyroid function tests, B12 and folate etc.):
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.
- Cognitive assessment:
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):
- To screen for electrolyte abnormalities (e.g. hyponatraemia)
- Neuroimaging (CT/MRI head):
- To screen for tumours or structural abnormalities
- Electroencephalogram (EEG):
- May show epileptiform changes
- Oxygen saturations:
Parkinson’s disease
- A history and physical exam may reveal:
- TRAP features:
- Tremors
- Rigidity
- Akinesia/bradykinesia
- Postural instability
- TRAP features:
- 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
- Shows a crescenteric collection that is not limited by the suture lines
- CT head:
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
- Neurally-mediated syncope:
- 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
- Lying-standing blood pressure:
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
- Lying and standing blood pressure: