Falls

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⚠️ Falls are a major geriatric syndrome, affecting ~30% of adults >65 each year and up to 50% of those >80. They are usually multifactorial, involving medical, functional, environmental, and social factors. Consequences include fractures, head injury, loss of independence, fear of falling, and increased mortality. A structured, multidisciplinary approach is essential for both diagnosis and prevention. 🌟

🔎 General Approach

• Start by clarifying whether the episode was a fall, syncope, or seizure (ask: “what do you mean by fall?”).
• Consider multifactorial causes: frailty, balance issues, medications, environment, comorbidities.
• Use a comprehensive geriatric assessment (CGA) framework: history, examination, functional review, social circumstances, and environment.
• Every fall is a red flag for frailty and an opportunity to review wider health and social care needs.

📋 Key Risk Domains to Assess

• 🧠 Intrinsic (medical): Cognitive impairment, Parkinson’s disease, neuropathy, stroke, diabetes, postural hypotension, cardiovascular disease.
• 💊 Medication-related: Sedatives, hypnotics, antidepressants, antipsychotics, antihypertensives, diuretics, polypharmacy.
• 👣 Functional: Muscle weakness, arthritis, impaired balance or mobility, previous falls, use of walking aids.
• 👁️ Sensory: Vision, hearing, proprioception deficits.
• 🏡 Environmental: Poor lighting, loose rugs, stairs, unsafe flooring, unsuitable footwear.
• 🥤 Nutrition & hydration: Malnutrition, dehydration, vitamin D deficiency.
• 🧑‍🤝‍🧑 Social: Living alone, lack of support, unsafe housing.

📊 Structured Risk Assessment Tools

• 🚶 Timed Up and Go (TUG): >12 seconds indicates ↑ fall risk.
• 🛏️ STRATIFY score: Predicts inpatient falls risk.
• 🧠 FRAT (Falls Risk Assessment Tool): Used in community/primary care.
• 💡 Always interpret scores alongside clinical judgement and CGA findings.

📋 History (Key Elements)

• 🕒 Event: Circumstances, activity, witness account, location.
• ⚡ Prodrome: Dizziness, palpitations, chest pain, aura, vertigo.
• 🧠 Consciousness: LOC? Post-ictal signs? Incontinence/tongue biting?
• 🚶 Mobility baseline: Walking aids, prior falls, gait and balance.
• 💊 Medication review: High-risk drugs, polypharmacy, recent changes.
• 🩺 Medical history: Neurological, cardiovascular, diabetes, arthritis, prior fractures.
• 🏡 Social/home environment: Support, stairs, rugs, lighting, footwear.
• 🥤 Nutrition & hydration: Recent weight loss, poor intake, dehydration, vitamin D intake.

👩‍⚕️ Examination (Targeted)

• 🩺 General: Vital signs, hydration, frailty score.
• 🧠 Neurological: Cognition, cranial nerves, cerebellar testing, neuropathy.
• 💓 Cardiovascular: Pulse, murmurs, carotids, arrhythmias, orthostatic BP.
• 🦵 Musculoskeletal: Strength, joints, gait, balance.
• 📏 Postural BP: Drop >20 mmHg systolic = postural hypotension.
• 👁️👂 Sensory: Vision, hearing, proprioception.

🔬 Investigations

• 📈 ECG: Identify arrhythmias or conduction defects.
• 📊 24h Holter/event monitor: If arrhythmia suspected.
• 🧪 Bloods: FBC, U&E, glucose, TFTs, vitamin D, calcium, renal function.
• 🦴 Imaging: X-ray if fracture suspected; CT head if head injury, anticoagulated, or neuro signs.
• 🏃 Functional assessment: “Get Up and Go”, gait and balance testing.

🛠️ Management Principles

• 🔍 Identify & treat reversible causes: infection, anaemia, dehydration, electrolyte imbalance.
• 💊 Medication review: Stop/reduce sedatives, hypnotics, antidepressants, antipsychotics, antihypertensives, diuretics.
• 🏃 Exercise: Strength and balance training (Otago program, Tai Chi, physiotherapy).
• 👩‍🔧 OT/Home safety: Rails, lighting, remove trip hazards, footwear advice.
• 🦴 Bone protection: FRAX score, DEXA scan, bisphosphonates ± calcium & vitamin D if osteoporosis risk.
• ☀️ Vitamin D supplementation: ≥800 IU/day for older adults at risk.
• 🥤 Nutrition/hydration optimization: Ensure adequate intake, treat malnutrition.
• 👥 Multidisciplinary: Physiotherapist, OT, geriatrician, pharmacist, social services.
• 📝 Document a personalized falls care plan including follow-up and monitoring.

🚨 Red Flags (“Falls + …”)

• 💔 Chest pain, palpitations, exertional syncope → possible arrhythmia/ACS.
• 🧠 New neurological deficit → stroke, seizure, spinal cord pathology.
• 🦴 Severe pain → suspect fracture (hip, pelvis, spine).
• 🩸 Head injury on anticoagulation → urgent CT head.
• ⚡ Recurrent unexplained LOC → cardiac cause until proven otherwise.

📚 References (UK / NICE compliant)

• NICE NG56: Falls in older people – assessment and prevention
• British Geriatrics Society – Falls Guidelines
• Royal College of Physicians – Falls in Older Adults
• NICE CKS – Osteoporosis and Bone Health