Falls are common in elderly patients and are often multi-factorial. Risk factors must be minimised and all patients who fall frequently need multidisciplinary assessment by doctors/nurses, physiotherapists, occupational therapists and social services (in case more care is required). The differential diagnosis of falls is covered here.

Falls history

• Age
• Frequency of falls (in past 12 months)
• Reason for falls, e.g. trip, unsteadiness, syncope
• Injuries sustained
• Fear of falling

Past medical history/review of systems

General	Sensory or visual impairment
Musculoskeletal	Immobility, previous low impact fractures/osteoporosis, arthritis, myopathy
Nervous system	Parkinson’s disease, strokes, neuropathy, confusion/dementia/delirium, dizziness, syncope
Cardiovascular	Postural hypotension, syncope, arrhythmias, breathlessness on exertion (aortic stenosis)
Endocrine	Diabetes mellitus (peripheral neuropathy, hypoglycaemia, retinopathy)
Gastrointestinal/genitourinary	Nutrition, incontinence (rushing to toilet), nocturia (may result in patients ambling in the dark)

Drug history

• Polypharmacy (>5 is an independent risk factor for falls)
• Medications with potentially troublesome side effects: antihypertensives (hypotension), antiepileptics (seizure control), benzodiazepines (sedation), psychotropics (extrapyramidal side effects), corticosteroids (osteoporosis, myopathy), beta-blockers (bradycardia), hypoglycaemics (hypoglycaemia), antidepressants (postural hypotension), diuretics (urinary frequency, dehydration), anticoagulants (bleeding risk)
• Bone protection: bisphosphonates, calcium, vitamin D (reduce fracture risk)

Social history and environment

• Living situation 
  • Residence
  • Any stairs?
  • Who they live with
  • Carers/home support
• Who performs their daily tasks (if the patient does them, how well?)
  • Washing
  • Dressing
  • Cooking
  • Cleaning
  • Shopping 
• Mobility: baseline, mobility aids
• Alcohol
• Footwear: appropriately fitting?
• Exercise: increases muscle strength, reduces frailty and falls risk
• Home hazards: rugs, cables, furniture, wet floors, stairs, lighting

Examination – adapt depending on risk factors from history

• General examination: frailty, myopathy, sarcopenia
• Cognitive assessment: e.g. mini-mental state examination
• Neurological examination: including gait, balance and signs of parkinsonism
• Visual examination
• Cardiovascular exam, postural BPs and ECG
• Specific falls risk tests
  • Timed ‘up and go’ test: request that the patient rise from a chair without the support of their arms, walk 3 metres, then turn round and sit down again. A walking aid can be used if required. Completion of the test without unsteadiness or difficulty suggests a low risk of falling.
  • ‘Turn 180°’ test: request that the patient stand up and turn around until they are facing the opposite direction. If more than four steps are required to do this, further assessment is indicated.
• Physiotherapy and occupational therapy assessments

Conclusion

• Thank patient
• Summarise your findings and risk factors
• Suggest how risk factors could be mitigated

Test yourself!