Table of Contents
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.
- 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)|
- 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
- Any stairs?
- Who they live with
- Carers/home support
- Who performs their daily tasks (if the patient does them, how well?)
- Mobility: baseline, mobility aids
- 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
- Thank patient
- Summarise your findings and risk factors
- Suggest how risk factors could be mitigated
How can falls risk be mitigated?
List some causes of parkinsonism