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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

GeneralSensory or visual impairment 
MusculoskeletalImmobility, previous low impact fractures/osteoporosis, arthritis, myopathy
Nervous systemParkinson’s disease, strokes, neuropathy, confusion/dementia/delirium, dizziness, syncope
CardiovascularPostural hypotension, syncope, arrhythmias, breathlessness on exertion (aortic stenosis)
EndocrineDiabetes mellitus (peripheral neuropathy, hypoglycaemia, retinopathy)
Gastrointestinal/genitourinaryNutrition, 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, for example:
    • Strength and balance training
    • Home hazard intervention (occupational therapy assessment)
    • Visual assessment/referral
    • Medication review
    • Alcohol cessation
    • Psychiatric assessment if evidence of cognitive impairment 
    • Continence assessment
    • Correct postural hypotension (stop causative medications, keep hydrated, TEDs, fludrocortisone if severe)
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