Falls

⚠️ Falls are a major geriatric syndrome, affecting ~30% of adults >65 each year and up to 50% of those >80. They are rarely due to a single cause - usually a mix of medical, environmental, and functional 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 establishing if the episode was a fall, syncope, or seizure (always clarify “what do you mean by fall?”).
• Think multifactorial → often a combination of balance problems, frailty, environment, and medications.
• Use a comprehensive geriatric assessment (CGA) framework: history, examination, functional review, social circumstances, and environment.
• Falls are a red flag for frailty - each fall is an opportunity to review wider health and social care needs.

📋 Key Risk Domains to Assess

• 🧠 Intrinsic (medical): Cognitive impairment, Parkinson’s, neuropathy, stroke, diabetes, postural hypotension.
• 💊 Medication-related: Sedatives, antidepressants, antihypertensives, diuretics, polypharmacy.
• 👣 Functional: Muscle weakness, arthritis, impaired balance or mobility, need for walking aids.
• 👁️ Sensory: Visual impairment, hearing loss, proprioceptive deficits.
• 🏡 Environmental: Poor lighting, loose rugs, stairs, unsuitable footwear.
• 🧑‍🤝‍🧑 Social: Living alone, lack of support, unsafe housing.

📊 Structured Risk Assessment Tools

• 🚶 Timed Up and Go (TUG): >12 seconds = ↑ 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.

📋 History (Key Elements)

• 🕒 Event: Circumstances, activity, witness account.
• ⚡ Prodrome: Dizziness, palpitations, chest pain, aura, vertigo.
• 🧠 Consciousness: LOC? Post-ictal state? Incontinence/tongue biting (seizure).
• 🚶 Mobility baseline: Walking aids, prior falls, functional status.
• 💊 Medication review: High-risk drugs, polypharmacy.
• 🩺 Medical history: Neurological, cardiovascular, diabetes, arthritis.
• 🏡 Social/home environment: Stairs, carpets, lighting, footwear, support.

👩‍⚕️ Examination (Targeted)

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

🔬 Investigations

• 📈 ECG: arrhythmia, heart block, QT prolongation.
• 📊 24h Holter/event monitor: if arrhythmia suspected.
• 🧪 Bloods: FBC, U&E, glucose, TFTs, vitamin D.
• 🦴 X-ray: Suspected fractures (hip, wrist, ribs).
• 🧠 CT head: If head injury, anticoagulated, or neuro signs.
• 🏃 Functional: “Get Up and Go”, gait analysis, balance testing in clinic.

🛠️ Management Principles

• 🔍 Identify & treat reversible causes (infection, anaemia, drugs, dehydration).
• 💊 Review medications (stop or reduce sedatives, antihypertensives, polypharmacy).
• 🏃 Exercise: Strength & balance training (Otago, Tai Chi, physiotherapy).
• 👩‍🔧 OT/Home safety assessment: Rails, lighting, remove trip hazards, footwear advice.
• 🦴 Bone protection: FRAX, DEXA, bisphosphonates ± Vit D/calcium if osteoporosis risk.
• ☀️ Vitamin D: ≥800 IU/day in older adults at risk.
• 👥 Multidisciplinary: Physio, OT, geriatrician, pharmacist, social services.

🚨 Red Flags (“Falls + …”)

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