Medicine of the older adult.: Falls, syncope, mobility and fragility fractures

• Falls: Why Falls Matter | Causes and Risk Factors | Assessing a Fall — History | Assessing a Fall — Examination and Tests | Multifactorial Falls Prevention | Exercise, Fear of Falling and Home Safety
• Blackouts and dizziness: Syncope or Fall? | Orthostatic Hypotension | Dizziness in Older People | Gait Disorders
• After a fall: The Long Lie | Falls in Hospital
• Fractures and bone health: Fragility Fractures | Hip Fracture — Orthogeriatric Care | Other Common Fractures in Older People | Bone Health After a Fall
• Revision: Falls and Fractures at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Falls, syncope, mobility and fragility fractures — page 2 of the Medicine of the Older Person chapter. About 1 in 3 people over 65 and half of those over 80 fall each year. A fall is a symptom, not a diagnosis — usually several risk factors acting together. Falls cause fractures, head injuries, long lies, loss of confidence and care home admission, but many can be prevented. Hip fracture surgery is on the Trauma and Orthopaedics page; osteoporosis drugs are in the Bone Medicine chapter; syncope investigation is in the Cardiology chapters.
Your four questions for every patient who falls: Was this a trip, a collapse or a blackout (syncope)? What injuries are there — including head injury on anticoagulants and a long lie? Which risk factors can be changed — drugs, blood pressure, vision, strength and balance, home hazards? Is bone health protected?

Why Falls Matter

• Common — about a third of people over 65 living at home fall each year; rates are higher in care homes and hospitals.
• Injuries — most falls cause no serious injury, but about 5–10% cause fractures (hip, wrist, pelvis, vertebrae, humerus) or head injuries (subdural haematoma, especially on anticoagulants).
• Hip fractures — about 70,000 a year in the UK; about 1 in 4 people are no longer alive at 1 year and many lose independence.
• Long lie — unable to get up for an hour or more — rhabdomyolysis, pressure damage, hypothermia, pneumonia, dehydration and death.
• Psychological harm — fear of falling, loss of confidence, reduced activity (which increases future falls — a vicious circle), social isolation.
• Falls as a marker — of frailty and acute illness (infection, delirium, dehydration, drugs, arrhythmia).
• Cost — falls are a leading cause of emergency admissions and care home placement in older people.

Causes and Risk Factors

• Most falls are multifactorial — intrinsic factors (the person) plus extrinsic factors (environment) plus a trigger (activity, acute illness).

Assessing a Fall — History

• The fall itself:
  • What was the person doing? — standing up (orthostatic), turning the head (carotid sinus), exertion (aortic stenosis, arrhythmia), walking (gait, trip), after a meal (post-prandial hypotension), at night (nocturia, sedatives), coughing or passing urine (situational syncope).
  • Symptoms before — dizziness, light-headedness, palpitations, chest pain, visual changes, sweating, nausea, or none (arrhythmia).
  • Loss of consciousness? — often can't remember; amnesia for loss of consciousness is common — "I don't know, I just found myself on the floor" may be syncope.
  • Witness account — colour, jerking, duration, recovery (seizure — prolonged confusion, tongue biting).
  • Injuries, ability to get up, time on the floor.
• Background — previous falls (how many, pattern), fear of falling, mobility and aids, footwear, vision and hearing, bladder (urgency, nocturia), cognition, alcohol, full drug history (recent changes), anticoagulants and antiplatelets, osteoporosis and previous fractures.
• Ask everyone over 65 at routine contacts — have you fallen in the past year? (NICE NG249).
• Red flags — loss of consciousness, exertional collapse, palpitations, chest pain, falls with a new murmur, abnormal ECG, family history of sudden death, a fall causing serious injury — need cardiac assessment (see the Cardiology chapters).

Assessing a Fall — Examination and Tests

• Injury screen — head, neck, hips, wrists, ribs, pelvis; pressure areas and skin (long lie).
• Lying and standing blood pressure — essential (see Orthostatic Hypotension).
• Cardiovascular — pulse (irregular, slow), murmurs (aortic stenosis), carotid bruits, heart failure.
• Neurological — focal signs, Parkinsonism (tremor, rigidity, bradykinesia), peripheral neuropathy (sensation, proprioception, reflexes), cerebellar signs, cognition (4AT, AMTS).
• Musculoskeletal — joint pain and deformity, muscle strength, feet (deformity, ulcers, nails, footwear).
• Vision — acuity, fields; hearing.
• Gait and balance — watch the patient walk and turn; Timed Up and Go (over 12–14 seconds), gait speed, sit-to-stand, Romberg's test.
• Investigations:
  • ECG — arrhythmias, heart block, long QT, bundle branch block.
  • FBC, U&E (sodium, kidney function), glucose, bone profile, vitamin D, B12 and folate, TFTs, CK (if long lie), CRP if illness suspected.
  • Imaging for injuries (X-ray; CT head per NICE head injury guidance — lower threshold in anticoagulated or older patients).
  • Further tests as indicated — echo (murmur), ambulatory ECG or implantable loop recorder (unexplained syncope), carotid sinus massage (specialist, unexplained falls with head-turning), tilt test, bone density.

Multifactorial Falls Prevention

• Multifactorial assessment and intervention — offered to older people at higher risk of falling (e.g. a fall with injury, recurrent falls, gait or balance problems, a fall needing medical attention), following NICE NG249 (2025, replacing CG161).
• Interventions matched to risk factors:

  Risk factor	Intervention
  Weakness and poor balance	Strength and balance exercise programme — the single most effective intervention
  Medicines	Review and reduce falls-risk drugs (sedatives, antipsychotics, antihypertensives, anticholinergics) — see page 4
  Orthostatic hypotension	Medication review, fluids, compression, slow standing, specialist drugs
  Vision	Eye test; cataract surgery (especially first eye); single-lens distance glasses for walking outdoors
  Home hazards	OT home hazard assessment and modification (rails, lighting, removing rugs)
  Feet and footwear	Podiatry, well-fitting shoes with a firm sole and low heel
  Cardiac causes	Pacemaker for bradyarrhythmias or cardioinhibitory carotid sinus hypersensitivity; treat AF, aortic stenosis
  Continence	Treat urgency and nocturia; commode near the bed; night lights
  Cognition and mood	Assess and support; treat delirium and depression
  Alcohol	Advice and support to reduce
  Fracture risk	Bone health assessment and treatment

• Vitamin D supplements — correct deficiency, but vitamin D alone is not a falls-prevention treatment.
• Hip protectors — may help in care homes if worn; adherence is poor.
• Care homes — exercise, medication review, staff training, environment.

Exercise, Fear of Falling and Home Safety

• Strength and balance training reduces falls by about a quarter to a third:
  • Progressive, challenging and long-lasting — usually at least 50 hours in total (e.g. twice a week for 6 months).
  • Evidence-based programmes — FaME (Falls Management Exercise, group), Otago (home-based), tai chi.
  • Simple walking alone doesn't reduce falls (and brisk walking can increase them in frail people).
• Fear of falling — common after a fall; leads to restricted activity, deconditioning and more falls — address with exercise, confidence building, CBT approaches, practising getting up from the floor ("backward chaining").
• Getting up after a fall — teach how to get up safely or how to stay warm and summon help.
• Telecare — pendant alarms or watches (falls detectors), linked to a response service; useful only if worn (many people don't wear them at night or in the bath).
• Home safety — good lighting (including night lights), remove trip hazards (rugs, cables, clutter), grab rails (bathroom, stairs), raised toilet seats, bath or shower aids, keep items within reach, non-slip mats.
• Walking aids — sticks, frames (Zimmer, wheeled frames, "rollators") — should be assessed and set to the right height by a physiotherapist.

Syncope or Fall?

• Syncope — transient loss of consciousness from reduced blood flow to the brain, with rapid, complete recovery.
• Overlap is common — older people often don't remember losing consciousness, and witnesses are often absent; up to a third of "unexplained falls" are actually syncope.
• Causes of syncope in older people:
  • Orthostatic hypotension (commonest in older people) — drugs, dehydration, autonomic failure.
  • Reflex syncope — vasovagal, carotid sinus hypersensitivity (head turning, tight collars, shaving), situational (micturition, cough, defecation, post-prandial).
  • Cardiac — bradyarrhythmias (sick sinus syndrome, complete heart block), tachyarrhythmias (VT), aortic stenosis, hypertrophic cardiomyopathy, PE — highest risk.
• High-risk features (urgent cardiac assessment) — ECG abnormality (heart block, bundle branch block, long QT, Brugada), heart failure or structural heart disease, syncope on exertion or lying down, palpitations before collapse, family history of sudden death, new or unexplained breathlessness, a murmur (NICE CG109).
• Carotid sinus hypersensitivity — carotid sinus massage (with ECG and BP monitoring, specialist, avoid with recent stroke or carotid bruit) causes a pause of over 3 seconds (cardioinhibitory — consider dual-chamber pacemaker) or a BP fall over 50 mmHg (vasodepressor).
• Other causes of transient loss of consciousness — seizures, hypoglycaemia, TIA (rarely causes loss of consciousness), intoxication.
• Driving — syncope may affect driving; advise according to DVLA guidance.

Orthostatic Hypotension

• Definition — a fall in BP of 20 mmHg or more systolic, or 10 mmHg or more diastolic, within 3 minutes of standing (or a fall to systolic under 90 mmHg) — symptoms may or may not occur.
• How to measure (RCP "lying and standing BP") — lying for 5 minutes, then stand and measure at 1 and 3 minutes; record symptoms; use a manual or validated device; some people have a delayed drop (beyond 3 minutes).
• Causes:
  • Drugs (commonest) — antihypertensives, diuretics, alpha-blockers (tamsulosin, doxazosin), nitrates, antidepressants (tricyclics, trazodone), antipsychotics, Parkinson's drugs, opioids, PDE5 inhibitors.
  • Hypovolaemia — dehydration, bleeding, diarrhoea, poor intake.
  • Autonomic failure — Parkinson's disease, multiple system atrophy, Lewy body dementia, diabetes, amyloidosis, B12 deficiency, alcohol.
  • Adrenal insufficiency, prolonged bed rest, anaemia, heart failure.
  • Post-prandial hypotension — BP falls within 2 hours of a large carbohydrate meal.
• Symptoms — dizziness or light-headedness on standing, blurred or "greying" vision, weakness, "coat-hanger" neck and shoulder pain, falls, syncope; worse in the morning, after meals, in heat and after exercise.
• Management:
  • Review and reduce drugs — first and most effective step; relax BP targets in frail people.
  • Fluids — 1.5–2 L a day (unless heart failure); a glass of water before getting up; avoid alcohol.
  • Behaviour — stand slowly in stages (sit on the edge of the bed first), leg crossing and muscle tensing, avoid large carbohydrate meals and hot baths, raise the head of the bed (10–20°).
  • Compression stockings (waist-high) or abdominal binders.
  • Drugs (specialist) — midodrine (alpha-agonist — supine hypertension, urinary retention), fludrocortisone (low potassium, oedema, supine hypertension, heart failure).
• Supine hypertension — common with autonomic failure; avoid lying flat; balance treatment carefully.

Dizziness in Older People

• Multisensory dizziness — several mild impairments together (vision, neuropathy, vestibular) — common in older people.
• Red flags for stroke — sudden vertigo with headache, inability to walk, diplopia, dysarthria, new focal signs, normal head impulse test in acute vestibular syndrome (HINTS) — urgent imaging.

Gait Disorders

• Cervical myelopathy — clumsy hands, unsteady gait, UMN signs in the legs — easily missed in older people (MRI).
• Normal pressure hydrocephalus — gait first, then incontinence and cognition — CT, tap test, shunt (see the Neurology chapters).

The Long Lie

• Long lie — lying on the floor for an hour or more unable to get up; about half of older people who fall can't get up without help.
• Complications:
  • Rhabdomyolysis — very high CK, dark urine (myoglobin), AKI, high potassium.
  • Pressure damage — pressure ulcers over the hips, sacrum, heels, shoulders; compartment syndrome (rare).
  • Hypothermia — low-reading thermometer.
  • Dehydration and hypernatraemia.
  • Aspiration pneumonia, VTE.
  • Fear of falling and loss of confidence; increased mortality.
• Assessment — time on the floor, injuries, skin, temperature, hydration, CK, U&E (potassium, creatinine), urine dipstick (blood without red cells = myoglobin), ECG, look for the cause of the fall (stroke, MI, sepsis).
• Treatment — IV fluids (aim for good urine output), treat high potassium, pressure care, rewarming, treat the cause; rehabilitation and telecare.
• Prevention — teaching how to get up, pendant alarms, regular contact (family, carers), falls prevention.

Falls in Hospital

• Falls are the commonest reported patient safety incident in hospitals; risk is highest with delirium, dementia, unfamiliar surroundings, urgency, sedatives and lines.
• Prevention (NICE NG249, RCP National Audit of Inpatient Falls):
  • Multifactorial assessment for everyone over 65 (and those 50–64 at higher risk) — don't rely on falls risk prediction scores.
  • Lying and standing BP, delirium screening, continence plan, vision check, medication review, walking aid within reach, footwear, call bell within reach, low beds, good lighting.
  • Enhanced supervision ("bay nursing") for high-risk patients; avoid bed rails if confused (entrapment risk); avoid restraint.
• After an inpatient fall (post-fall protocol):
  • Check for injury before moving — especially spinal and hip injury; if suspected — flat lifting equipment (not manual lifting).
  • Medical review — head injury (neuro observations; CT head if on anticoagulants or with signs of injury — per NICE head injury guidance), fractures (X-ray; a painful hip after a fall — consider MRI if X-ray normal), cause of the fall.
  • Inform the family; complete an incident report; update the falls prevention plan.
• Missed fractures — a patient who can't weight bear after a fall has a fracture until proven otherwise.

⚠️ Safety Pearl — after a fall in hospital, check for injury before moving the patient, and use flat-lifting equipment if spinal or hip injury is possible. Patients on anticoagulants who hit their head need neuro observations and a low threshold for CT.

Fragility Fractures

• Fragility fracture — a fracture from a fall from standing height or less (a force that would not normally break a healthy bone) — a sign of osteoporosis.
• Common sites — hip, vertebrae (often without a fall), distal radius (wrist), proximal humerus, pelvis (pubic rami), ribs, ankle.
• A first fragility fracture doubles the risk of another — the "imminent risk" is highest in the first 1–2 years.
• Fracture Liaison Services — identify people over 50 with fragility fractures and arrange bone health assessment and treatment ("secondary prevention").
• Risk factors for osteoporosis — age, female sex, previous fragility fracture, parental hip fracture, steroids, smoking, alcohol (3+ units/day), low BMI, RA, early menopause, hypogonadism, malabsorption, hyperthyroidism, hyperparathyroidism, drugs (aromatase inhibitors, androgen deprivation, antiepileptics, PPIs).
• Assessment — FRAX or QFracture (10-year fracture risk), DEXA scan (T-score −2.5 or less = osteoporosis), NOGG intervention thresholds; bloods to exclude secondary causes (calcium, ALP, vitamin D, U&E, LFTs, TFTs, FBC, ESR, protein electrophoresis, testosterone in men, coeliac serology).
• Very high risk — e.g. multiple vertebral fractures, recent fracture with very low T-score — consider anabolic treatment first (teriparatide, romosozumab) (specialist).

Hip Fracture — Orthogeriatric Care

• Orthogeriatric care (shared care between orthopaedic surgeons and geriatricians) reduces mortality and improves outcomes (NICE CG124, National Hip Fracture Database standards).
• Before surgery:
  • Analgesia — paracetamol, fascia iliaca or femoral nerve block, cautious opioids (avoid NSAIDs).
  • Optimise rapidly — fluids, electrolytes, anaemia, heart failure; don't delay surgery unnecessarily (surgery on the day of or after admission).
  • Anticoagulants — warfarin reversal with vitamin K (± PCC); DOACs — plan with anaesthetists (often operate within 24–48 hours); aspirin and clopidogrel are not reasons to delay.
  • Murmur — don't delay for echo unless it changes management (point-of-care echo where available).
  • Look for the cause of the fall (syncope, stroke, infection).
• After surgery:
  • Mobilise the day after surgery, full weight bearing.
  • Delirium screening and prevention (common — up to half).
  • Watch for — anaemia, AKI, hyponatraemia, pneumonia, constipation, urinary retention, pressure ulcers, VTE, heart failure, cement reaction.
  • Nutrition (supplements), continence, pain control.
  • Bone protection and falls prevention before discharge.
  • Early discharge with rehabilitation (Early Supported Discharge, intermediate care).
• Outcome — about 1 in 4 die within a year; many need more care; early rehabilitation improves independence.
• Palliative approach — in very frail patients near the end of life, surgery is still often the best pain relief; discuss goals with the patient and family.

Other Common Fractures in Older People

• Vertebral fractures — the commonest osteoporotic fracture; often without a fall (lifting, coughing) and often unrecognised; sudden back pain, height loss (over 4 cm), kyphosis, breathlessness, reflux, early satiety; X-ray or DEXA vertebral fracture assessment; analgesia, early mobilisation, bone treatment; exclude myeloma and metastases.
• Pubic rami fractures — groin pain and difficulty walking after a fall with normal hip X-ray; usually managed with analgesia and mobilisation; may need a short admission; look for associated sacral insufficiency fractures (CT).
• Distal radius (Colles') fractures — often the first fragility fracture (women aged 50–70) — an opportunity for bone health assessment.
• Proximal humerus — sling, early movement; affects independence (washing, dressing).
• Rib fractures — risk of pneumonia and respiratory failure — good analgesia (including nerve blocks), physio, incentive spirometry.
• Odontoid (C2) fractures — falls onto the face or head in older people; neck pain after a fall — CT cervical spine (Canadian C-spine rule — 65 and over is high risk).
• Periprosthetic fractures — around joint replacements; specialist surgery.
• Atypical femoral fractures — thigh pain on long-term bisphosphonates — X-ray both femurs.

Bone Health After a Fall

• Everyone with a fragility fracture (and many who fall) should have a bone health assessment.
• General measures — adequate calcium (diet first; supplements if intake low), vitamin D (800–1,000 units daily for those at risk), weight-bearing and strength exercise, stop smoking, limit alcohol, falls prevention.
• Drug treatment (NOGG; see the Bone Medicine chapter):
  • Oral bisphosphonates (alendronic acid weekly, risedronate) — first line; take upright, with water, 30 minutes before food; avoid in eGFR under 35; check vitamin D and calcium first; review at 5 years (drug holiday for some).
  • IV zoledronic acid (yearly) — if oral not tolerated, swallowing problems or adherence concerns (common after hip fracture); flu-like reaction; check calcium and kidneys.
  • Denosumab (6-monthly injection) — can be used in CKD; must not be stopped without follow-on treatment (rebound vertebral fractures); risk of hypocalcaemia (check calcium, vitamin D).
  • Anabolic — teriparatide, romosozumab (very high risk, specialist).
  • HRT — younger postmenopausal women.
• Dental check before antiresorptives where possible (osteonecrosis of the jaw — rare).
• Treat in care homes too — residents have the highest fracture risk; IV zoledronic acid or denosumab are practical options.

Falls and Fractures at a Glance

Spot the Diagnosis

Exam-style Scenarios

1. An 81-year-old woman has had 4 falls in 6 months, usually when getting up from a chair. She takes amlodipine, ramipril, bendroflumethiazide, doxazosin, amitriptyline (for sleep) and zopiclone. Lying BP 152/84, standing BP 118/70 at 3 minutes with dizziness.
Answer: Recurrent falls with orthostatic hypotension and falls-risk medicines.

• Medication review — stop doxazosin and the thiazide; reduce antihypertensives (relaxed BP targets); taper and stop amitriptyline and zopiclone (anticholinergic and sedative).
• Fluids, slow standing, compression; recheck lying and standing BP.
• Multifactorial falls assessment — strength and balance programme, vision, home hazard assessment, ECG, bloods, bone health (FRAX).

2. A 77-year-old man has had two episodes of sudden collapse without warning in the last month. He recovered within a minute both times. ECG shows sinus rhythm with right bundle branch block and left anterior fascicular block.
Answer: Unexplained syncope with bifascicular block — high risk of intermittent complete heart block.

• Urgent cardiology assessment; ambulatory ECG monitoring or implantable loop recorder; echo.
• Likely permanent pacemaker if bradyarrhythmia confirmed (or empirically in some).
• Advise not to drive until assessed (DVLA); falls and injury assessment.

3. An 86-year-old woman was found on her kitchen floor by a carer. She had been there overnight. She is confused, temperature 35.1°C. CK 18,000, potassium 6.1, creatinine 210 (baseline 80). There is a red area over her left hip.
Answer: Long lie with rhabdomyolysis, AKI, hyperkalaemia, hypothermia and pressure damage.

• ECG and treat hyperkalaemia; IV fluids (monitor urine output and fluid balance); passive rewarming.
• Look for injuries (hip X-ray) and the cause of the fall (sepsis, stroke, MI, arrhythmia); delirium screen; pressure care.
• Before discharge — falls prevention, pendant alarm, care needs review, teach getting up from the floor, bone health.