🩺 Falls in the Elderly

Falls are a major cause of morbidity, mortality, and loss of independence in older adults. They are rarely caused by a single factor and usually result from an interaction between intrinsic (patient-specific) and extrinsic (environmental) factors. A comprehensive assessment is required to identify modifiable risks and prevent future fractures or 'long lie' events. Management involves MDT input, medication review, and strength/balance training.

Identify the circumstances of the fall: was there a prodrome (dizziness, palpitations) or a clear environmental trigger (loose rug)? Ask about frequency and any previous fractures. Review the drug history for antihypertensives, sedatives, and polypharmacy. Screen for symptoms of 'Geriatric Giants'—confusion, incontinence, and immobility. Inquire about the 'long lie' time and the patient's ability to call for help (e.g., pendant alarms). Social history is vital: home layout, stairs, and current support.

Conduct a 'Get Up and Go' test to assess gait and balance. Take lying and standing blood pressure (a drop of >20/10 mmHg is significant). Perform a full neurological exam checking for Parkinsonian features, sensory loss, or cerebellar signs. Examine the feet for poor footwear or podiatric issues. Check vision and perform a cognitive screen (e.g., AMTS or MoCA). Assess for injury, especially hip tenderness or bruising, which may indicate a fracture even if the patient is walking.

Postural Hypotension, Cardiac Arrhythmia, Polypharmacy, Sarcopenia/Frailty, Visual Impairment, Parkinson’s Disease, Urinary Tract Infection (delirium), and Environmental Hazards.

Loss of consciousness (syncope), focal neurological deficits, head injury on anticoagulants, hip pain with inability to weight bear, and new-onset palpitations/chest pain.

Standard tests include FBC (anaemia/infection), U&Es (dehydration/AKI), and Bone Profile (Vitamin D). A 12-lead ECG is mandatory to screen for arrhythmias or conduction blocks. If the patient had a 'long lie', check Creatine Kinase (CK) for rhabdomyolysis. Imaging like a hip or pelvic X-ray is required if there is localized pain or inability to weight bear. CT Head is indicated if there was an unwarned fall, head injury with anticoagulation, or new focal neurology. Consider a Bone Densitometry (DEXA) scan.

A 'fall' is often a marker of underlying frailty rather than an isolated event. Always distinguish between a 'mechanical' trip and a 'syncopal' event (where the patient loses consciousness). Check for 'long lie' complications like rhabdomyolysis or hypothermia. Review medications for 'pill-burden' and specific culprits like tamsulosin (postural hypotension) or benzodiazepines. Fear of falling is a major contributor to further deconditioning and subsequent falls.

The MLA focuses on the Multifactorial Falls Risk Assessment and the role of the Multi-Disciplinary Team (MDT). Understand the NICE criteria for CT Head in head injury. Recognise the importance of osteoporosis primary and secondary prevention post-fall (e.g., Bisphosphonates).