Falls and Funny Turns
Falls and fallers
A fall is an event that results in a person non-intentionally coming to rest at a lower level (usually the floor). Falls are common and important, affecting 1/3 of people living in their own homes each year. They result in fear, injury, dependency, insitutionalization and death. Many can be prevented and their consequences minimized.
Factors influencing fall frequency
Intrinsic factors. Maintaining balance—and avoiding a fall—is a complex, demanding, multisystem skill. It requires muscle strength (power: weight ratio), stable but flexible joints, multiple sensory modalities (eg proprioception, vision, eye sight), and a functional peripheral and central nervous system. Higher level cognitive function permits risk assessment, giving insight into the danger that a planned activity may pose
Extrinsic factors. These include environmental factors, eg lighting, obstacles, the presence of grab rails and the height of steps and furniture, as well as the softness and grip of the floor
Magnitude of ‘stressor’. All people have the susceptibility to fall, and the likelihood of a fall depends on how close to a ‘fall threshold’ a person sits. Older people, especially with disease, sit closer to the threshold, and are more easily and more often pushed over it by stressors. These can be internal (eg transient dizziness due to orthostatic hypotension) or external (eg a gust of wind, or a nudge in a crowded shop); they may be minor or major (no one can avoid ‘falling’ during complete syncope)
If insight is preserved, the older person can to some extent reduce risk, by limiting hazardous behaviours and minimizing stressors (eg walking only inside, avoiding stairs or uneven surfaces, using walking aids or asking for supervision).
Factors influencing fall severity
In older people, the adverse consequences of falling are greater, due to:
Multiple system impairments which lead to less effective saving mechanisms. Falls are more frightening and injury rates per fall are higher
Osteoporosis and increased fracture rates
Secondary injury due to post-fall immobility, including pressure sores, burns, dehydration, and hypostatic pneumonia. Half of older people cannot get up again after a fall
Psychological adverse effects including loss of confidence
Falls are almost always multifactorial. Think:
‘Why today?’ Often because the fall is a manifestation of acute or sub-acute illness, eg sepsis, dehydration or drug adverse effect
‘Why this person?” Usually because of a combination of intrinsic and extrinsic factors that increase vulnerability to stressors
▶A fall is often a symptom of an underlying serious problem, and is not a part of normal ageing.
Banned terms
The terms simple fall and mechanical fall are used commonly, but they are facile, imprecise, and unhelpful. ‘Simple’ usually refers to the approach adopted by the assessing doctor.
For every fall, identify the intrinsic factors, extrinsic factors, and acute stressors that have led to it
Within each of these categories, think how their influence on the likelihood of future falls can be reduced
Assessment following a fall
Think of fall(s) if a patient presents:
Having ‘tripped’
With a fracture or non-fracture injury
Having been found on the floor
With secondary consequences of falling (eg hypothermia, pneumonia)
Patients who present having fallen are often mis-labelled as having ‘collapsed’, discouraging the necessary search for multiple causal factors.
Practise opportunistic screening—ask all older people who attend primary or secondary care whether they have fallen recently.
History
Obtain a corroborative history if possible. May often need to use very specific, detailed, and directed questions. In many cases, a careful history differentiates between falls due to:
Frailty and unsteadiness
Syncope or near syncope
Acute neurological problems (eg seizures, vertebrobasilar insufficiency)
Gather information about:
Fall circumstances (eg timing, physical environment)
Symptoms before and after the fall
Clarification of symptoms, eg ‘dizzy’ may be vertigo or presyncope
Drugs, including alcohol
Previous falls, fractures and syncope (‘faints’), even as a young adult
Previous ‘near-misses’
Comorbidity (cardiac, stroke, Parkinson’s disease, seizures, cognitive impairment, diabetes)
Functional performance (difficulties bathing, dressing, toileting)
Drugs associated with falls
Falls may be caused by any drug that is either directly psychoactive or may lead to systemic hypotension and cerebral hypoperfusion. Polypharmacy (>4 drugs, any type) is an independent risk factor.
The most common drug causes are:
Benzodiazepines and other hypnotics
Antidepressants (tricyclics and serotonin selective reuptake inhibitors (SSRIs)
Antipsychotics
Opiates
Diuretics
Antihypertensives, especially ACE inhibitors and α-blockers
Antiarrhythmics
Anticonvulsants
Skeletal muscle relaxants, eg baclofen, tizanidine
Hypoglycaemics, especially:
Long-acting oral drugs (eg glibenclamide)
Insulin
Examination
This can sometimes be focused if the history is highly suggestive of a particular pathology. But perform at least a brief screening examination of each system.
Functional. Ask the patient to stand from a chair, walk, turn around, walk back and sit back down (‘Get up and go test’). Assess gait, use of walking aids, and hazard appreciation (eg leave an obstacle in the way and see how they negotiate it
Cardiovascular. Always check lying and standing BP. Check pulse rate and rhythm. Listen for murmurs (especially of aortic stenosis)
Musculoskeletal. Assess footwear (stability and grip). Remove footwear and examine the feet. Examine the major joints for deformity, instability, or stiffness
Neurological. To identify stroke, peripheral neuropathy, Parkinson’s disease, vestibular disease, myelopathy, cerebellar degeneration, visual impairment, and cognitive impairment
Tests
Vitamin D deficiency is common in older adults, and evidence suggests that replacing it reduces fall, so always check and replace appropriately.
Many other tests are of limited value, but the following are considered routine:
FBC
B12, folate
U, C+E
Glucose
Calcium, phosphate
If a specific cause is suspected, then test for it, eg:
24hr ECG in a patient with frequent near-syncope and a resting ECG suggesting conducting system disease
Echocardiogram in a patient with systolic murmur and other features suggesting aortic stenosis (eg slow rising pulse, left ventricular hypertrophy (LVH) on ECG)
However, all tests have false positive rates, and even a ‘true positive’ finding may have no bearing on the patient’s presentation. For example, a patient falling due to osteoarthritis and physical frailty will not benefit from echocardiogram that reveals asymptomatic mild aortic stenosis.
▶Use tests selectively, based on your judgement (following careful history and examination) of the likely factors contributing to falls.
Further reading
Kenny RA. (2008). Evidence-based algorithms and the management of falls and syncope in the acute medical setting. Clin Med 8: 157-62.
Interventions to prevent falls
The complexity of treatment reflects the complexity of aetiology:
Older people who fall more often have remediable medical causes
Do not expect to make only one diagnosis or intervention—making minor changes to multiple factors is more powerful
Tailor the intervention to the patient. Assess for relevant risk factors and work to modify each one
A multidisciplinary approach is key
Reducing fall frequency
Drug review. Try to reduce the overall number of medications. For each drug, weigh the benefits of continuing with the benefits of reduction or stopping. Stop if risk is greater than benefit. Reduce if benefit is likely from the drug class, but the dose is excessive for that patient. Taper to a stop if withdrawal effect likely, eg benzodiazepine
Treatment of orthostatic hypotension (see
‘Orthostatic (postural) hypotension’, p.118)
Strength and balance training. In the frail older person by a physiotherapist, exercise classes, or disciplines such as Tai Chi
Walking aids. Provide an appropriate aid and teach the patient how to use it (see
‘Walking aids’, p.88)
Vision. Ensure glasses are appropriate (avoid vari- or bifocal lenses)
Reducing stressors. This involves decision making by the patient or carers. The cognitively able patient can judge risk/benefit and usually modifies risk appropriately, eg limiting walking to indoors, using a walking aid properly and reliably, and asking for help if a task (eg getting dressed) is particularly demanding. However:
Risk can never be abolished
Enforced relative immobility has a cost to health
Patient choice is paramount. Most will have clear views about risk and how much lifestyle should change
Institutionalization does not usually reduce risk
‘Occupational therapy’, p.91Preventing adverse consequences of falls
Despite risk reduction, falls may remain likely. In this case, consider:
Osteoporosis detection and treatment
Teaching patients how to get up. Usually by a physiotherapist
Alarms, eg pullcords in each room or a pendant alarm (worn around the neck). Often these alert a distant call centre, which summons more local help (home warden, relative, or ambulance)
Supervision. Continual visits to the home (by carers, neighbours, family, and/or voluntary agencies) reduce the duration of a ‘lie’ post-fall
Change of accommodation. This sometimes reduces risk, but is not a panacea. A move from home to a care home rarely reduces risk—care homes are unfamiliar, often have hard flooring surfaces, and staff cannot provide continuous supervision
Preventing falls in hospital
Falls in hospital are common, a product of admitting acutely unwell older people with chronic comorbidity into an unfamiliar environment.
Multifactorial interventions have the best chance of reducing falls:
Treat infection, dehydration, and delirium actively
Stop incriminated drugs and avoid starting them
Provide good quality footwear, and an accessible walking aid
Provide good lighting and a bedside commode for those with urinary or faecal urgency or frequency
Keep a call bell close to hand
Care for the highest risk patients in a bay under continuous staff supervision
Interventions that are rarely effective and may be harmful
Bedrails (cotsides). Injury risk is substantial: limbs snag on unprotected metal bars and patients clamber over the rails, falling even greater distances onto the floor below
Restraints. These increase the risk of physical injury, including fractures, pressure sores, and death. Also increase agitation
Hip protectors
Impact absorptive pads stitched into undergarments
Limited evidence that they are effective in hospitals although there is some evidence in a care home setting
Success relies on meticulous use which is difficult—they are tricky to put on, can be uncomfortable, and multiple pairs (£40 each) are needed if incontinence is a problem
Further reading
Gillespie LD, Robertson MC, Gillespie WJ, et al. (2009). Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2: CD007146.
Oliver D, Connelly JB, Victor CR, et al. (2006). Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 334: 82.
Syncope and presyncope
Syncope is a sudden, transient loss of consciousness due to reduced cerebral perfusion. The patient is unresponsive with a loss of postural control (ie slumps or falls). Presyncope is a feeling of light-headedness that would lead to syncope if corrective measures were not taken (usually sitting or lying down).
These conditions:
Are a major cause of morbidity (occurring in a quarter of institutionalized older people), recurrent in 1/3. Risk of syncope increases with advancing age and in the presence of cardiovascular disease
Account for 5% of hospital admissions, and many serious injuries (eg hip fracture)
Cause considerable anxiety and can cause social isolation as sufferers limit activities, in fear of further episodes
Causes
These are many. Older people with decreased physiological reserve are more susceptible to most. They can be subdivided as follows:
Peripheral factors Hypotension may be caused by the upright posture, eating, straining, or coughing; and may be exacerbated by low circulating volume (dehydration), hypotensive drugs or intercurrent sepsis. Orthostatic hypotension is the most common cause of syncope
Vasovagal syncope (‘simple faint’) Common in young and old people. Vagal stimulation (pain, fright, emotion, etc.) leads to hypotension and syncope. Usually, an autonomic prodrome (pale, clammy, light-headed) is followed by nausea or abdominal pain, then syncope. Benign, with no implications for driving. Diagnose with caution in older people with vascular disease, where other causes are more common
Carotid sinus syndrome
Pump problem. Myocardial infarction or ischaemia, arrhythmia (tachy- or bradycardia, eg ventricular tachycardia (VT), supraventricular tachycardia (SVT), fast atrial fibrillation (AF), complete heart block etc.)
Outflow obstruction, eg aortic stenosis
Pulmonary embolism
The main differential is seizure disorder, where the loss of consciousness is due to altered electrical activity in the brain (see 
‘Epilepsy’, p.166).
‘Epilepsy’, p.166).History
The history often yields the diagnosis, but accuracy can be difficult to achieve—the patient often remembers little. Witness accounts are valuable and should be sought.
Ensure that the following points are covered:
Situation—was the patient standing (orthostatic hypotension), exercising (ischaemia or arrhythmia), sitting or lying down (likely seizure), eating (post-prandial hypotension), on the toilet (defecation or micturition syncope), coughing (cough syncope), in pain or frightened (vasovagal syncope)?
Prodrome—was there any warning? Palpitations suggest arrhythmia; sweating with palpitations suggests vasovagal syndrome; chest pain suggests ischaemia; light-headedness suggests any cause of hypotension. Gustatory or olfactory aura suggests seizures. However, associations are not absolute, eg arrhythmias often do not cause palpitationsRelated posts:
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