• Falls are common in the elderly
• may be the presenting symptom of an acute illness
• Causes are generally multifactorial

Falls and syncope

• Often overlap or difficult to distinguish
• patient may have no memory of the event
• may be no eyewitness accounts
• See blackout/syncope guideline

Risk factors

• Gait and balance impairment
• Reduced muscle strength
• Reduced visual acuity
• Cognitive impairment
• Drugs - polypharmacy
• sedatives/hypnotics, antidepressants, neuroleptics
• diuretics, class 1 anti-arrhythmics, alcohol, anti-cholinergics
• Predisposing conditions
• alzheimer’s disease, stroke, Parkinsonism,
• depression, visual impairment
• peripheral neuropathy, arthropathy, cardiac failure
• Environmental hazards
• poor lighting, loose carpets, lack of safety equipment
• poorly fitting shoes or clothes

History

Circumstances of fall

• Obtain an eye witness account if possible
• Ask for information that may suggest:
• syncope
• vertigo
• dizziness
• unsteadiness
• seizures

Consequences of the fall

• Time spent on floor
• Injuries sustained

Document any risk factors

• Medications that can precipitate postural hypotension
• History of falls, including previous fractures
• Impaired mobility
• Fear of falling
• Poor vision
• Incontinent of urine
• Confirmed dementia

Social history

• Carer support
• Lives alone?
• Environmental hazards

Examination

Cardiovascular

• Check for postural drop (after standing for 3 min)
• 20 mmHg in systolic BP or 10 mmHg in diastolic BP
• if drop confirmed, review diuretic therapy, antihypertensives and major tranquillizers
• Arrhythmias
• Structural heart disease
• Heart failure

Neurological

• Evidence of head injury
• Glasgow Coma Score
• Vision
• Muscle strength
• Tone
• Lower extremity peripheral nerves
• Proprioception
• Extrapyramidal and cerebellar function

Cognitive assessment

• Complete a 4AT score first to screen for both delirium and/or dementia, then
• Once confusion lessens complete a Six item cognitiveimpairment test (6 CIT) score to assess for cognitive impairment 

Locomotor

• Evidence of hip fracture or other bony injury
• Presence of muscle wasting
• Leg ulcers
• Deformities

• FBC, U&E
• ECG
• Urinalysis
• Imaging to identify injuries or acute illness

A&E

• Check the Patient Risk Assessment completed by A&E nursing staff

Falls in hospital

• Complete post falls proforma and a STOP5 debrief
• ensure all interventions required have taken place

• Treat injuries

Acute medical problems

• Commence treatment and refer to appropriate medical team
• If patient has Rockwood Clinical Frailty Score of ≥4  and requires admission, request elderly care bed
• If syncope suspected, see blackout/syncope guideline

• Ward nursing staff complete Patient Risk Assessment booklet
• Start falls prevention care plan with a list of interventions
• In plan, doctor/pharmacist complete a medication review
• assess stopping/reducing drugs e.g. antidepressants, night sedation, antipsychotics, and antihypertensives

Full multifactorial assessment

Drugs

• Check medications that may cause falls
• Polypharmacy, especially if:
• cardiovascular drugs
• insulin or oral hypoglycaemic agents
• hypnotics
• psychotropic drugs
• Alcohol

Environment

• Refer to occupational therapy

Neurovascular problems

• Gait and balance, refer to physiotherapy

Living arrangements

• Social work referral

Investigations

Cardiovascular

• If aortic stenosis or hypertrophic obstructive cardiomyopathy (HOCM) suspected, echocardiogram
• 24 hr tape if:
• bradycardia
• first degree atrioventricular block
• right bundle branch block (RBBB) and left axis deviation
• second or third degree atrioventricular block
• recurrent episode of loss of consciousness, with no features of epilepsy
• if abnormalities on 24 hr tape, cardiology referral may be needed

Neurological

• If epilepsy suspected, EEG
• if EEG suggestive of epilepsy, see First seizure guideline

Osteoporosis Assessment

• Check for a history of fragility fracture (wrist, spine, hip, pelvis or neck of humerus)
• Vertebral fractures are common and often missed
• check imaging for any vertebral wedging/height loss/collapse
• if back pain, kyphosis, or height loss >2 inches, consider x-ray thoracic and lumbar spine

Previous fragility fracture

• Refer to Fracture Liaison Service
• For any patient not taking a bisphosphonate, check if it is contraindicated or tried and not tolerated
• If no contraindication and no report of intolerance, prescribe an oral bisphosphonate alendronate 70 mg or risedronate 35 mg once per week on the same day, swallowed whole ≥30 min before first food, beverage, or medicinal product of the day with plain water only. Patients should not lie down for ≥30 min after taking alendronate or risedronate
  • prescribe concomitant daily calcium and vitamin D supplementation, to be taken ≥30 min after bisphosphonate on the day this is also taken
• If fracture spontaneous, check bone profile, thyroid function, and consider myeloma screen 

No history of fragility fracture

• Check bone profile and consider Calcium and Vitamin D supplementation
• Use FRAX, remember to enter UK and if Bone Mass Density (BMD not available, leave blank) to determine future fracture risk and need for further treatment or DXA scan
• if at intermediate risk (yellow) in FRAX, refer for DXA scan
• if at high risk of fracture in FRAX, consider an oral bisphosphonate, or if intolerant/unsuitable, refer to osteoporosis service

Specialist referral

• Depending on clinical findings, refer to appropriate specialist

Recurrent falls

• Unless patient has moderate-severe dementia, refer to Falls service

• If at high risk of falls (a YES answer to any of the 4 falls risk screening questions in Patient Risk Assessment booklet) explain in discharge letter
• If medical team feel further outpatient investigation or attendance at a Falls programme required, refer patient to Falls service
• information about recent falls and falls-related injuries
• known contributing factors (medical history etc.)
• If inpatient echo and 24 hr tape have been requested, doctor who ordered the test to forward the results to the GP