Falls - assessment
Exam Tips
- In OSCEs, always separate "fall" from "collapse": ask about prodrome, loss of consciousness, witness account, and post-event confusion.
- High-yield thresholds: Timed Up and Go >12 seconds suggests increased falls risk; Turn 180 degrees needing 5 or more steps warrants further assessment.
- State clearly that multifactorial clinical assessment is preferred and a simple falls risk score should not replace clinical judgement.
- Mention frailty, polypharmacy, and home hazards together; examiners expect a holistic plan.
- If fall involved head strike or anticoagulants, escalate urgently for head injury assessment.
- Image cue for revision: See Figure (Timed Up and Go sequence: chair rise, 3 m walk, turn, return, sit) and Figure (multifactorial falls cycle: fall -> fear -> inactivity -> sarcopenia -> recurrent fall).
Definition
A fall is an unintentional event in which a person comes to rest on the ground or a lower level. In UK clinical practice, falls assessment in older adults distinguishes a "simple fall" (usually from chronic gait, balance, vision, cognition, or frailty problems) from collapse due to an acute medical cause such as arrhythmia, transient ischaemic attack, seizure, or severe vertigo.
Pathophysiology
Falls are usually multifactorial and occur when postural stability fails because sensory input (vision, proprioception, vestibular function), central processing (cognition, reaction time), and motor output (strength, coordination, gait) are impaired. Ageing, multimorbidity, frailty, and deconditioning reduce physiological reserve, while acute stressors (infection, dehydration, pain) can tip a vulnerable person into instability. Drugs can worsen this through sedation, impaired alertness, extrapyramidal effects, or orthostatic hypotension. Recurrent falls often follow a vicious cycle: injury or fear of falling leads to activity restriction, sarcopenia, poorer balance, and further falls.
Risk Factors
- Previous fall (strongest predictor; recurrence risk is high within 1 year)
- Age 65 years and over (risk rises further at 80+)
- Frailty and multimorbidity
- Gait or balance impairment, lower-limb weakness, arthritis
- Neurological disease (stroke, Parkinson's disease, peripheral neuropathy)
- Cognitive impairment or delirium
- Visual impairment
- Urinary incontinence/nocturia (urgent rushing to toilet)
- Depression and alcohol misuse
- Polypharmacy and falls-risk-increasing drugs (for example benzodiazepines, antipsychotics, antidepressants, opioids, antihypertensives, sedating antihistamines, NSAIDs)
- Postural hypotension or syncope history
- Environmental hazards (poor lighting, loose rugs, wet floors, poor footwear)
Clinical Features
Symptoms
- One or more falls in the last 12 months
- Pre-fall prodrome: light-headedness, palpitations, vertigo, transient visual dimming, blackout
- Mechanical trigger history: trip/slip, turning, rising from chair, rushing to toilet
- Post-fall pain, reduced mobility, fear of falling, loss of confidence
- Functional decline: reduced ADLs, activity avoidance, social withdrawal
Signs
- Injuries (bruises, lacerations, head injury signs, possible fracture)
- Abnormal gait (short stride, shuffling, broad-based or unsteady gait)
- Impaired balance or postural sway
- Timed Up and Go test >12 seconds or visibly unsafe transfer/turning
- Turn 180 degrees test taking 5 or more steps
- Postural blood pressure drop (suggesting orthostatic hypotension)
- Neurological deficits or parkinsonian features
- Visual impairment, poor footwear, walking-aid misuse
Investigations
Management
Lifestyle Modifications
- Do not use a generic falls risk scoring tool; use clinical multifactorial assessment.
- Offer comprehensive falls assessment if high risk (frailty, recurrent falls, fall with injury needing treatment, loss of consciousness, or inability to get up after fall).
- Provide strength and balance exercise programme (for example supervised physiotherapy-based falls prevention classes).
- Arrange home hazard assessment and modification (lighting, rugs, bathroom safety, handrails, footwear).
- Address vision, hearing, continence urgency, alcohol excess, nutrition, hydration, and fear of falling.
- Give education on safe transfers, walking aids, and when to seek urgent care after head injury.
Pharmacological Treatment
Deprescribing / medication optimisation
- Diazepam (for anxiety) usually reduced gradually by about 1-2 mg every 1-2 weeks in long-term users
- Zopiclone 3.75-7.5 mg at night: consider tapering and stopping if persistent sedation or night-time imbalance
- Amitriptyline 10-25 mg at night (if used): switch/reduce due to anticholinergic and postural effects
- Oxycodone immediate release 5 mg every 4-6 hours PRN: review need and reduce if sedation, confusion, or dizziness
Primary strategy is to reduce or stop falls-risk-increasing drugs where safe. Taper sedatives/opioids to avoid withdrawal; monitor pain, mood, sleep, and blood pressure during changes. Avoid abrupt benzodiazepine cessation because of withdrawal seizures risk.
Orthostatic hypotension treatment (selected patients)
- Fludrocortisone 50-100 micrograms each morning, titrated cautiously
- Midodrine 2.5 mg three times daily, increased (for example to 10 mg three times daily) if needed
Use after non-drug measures and specialist review. Contraindications/cautions: supine hypertension, severe organic heart disease, acute kidney injury, urinary retention (midodrine), hypokalaemia/fluid overload (fludrocortisone). Check lying/standing BP and electrolytes.
Bone protection when fragility fracture risk is high
- Alendronic acid 70 mg once weekly
- Colecalciferol 800 IU daily (or calcium/vitamin D combination if intake is low)
Not a direct anti-fall treatment but reduces fracture consequences. Alendronate cautions/contraindications: inability to sit upright for 30 minutes, oesophageal stricture/achalasia, hypocalcaemia, severe renal impairment; counsel administration on empty stomach with water.
Complications
- Fractures (especially hip fracture) and traumatic brain injury
- Hospital admission and loss of independence
- Functional decline and deconditioning
- Fear of falling with activity restriction and social isolation
- Depression and reduced quality of life
- Institutionalisation and increased 1-year mortality after hip fracture
Prognosis
Prognosis depends on frailty, comorbidity burden, and whether modifiable risks are corrected. After one fall, recurrence risk is substantial over the next year, and repeated falls are associated with worsening function, reduced independence, and higher morbidity/mortality. Early multifactorial intervention (exercise, medication optimisation, environmental modification, and treatment of underlying causes) improves outcomes and reduces injury risk.
Sources & References
✅NICE Guidelines(1)
- Falls - assessment[overview]
📖Textbook References(5)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1766)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1762)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1762)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1762)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1767, 1768)[context]