Common medical presentations

Falls

Whats new?

Rose A Kenny

Unfortunately, there is nothing new about falls being

a frequent problem in older people with devastating
consequences
Progress has been made in the standardization of fall
definitions and assessment tools, but consensus is still not
universal
Considerable research efforts are being devoted to fall
prevention strategies

Roman Romero-Ortuno
Lisa Cogan

Abstract
Falls in older people are very common and for some the consequences
can be devastating. The clinical assessment, management and investigation of patients who present with falls can be challenging for the nonspecialist, and multiple guidelines and algorithms have been published
to aid that process. This article has been prepared as a concise reference
that reviews the most recent evidence and covers the medical competencies on falls outlined in the Curriculum for General Internal Medicine
(Acute) of the Federation of Royal Colleges of Physicians of the UK. As
in the curriculum, the emphasis is on the acute setting. Important topics
covered include the epidemiology of falls, definition and classification,
causes and risk factors, cumulative effect of risk factors and the concept
of individual falling threshold, physical and psychosocial consequences
of falling, medical falls assessment in the acute setting, differentiation
between falls and syncope, principles of multifactorial falls assessment
and intervention, teamwork and communication skills, and evidencebased strategies for prevention, including latest developments in falls
prevention research.

age group, with 15% of older people falling at least twice.1

Incidence rates in hospitals are higher, and in long-term care settings approximately 3050% of people fall each year, with 40%
falling recurrently.2 The combination of high frequency and high
susceptibility to injury in older people makes falling a geriatric
giant in its own right.

Definition and classification

Despite the lack of standardization,3 a commonly used definition
of a fall is the one used in the 2004 National Institute for Clinical
Excellence (NICE) Clinical practice guideline for the assessment
and prevention of falls in older people, where a fall is defined
as an event whereby an individual comes to rest on the ground
or another lower level with or without loss of consciousness.4
Falls can be classified according to their self-reported mechanism
(explained/unexplained), objective mechanism (extrinsic/intrinsic), severity (non-injurious/injurious) and frequency (single/
recurrent).

Keywords accidental falls; diagnosis; disease management; evidencebased medicine; geriatric assessment; practice guidelines as topic;
prevention; quality of life; syncope

Epidemiology
Around 4060% of falls lead to injuries, with 3050% being
minor injuries, 56% major injuries excluding fractures and 5%
fractures. Up to 1% of falls in older people result in hip fracture.
Injuries are the fifth most common cause of death in older people
and falls are the most common cause of injury-related death in
persons over 75 years.1
According to the British Geriatrics Society, more than 600,000
fall-related accident and emergency (A&E) attendances occur
each year in the UK for persons over the age of 60 years and of
these 66% occur in those over the age of 75 years. These falls
result in over 200,000 admissions to hospital, 78% of which are
in those over 75 years of age.5 Fall-related accidents are predisposing factors in 40% of the events leading to long-term institutional care.1 With ageing societies, healthcare impacts and costs
of falls are increasing all over the world.2

Falls: how common are they?

Falls in older people are very common and their incidence
increases with age. In the community, the proportion of people
who sustain at least one fall over a 1-year period varies from
2835% in the 65 year age group to 3242% in the 75 year

Rose A Kenny MB BCh MD FRCPI FRCP is Professor of Medical Gerontology at

Trinity College and Director of the Falls and Blackout Unit at St Jamess
Hospital, Dublin, Ireland. She co-chairs the Panel on Falls Prevention
of the American Geriatrics Society and the British Geriatrics Society.
Competing interests: none declared.
Roman Romero-Ortuno Lic Med (Barcelona) MSc MRCP (UK) is Research
Registrar at the Department of Medical Gerontology, Trinity College
Dublin, Ireland. His research interests include psychological and social
aspects of falls. Competing interests: none declared.

Pathology and pathogenesis

The ultimate cause/s (precipitant/s) of a fall should be seen in
the light of individual risk factors for falling. Risk factors can
be classified as intrinsic (e.g. muscle weakness, balance and/
or gait disorders, cognitive impairment/dementia, neurocardiovascular instability, visual deficits, infection) or extrinsic

Lisa Cogan MB BCh MSc MRCPI is Research Registrar at the Department of

Medical Gerontology of Trinity College Dublin, Ireland. Her research
interests include neurological and cardiovascular aspects of falls.
Competing interests: none declared.

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Common medical presentations

often normal in many cardiac conditions. If the ECG is normal,

cardiac symptoms (e.g. palpitations, chest pain, dizziness, loss
of consciousness) will help inform its interpretation, particularly if there is known structural heart disease.14,15 If the ECG
shows ischaemic changes, atrioventricular conduction abnormalities and/or brady-or tachyarrhythmias, the management of
these should take priority. Blood tests may disclose contributory
abnormalities (e.g. electrolyte imbalance, sepsis), and requests
should be guided clinically. Requests for clinical imaging should
be informed by survey findings (e.g. pain, deformity, functional
impairment), bearing in mind that NICE have produced a guideline on computed tomography (CT) scanning of the head following head injury16 (Table 1).

(e.g. medications, environmental factors such as poor lighting,

loose carpets, etc.).6,7 It is of crucial importance to appreciate the
interactive and synergistic effects between risk factors. There is
often more than one possible risk factor for a fall and attributing
a cause can be difficult; hence, the recommendation is to modify
all known risk factors for maximum benefit. The evidence for
culprit medications is very strong, especially for sedatives and
hypnotics,8 so requests for night sedation should be scrutinized
since falls in older inpatients have a peak incidence just before
midnight.6
A major mediating factor between falls and fractures in older
people is osteoporosis. There is a strong inverse relationship
between bone density and fracture risk, with a two- to three-fold
increase in fracture incidence for each standard deviation reduction in bone mineral density. The relation between bone density
and fracture risk is comparable to that between blood pressure
and incidence of stroke and superior to that between serum cholesterol and myocardial infarction.9

Differential diagnosis
There are many conditions that may present as a fall and/or lower
an individuals threshold for falling. Figure 1 has been adapted
from a recent review by Voermans et al.7 and outlines an easy
way to remember the main causes. As emphasized above, diagnosing a fall in the older person is not only about identification of
the most likely cause but also recognition of coexistent risk factors. The majority of falls in older people are multifactorial, and
the exact cause of an event can be difficult to determine.

Course of disease, implications in old age

The consequences of falling include mobility impairment, disability, dependency, social isolation and psychological problems,
including fear of falling, anxiety, loneliness and depression.10,11
Many older fallers are unable to get up again without assistance
and this is a marker of poor prognosis12; if prolonged, the long lie
may lead to hypothermia, dehydration, rhabdomyolysis, aspiration pneumonia and pressure sores.
Fear of falling (FOF) is part of the so-called post-fall syndrome
and has been the focus of extensive research in the recent past
years. Around one-third of older people develop FOF after
a fall, and those with FOF have worse prognosis in terms of
reduced activities of daily living, loss of self-efficacy and selfconfidence, activity avoidance, lower quality of life and increased
institutionalization.11

Management
The emergency management of a fall includes prescribing appropriate pain relief and dealing with the physical injuries. A fall is a

Indications for computed tomography (CT) scanning

in falls16
Adult patients who have sustained a head injury and present
with any one of the risk factors below should have CT scanning
of the head requested immediately:
GCS less than 13 on initial assessment
GCS less than 15 at 2 hours after the injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, panda
eyes, cerebrospinal fluid leakage from the ear or nose,
Battles sign)
Post-traumatic seizure
Focal neurological deficit
More than one episode of vomiting
Amnesia for events more than 30 minutes before impact

Diagnosis: history and physical examination

The emergency response to a fall must follow the principles of
basic trauma life support. A primary survey should be conducted
looking for problems with the Airway, Breathing and Circulation,
followed by assessment of Disability (i.e. level of consciousness
and targeted neurological examination) and Exposure (e.g. signs
indicative of injury such as externally rotated and shortened leg
typical of a hip fracture). The secondary survey consists of an
AMPLE history including Allergies, Medications (with special
attention to culprit medications), Past medical history, Last meal
and Events prior to injury.13 A full report of the circumstances
and symptoms surrounding the fall is important, since these can
point to a specific aetiology or narrow down the differential diagnosis. Reports from witnesses are also important since 2530%
of older patients with cardiovascular syncope have amnesia for
loss of consciousness and present as unexplained falls.14

CT should also be requested immediately in patients with any

of the risk factors below, provided they have experienced some
loss of consciousness or amnesia since the injury:
Age 65 years or older
Coagulopathy (history of bleeding, clotting disorder, current
treatment with warfarin)
Dangerous mechanism of injury (e.g. fall from a height of
greater than 1 m or five stairs)

Investigations
In the acute setting, a quick and simple investigation to help
differentiate between cardiac (e.g. syncope) and non-cardiac
causes of a fall is an electrocardiogram (ECG), although this is

MEDICINE 37:2

CT, computed tomography; GCS, Glasgow Coma Scale.

Table 1

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Common medical presentations

clinical incident that should be reported in line with the local clinical governance structures. A period of neuro-observations should
be requested if there is significant head injury. In consultation
with seniors, consideration should be given to the transfer/referral of the patient to other clinical areas/teams as appropriate.
Once the acute episode is over, ideally before hospital discharge, the managing team should consider whether the patient
will benefit from a systematic multifactorial falls assessment and
intervention. Criteria are based on common sense: loss (or nearloss) of consciousness, unexplained, intrinsic, injurious and/or
recurrent are all red flags that point towards the need for a more
detailed evaluation. The components of a multifactorial falls
assessment and intervention are summarized by the END FALLS
mnemonic17 (Table 2).

Causes and risk factors of falls in older people

Reflex syncope
(e.g. vasovagal,
carotid sinus
syndrome

Syncope

Orthostatic
syncope (primary
and secondary)
Cardiac or
cardiopulmonary
syncope

Secondary to LOC
or near-LOC

Epileptic seizures

Explanation to patient and carers and follow-up

Non-syncopal

Metabolic
disorders (e.g.
hypoxia,
hypoglycaemia,
hyperventilation

It is important that the patient and carer/s understand the cause/

s of falls in the individual. Healthcare professionals should
respect and incorporate the knowledge and experience of people
who have been at long-term risk of falling and have been selfmanaging this risk.4
Doctors also have a role to co-ordinate the multidisciplinary
management of falls, including community services, and to
contribute regularly to the multidisciplinary team discussions
and management. There are three essentials for a successful
fall management: communication, policies and procedures, and
teamwork.18

Visual
impairment

Fall

Afferent
disorder

Vestibular
dysfunction
Disturbed
proprioception
Pyramidal

Multifactorial assessment and intervention (END

FALLS)17

Extrapyramidal
Cerebellar
Efferent
disorder

Environment: occupational therapy assessment

Neuromuscular problems: gait and balance (physiotherapy,
arthritis management, Parkinsonism, etc.)
Drugs: polypharmacy, psychotropics, alcohol, cardiovascular,
hypoglycaemics, etc.
Falls And Syncope Service (FASS) referral (consider external
referral if not available in your centre). The most commonly
performed investigations are:
active stand test (for better characterization of
orthostatic hypotension)
carotid sinus massage (for diagnosis of carotid sinus
syndrome)
head-up tilt tests (vasovagal syncope)
autonomic function tests (autonomic neuropathies)
Address osteoporosis: bone chemistry, TFT, PTH, Vitamin D,
DEXA, etc.
Low BP: postural BP measurement. Consider FASS referral if
concerned
Living arrangements: social work referral
Specialist referral: cardiology, neurology, orthopaedics,
ophthalmology, old age psychiatry, stroke, etc.

Lower motor
neurone
Neuromuscular
junction

Without LOC

Muscles
Joints
Cognitive slowing/
decline
Central
processing
disorder

Impaired alertness
Delirium
Medication/
intoxication

Other
Environment

BP, blood pressure; DEXA, dual-energy X-ray absorptiometry; PTH, parathyroid hormone; TFT, thyroid function test.

Adapted from Voermans NC, Snijders AH, Schoon Y, Bloem BR. Why old
people fall (and how to stop them). Pract Neurol 2007; 7: 15871.7

Table 2

Figure 1
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Common medical presentations

15 Romero-Ortuno R, Kenny RA. Is it cardiac? Assessment of syncope

with a scoring system. Heart 2008; 94: 152829.
16 NICE. Head injury: triage, assessment, investigation and early
management of head injury in infants, children and adults: partial
update of NICE clinical guideline 4 (NICE clinical guideline 56).
London: National Institute for Health and Clinical Excellence, 2007.
17 Parry SW, Frearson R, Steen N, Newton JL, Tryambake P, Kenny
RA. Evidence-based algorithms and the management of falls and
syncope presenting to acute medical services. Clin Med 2008; 8:
15762.
18 Wright S, Goldman B, Beresin N. Three essentials for successful
fall management: communication, policies and procedures, and
teamwork. J Gerontol Nurs 2007; 33: 4248.
19 Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C.
Prevention of falls in the elderly trial (PROFET): a randomised
controlled trial. Lancet 1999; 353: 9397.
20 American Geriatrics Society. British Geriatrics Society, and American
Academy of Orthopaedic Surgeons Panel on Falls Prevention.
Guideline for the prevention of falls in older persons. J Am Geriatr
Soc 2001; 49: 66472.
21 Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG,
Rowe BH. Interventions for preventing falls in elderly people.
Cochrane Database Syst Rev 2003(4): CD000340.
22 Cumming RG, Sherrington C, Lord SR, et al. Cluster randomised trial
of a targeted multifactorial intervention to prevent falls among older
people in hospital. BMJ 2008; 336: 75860.
23 Tinetti ME. Clinical practice. Preventing falls in elderly persons.
N Engl J Med 2003; 348: 4249.
24 Oliver D, Hopper A, Seed P. Do hospital fall prevention programs
work? A systematic review. J Am Geriatr Soc 2000; 48: 167989.
25 Parker MJ, Gillespie WJ, Gillespie LD. Hip protectors for preventing
hip fractures in older people. Cochrane Database Syst Rev 2005(3):
CD001255.
26 Fosnight SM, Zafirau WJ, Hazelett SE. Vitamin D supplementation to
prevent falls in the elderly: evidence and practical considerations.
Pharmacotherapy 2008; 28: 22534.

Prevention
An appropriate multidisciplinary falls assessment and intervention programme is the key to prevention. Since publication of
the Prevention of falls in the elderly (PROFET) trial,19 mounting evidence has confirmed the beneficial preventative effect of
this approach.2024 Interventions can be multifaceted (comprehensive), targeted multifactorial (on the risk factors identified)
or single. The Prevention of Falls Network Europe (ProFaNE)
(http://www.profane.eu.org) is a useful resource for clinicians
and researchers.
Falls prevention remains a very active area of research with
two major recent themes having been hip protectors and vitamin
D. Doubt has been cast on the effectiveness of hip protectors in
reducing hip fractures25; however, supplementation with vitamin
D has emerged as an important therapy for falls prevention26 and
will feature in future guidelines.

References
1 Masud T, Morris RO. Epidemiology of falls. Age Ageing 2001;
30(Suppl. 4): 37.
2 World Health Organization. WHO global report on falls prevention
in older age. Geneva: WHO Department of Ageing and Life Course,
2007.
3 Hauer K, Lamb SE, Jorstad EC, Todd C, Becker C. Systematic review
of definitions and methods of measuring falls in randomised
controlled fall prevention trials. Age Ageing 2006; 35: 510.
4 NICE. Clinical practice guideline for the assessment and prevention
of falls in older people. London: Royal College of Nursing, 2004.
5 Birns J, Beaumont D. The older person in the Accident & Emergency
Department British Geriatrics Society compendium document
3.2. (revised March 2008). http://www.bgs.org.uk/Publications/
Compendium/compend_32.htm (accessed 21.05.08).
6 Frels C, Williams P, Narayanan S, Gariballa SE. Iatrogenic causes of
falls in hospitalised elderly patients: a case-control study. Postgrad
Med J 2002; 78: 4879.
7 Voermans NC, Snijders AH, Schoon Y, Bloem BR. Why old people fall
(and how to stop them). Pract Neurol 2007; 7: 15871.
8 Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor
for falls: critical systematic review. J Gerontol A Biol Sci Med Sci
2007; 62: 117281.
9 Francis RM. Falls and fractures. Age Ageing 2001; 30(Suppl 4):
2528.
10 Kerse N, Flicker L, Pfaff JJ, et al. Falls, depression and
antidepressants in later life: a large primary care appraisal. PLoS
ONE 2008; 3: e2423.
11 Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij
SE. Fear of falling: measurement strategy, prevalence, risk factors
and consequences among older persons. Age Ageing 2008; 37:
1924.
12 Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability
to get up after falls among elderly persons. J Am Med Assoc 1993;
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13 Stead L. Emergency medicine. Philadelphia: Lippincott Williams &
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14 Brignole M. Distinguishing syncopal from non-syncopal causes of
fall in older people. Age Ageing 2006; 35(Suppl 2): ii46ii50.

MEDICINE 37:2

Practice points
Diagnose the cause and assess the risk factors for falling at
the same time
Rationalize the use of medications and remember that many
falls are iatrogenic
In the acute setting, follow the principles of basic trauma life
support and use the history and basic investigations (e.g.
ECG, bloods) to actively look for cardiovascular causes
Loss (or near-loss) of consciousness, unexplained, intrinsic,
injurious and/or recurrent are all red flags that point
towards the need for a multifactorial falls assessment and
intervention programme
Be familiar with the NICE documentClinical practice guideline
for the assessment and prevention of falls in older people
Remember that falls hurt souls as well as bodies
There are three essentials for successful fall management:
communication, policies and procedures, and teamwork.

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2008 Elsevier Ltd. All rights reserved.