Post-Fall Syndrome

Post-fall syndrome is the loss of confidence, fear of falling and self-restricted activity that follow a fall, with tentative gait, instability and sometimes refusal to stand or walk.

About a third of people aged 65 and over fall each year, and a third to a half of fallers develop significant fear of falling.

Pathophysiology. Fear leads to avoidance of activity, which causes deconditioning, weakness and poorer balance, and in turn raises the real risk of falling again. A cautious gait with stiff, slow movement may reduce the ability to recover from a stumble.

Tentative, cautious gait, clinging to furniture or walls, wide base, reluctance to let go of support, anxiety, loss of independence and refusal to rise from a chair or bed, sometimes with apparent leg weakness that resolves on examination while supine. Social withdrawal and low mood are common.

Red flags.

• Long lie of more than an hour.
• Head injury in a person taking an anticoagulant.
• Pain on weight bearing, which may signal an occult fracture.
• New focal neurological deficit or urinary retention.

First exclude injury and acute illness: examine the hip, pelvis, spine and head, and request radiographs or CT where fracture or intracranial bleeding is possible. Then conduct a multifactorial falls assessment covering lying and standing blood pressure, ECG, vision, feet and footwear, gait and balance, cognition, mood, continence, medicines and the home. Assess fear of falling with a validated scale.

Differential diagnosis.

• Occult hip, pelvic or vertebral fracture.
• Subdural haematoma and stroke.
• Parkinsonism, normal pressure hydrocephalus and cardiac arrhythmia.
• Depression, delirium and functional gait disorder.

Treat injuries and underlying causes of falls. Offer a supervised exercise programme with balance and strength training (tai chi is effective) and graded return to walking. Add cognitive behavioural therapy for fear, home hazard modification, appropriate footwear and a walking aid when needed. Review medicines linked to falls. Replace vitamin D if deficient. Reassure and set steady, achievable goals.

Referral and escalation. Refer recurrent fallers to a falls service.