Recurrent falls

A fall is an unintentional event that brings a person to rest on the ground or a lower level. Recurrent falls means two or more in 12 months, and it points to a modifiable mix of intrinsic, drug related and environmental factors, or to an undiagnosed disease. It needs systematic evaluation, not reassurance.

Clinical relevance. Roughly one in three people over 65 fall each year, and the rate rises with age and frailty. Consequences are fracture (hip, wrist, humerus, pelvis), intracranial haemorrhage, rhabdomyolysis after a long lie, loss of confidence, institutional care and death.

Physiology. Stability depends on vision, vestibular and proprioceptive input integrated by the cerebellum and basal ganglia, timely motor output, and adequate cerebral perfusion. Ageing erodes reserve in each component, so a minor insult such as a new drug, infection or dehydration tips balance into failure.

Classification by mechanism.

• Accidental or extrinsic: trip or slip in a hazardous environment in an otherwise well person.
• Intrinsic: failure of gait, balance, strength or sensation.
• Syncopal or presyncopal: transient cerebral hypoperfusion, with or without recognised loss of consciousness.
• Drop attack: sudden loss of postural tone without warning, with the person finding themselves on the floor.
• Medication related: sedation, hypotension or impaired balance from drugs.
• Multifactorial: the usual finding in recurrent falls.

Key distinctions. Amnesia for the event is common in older adults, so separate loss of consciousness (syncope, seizure) from loss of balance using witnesses and circumstances. Falls when seated or lying, on exertion, or with palpitations carry a higher cardiac risk than a trip with a clear mechanical cause.

History.

• The fall: activity, place, time of day, prodrome (light-headedness, vertigo, palpitations, chest pain), loss of consciousness, witness account, injury, ability to rise, and duration of lie (over 1 hour marks severity).
• Triggers: standing, meals, micturition, coughing, head turning, exertion.
• Associated: urinary urgency, nocturia, visual change, cognitive change, weight loss, alcohol intake, fear of falling.
• Drugs: antihypertensives, diuretics, alpha blockers, nitrates, benzodiazepines, Z drugs, antipsychotics, antidepressants, opioids, gabapentinoids, anticholinergics, insulin and sulphonylureas, and total number of regular drugs (four or more raises risk).
• Medical: stroke, Parkinson disease, neuropathy, diabetes, arthritis, cardiac disease, cognitive impairment, osteoporosis, previous fracture, anticoagulant use.

Examination.

• Lying and standing blood pressure after 5 minutes supine, then at 1 and 3 minutes standing. Orthostatic hypotension is a systolic fall of 20 mmHg or more, a diastolic fall of 10 mmHg or more, or a systolic pressure under 90 mmHg. A heart rate rise under 15 beats/min suggests a neurogenic cause.
• Pulse rhythm, murmurs (aortic stenosis), signs of heart failure, volume status.
• Carotid sinus massage for 5 to 10 seconds, supine then upright, with continuous ECG and blood pressure, in patients over 40 with unexplained falls. A positive result is a pause of 3 seconds or more or a systolic fall of 50 mmHg or more. Contraindications: carotid bruit, stroke or transient ischaemic attack or myocardial infarction in the previous 3 months, ventricular tachycardia.
• Neurological: parkinsonism, cerebellar signs, proximal strength, peripheral sensation, reflexes, neck and spinal signs.
• Function: Timed Up and Go (12 seconds or more indicates risk), five chair stands (over 15 seconds is abnormal), tandem stance (unable to hold 10 seconds), gait observation, feet and footwear, visual acuity, cognition (Mini-Cog or MoCA).
• Injury: head, hip, wrist, spine, skin, pressure areas after a long lie.

Red flags.

• Syncope on exertion, in a supine position, or with chest pain or palpitations.
• Head injury while taking an anticoagulant, or any new focal neurological deficit.
• Fracture, or inability to bear weight.
• Long lie with muscle pain, dark urine or reduced urine output.
• New confusion or fever.
• Injury pattern or account suggesting abuse or neglect.

Special groups. In dementia, history comes from carers and falls are often tied to delirium or sedatives. In care homes, review falls in clusters and after medication changes.

Cardiovascular.

• Orthostatic hypotension: drug induced, volume depletion, or autonomic failure from diabetes, Parkinson disease, multiple system atrophy, Lewy body dementia.
• Carotid sinus hypersensitivity, vasovagal syncope, situational syncope.
• Arrhythmia: atrial fibrillation, sick sinus syndrome, atrioventricular block, ventricular tachycardia, torsades de pointes.
• Aortic stenosis, hypertrophic cardiomyopathy, heart failure.
• Acute myocardial infarction, pulmonary embolism, aortic dissection.

Neurological.

• Stroke, transient ischaemic attack, subdural haematoma, brain tumour.
• Parkinson disease, progressive supranuclear palsy, normal pressure hydrocephalus.
• Cervical spondylotic myelopathy, subacute combined degeneration of the cord, peripheral neuropathy, cerebellar degeneration.
• Alzheimer disease, vascular dementia, dementia with Lewy bodies.
• Epileptic seizure.
• Vestibular: benign paroxysmal positional vertigo, vestibular neuritis, Meniere disease.

Metabolic and systemic.

• Hypoglycaemia, hyponatraemia, hypercalcaemia, hypothyroidism, uraemia.
• Dehydration, anaemia, gastrointestinal bleeding.
• Sepsis from urinary tract infection or pneumonia, delirium.
• Vitamin D deficiency with proximal myopathy, alcohol intoxication or withdrawal.

Musculoskeletal and sensory. Osteoarthritis of hip or knee, sarcopenia, foot deformity or pain, cataract, macular degeneration, glaucoma, hearing loss.

Drug causes. Sedatives, antihypertensives, diuretics, antipsychotics, antidepressants, opioids, anticholinergics, hypoglycaemic agents.

Other. Depression with fear of falling, environmental hazards, inappropriate footwear or walking aids, elder abuse.

Work in order: exclude injury and head strike, decide whether syncope or seizure occurred, then run a multifactorial risk assessment.

First line. Lying and standing blood pressure, 12 lead ECG (rate, rhythm, PR interval, QRS width, QTc, pauses, bifascicular block, left ventricular hypertrophy), capillary glucose, full blood count, urea, creatinine, eGFR, sodium, potassium, corrected calcium, albumin, TSH, HbA1c, B12 and folate. Urinalysis only when urinary symptoms or fever are present, since bacteriuria without symptoms is common and should not be treated. Visual acuity, cognition and medication review.

Thresholds. Sodium under 135 mmol/L, haemoglobin under 130 g/L in men or under 120 g/L in women, corrected calcium over 2.60 mmol/L, and glucose under 4.0 mmol/L each justify a causal search.

Targeted tests.

• Echocardiography for murmur, heart failure, or syncope with an abnormal ECG.
• Ambulatory ECG for 24 hours to 14 days, or an implantable loop recorder, for unexplained suspected arrhythmic events.
• Head tilt testing for suspected reflex or neurogenic syncope not settled by bedside testing.
• CT head for head strike with anticoagulation, new neurological signs, reduced consciousness, vomiting, or a fall with persistent headache. MRI for suspected normal pressure hydrocephalus, myelopathy or posterior circulation disease.
• Creatine kinase after a long lie. 25 hydroxyvitamin D in housebound patients, bone disease or myopathy. DXA when fracture risk is unclear.
• Plain radiographs of the symptomatic hip, wrist or spine. If a hip radiograph is normal but the patient cannot bear weight, proceed to MRI or CT.

Limitations. Orthostatic hypotension can be delayed beyond 3 minutes, so repeat at 10 minutes when suspicion is high. Bedside gait tests predict risk but not cause. A normal 24 hour ECG does not exclude intermittent arrhythmia.

Immediate. Treat injury and pain. Check for rhabdomyolysis after a long lie and start intravenous isotonic fluid if creatine kinase is markedly raised or urine output falls. Hip fracture surgery should take place within 36 hours of admission. CT head within 8 hours for anticoagulated patients with head injury and no other indication, within 1 hour if other high risk features are present.

Analgesia. Paracetamol 1 g orally every 6 hours; maximum 4 g daily; monitor liver tests with prolonged use; reduce to a maximum of 3 g daily if weight is under 50 kg, malnutrition, chronic alcohol excess or liver disease is present.

Multifactorial intervention.

• Medication review: withdraw or reduce psychotropics, review antihypertensives and diuretics where orthostatic hypotension or low pressures are found, remove anticholinergics, avoid long acting benzodiazepines.
• Strength and balance exercise (Otago type or tai chi), at least three sessions weekly for 12 weeks or more, supervised initially.
• Occupational therapy home hazard assessment, footwear review, walking aid assessment, correction of visual impairment (cataract surgery when indicated, single vision lenses for walking outdoors).
• Treat reversible causes: anaemia, hypothyroidism, B12 deficiency, hypoglycaemia, infection.
• Pacing for cardioinhibitory carotid sinus hypersensitivity (dual chamber device). Treat arrhythmia and aortic stenosis by usual cardiology management.
• Postural measures for orthostatic hypotension: fluids, slow rising, compression stockings, drug reduction.

Bone health.

• Colecalciferol: 800 to 1000 IU orally once daily, long term, for housebound or care home patients and for confirmed deficiency (25 hydroxyvitamin D under 30 nmol/L, where a loading course of about 300,000 IU in total may be given first, for example 50,000 IU weekly for 6 weeks); maximum maintenance 4000 IU daily; monitor calcium if hypercalcaemia risk; caution in sarcoidosis, hypercalcaemia and renal stones.
• Alendronic acid for osteoporosis or fragility fracture: 70 mg orally once weekly, reviewed after 3 to 5 years; maximum 70 mg weekly; correct vitamin D and calcium first, check eGFR (avoid under 35 mL/min) and calcium; take fasting with a full glass of water and stay upright for 30 minutes; avoid with oesophageal stricture or inability to sit upright.

Special groups. Anticoagulation is not stopped solely because of falls, because the stroke prevention benefit usually exceeds the bleeding risk. In resource limited settings, prioritise medication review, orthostatic blood pressure, ECG, glucose and a home hazard check, which carry most of the yield.

Monitoring. Repeat orthostatic blood pressure after every antihypertensive change. Record falls in a diary. Review at 4 to 6 weeks.

Referral and escalation. Falls clinic or geriatrician for recurrent unexplained falls. Cardiology for suspected arrhythmic or structural syncope. Neurology for parkinsonism or suspected hydrocephalus. Orthopaedics for fracture. Physiotherapy and occupational therapy for all.

Admission criteria. Injury needing inpatient care, syncope with high risk features, new neurological deficit, rhabdomyolysis or acute kidney injury, acute illness, or unsafe at home.

Discharge and safety netting. Discharge with a written falls plan, community strength and balance programme, and review at 4 to 6 weeks. Carers are told to seek urgent help for a long lie, head injury, chest pain, palpitations or syncope.