Falls
Neurology
Introduction
Author: Naqiyya Hassanali
Falls are a common issue, particularly in older adults, often caused by multiple factors. A thorough history is essential to uncover the underlying cause and guide management. Start by asking the patient to describe what happened, including where and when the fall occurred and what they were doing at the time.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
When trying to uncover the reasons behind a fall, it is important to establish events leading up to the fall, during the fall and immediately after the fall. Here is a list of questions you should ask in this section:
Before the fall:
Dizziness - Ask if the patient went from lying/standing
Chest pain/palpitations - This could suggest ACS or a PE
Aura
Check for environmental factors, such as tripping or slipping?
Loss of consciousness?
How long it lasted and whether there were any warning signs?
During the fall:
How the patient landed?
Whether they hit their head?
Seizure-like activity: including shaking, incontinence, or tongue biting?
If someone witnessed the fall, gather their account of events.
Do they remember all events?
After the fall:
Confusion?
Weakness/loss of sensation
Drowsiness?
Weakness?
Amnesia?
Have similar episodes have occurred before and if so, ask for details?
ICE: Ideas, Concerns, Expectations
Ideas: What do they think caused the fall?
Concerns: Are they worried about anything specific?
Expectations: What are they hoping for in terms of treatment?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Review medications, particularly antihypertensive, sedatives, or antidepressants, and ask about any recent changes.
Family History
Family history for epilepsy or arrhythmias.
Social History
Explore living situation: Do they live alone, use stairs or have any modifications (e.g. rails)
Smoking History: Calculate pack-years history
Alcohol Consumption: How many units per week?
Recreational Drugs
If seizures are suspected, discuss their ability to drive.
Differential Diagnosis
Headaches can be caused by the following causes:
Seizures can be accompanied by tongue biting, incontinence, and post-ictal confusion.
Vasovagal syncope is brief and linked to emotions, pain, or standing.
Postural hypotension occurs when standing up and is often brief.
Cardiac or respiratory causes, such as aortic stenosis, myocardial infarction or pulmonary embolism may also play a role.
Environmental factors, including poor eyesight or unsafe home settings, are common contributors.
Management
Bedside:
Physical examination including
Assessment of gait, balance, vision, and cognition.
Neurological examination.
Cardiovascular examination
Lying and standing blood pressure
Laboratory:
Blood Tests: FBC, U&Es, CRP, and ESR.
Imaging and Special Tests:
ECG, with 24-hour monitoring if indicated.
Consider an echocardiogram if cardiac issues are suspected.
Management Plan
Address the underlying cause.
Advise deliberate movements to avoid postural drops.
Review medications.
Provide strength and balance training.
Ensure the home environment is safe, with modifications like rails if necessary. Social and occupational services may be involved for further support.