What happened, why, and what damage was done
Expansion
The history of the event
- Before: what were they doing, warning symptoms, dizziness, palpitations, chest pain, head turning, standing up, time of day
- During: witnessed, loss of consciousness, injury, how they landed, incontinence, tongue biting
- After: long lie, confusion, weakness, how they got up, how long it took
- Previous falls, and the fear of falling
Intrinsic causes
- Cardiovascular: postural hypotension, arrhythmia, aortic stenosis, carotid sinus hypersensitivity
- Neurological: stroke, Parkinson’s, neuropathy, cerebellar disease, cognitive impairment
- Musculoskeletal: arthritis, sarcopenia, foot problems
- Sensory: visual impairment, cataracts, varifocals, hearing
- Systemic: infection, anaemia, hypoglycaemia, electrolytes, dehydration
- Continence: rushing to the toilet, nocturia
Medication, which is the most modifiable factor. Culprits are antihypertensives, diuretics, benzodiazepines, antipsychotics, antidepressants, opioids, anticholinergics and alcohol. Four or more medicines independently increases falls risk.
Extrinsic causes: lighting, rugs, clutter, stairs, footwear, absent rails, pets.
Examination: lying and standing blood pressure, cardiac examination, gait and balance (timed up and go, turn 180 test), neurological screen, cognition, vision, feet and footwear, and injuries including the hip and head, with a low threshold for imaging in anticoagulated patients.
Investigations: electrocardiogram in all, plus bloods, and bone health assessment with a fracture risk score, since a fall plus osteoporosis is the fracture.