Why do People Fall? A Beginner's Guide to Taking a Falls History & Assessment

There are numerous reasons why patients fall, and often, this can be complex and multifactorial.

As clinicians, it is important to understand the pathophysiology behind different types of falls whilst also recognising the relevant risk factors and associated complications that can arise. By taking a comprehensive history, we can also help to prevent further falls and co-morbidity.

In this article, I have used a case vignette to help delve into factors that may contribute to falls and the common differentials to consider. I have also given an in-depth guide to taking a falls history and carrying out a falls assessment.

Case Vignette

An 87-year-old woman, Mable, has had a fall at home. She lives alone in a ground-floor flat. She is generally independent with her activities of daily living but receives help from her neighbours with weekly shopping. Mable mobilises with a stick.

Mable has a background of atrial fibrillation and is taking warfarin. She has had two other falls over the past year. Whilst there were no significant injuries from these falls, she has become increasingly housebound, having developed a fear of falling. Following the falls, Mable was recently diagnosed with Parkinson's disease by her GP and is due to be seen by the neurology clinic. She also suffers from recurrent urinary tract infections and takes prophylactic antibiotics for this.

Mable was rushing to get to the toilet when she fell onto a hard-tiled floor in the kitchen. She thinks the floor surface might have been wet, which caused her to slip and fall onto her right side. She did not feel unwell or dizzy before the fall. She does not think she lost consciousness during the fall. She is unsure if she hit her head as everything happened very quickly. She has been unable to get off the kitchen floor due to severe pain in her lower back and right leg. She is not in pain elsewhere but feels shaken by the fall. Mable can move her arms and left leg but cannot move her right leg. Mable was fortunately wearing a pendant alarm and managed to call her daughter for help. An ambulance was sent to her house, and she was quickly transferred to hospital.

What do you think are the risk factors relating to Mable's fall?

Environmental Factors

• Slippery floor in the kitchen.
• Potentially, a poor choice of shoes, e.g. poor grip.
• Rushing to the toilet, hence making slips and trips more likely.

Medical Factors

• Reaction times tend to slow down as people age and can contribute to the overall impact and likelihood of complications.
• Parkinson's disease puts her at increased risk of falls.
• General frailty, with reduced mobility and decline in muscle mass, again increases her falls risk.
• High risk of fractures due to an increased incidence of osteoporosis in this demographic.
• The fact she takes warfarin, and we do not know if she has hit her head.

What are the most likely and most concerning injuries that Mable might have sustained?

• Hip fracture.
• Wrist fracture/s (potentially if she fell onto an outstretched hand).
• Head injury (she is at increased risk of developing a subdural haemorrhage due to being on warfarin).
• Other fractures, e.g. rib fractures.
• Soft tissue injuries.

What do you need to know when a patient has had a fall?

The easiest way to break this down is to consider what happened before, during and after the fall.

Before the fall

• How did the person feel?
  • Well?
  • Dizzy?
  • Any chest pain?
  • Sweating?
  • Fevers?

During the fall

• How did the patient fall?
  • What type of surface did they fall onto?
  • Where was the main impact of the fall?
• e.g. was the fall onto an outstretched hand?
• From what height was the fall?
• Was it a witnessed or unwitnessed fall?
• What was the patient's colour like? e.g. did they appear pale?
• Was there any chest pain/sweating/shortness of breath/impending sense of doom? (these are all red flags for myocardial infarction).
• Any loss of consciousness?
  • For how long?
• Any seizure activity?
  • What did it look like? e.g. limb jerking?
  • How long did it last?
  • Any tongue biting?
  • Frothing at the mouth?
  • Incontinence?

After the fall

• How did they feel?
  • Tired?
  • Confused?
  • In pain?
  • Back to normal?
  • Is there any sign of reduced consciousness/drowsiness?
• Did they sustain any significant injuries?
  • Where is the pain?
  • Any obvious injuries/ limb deformities?
  • Did they hit their head? Is there any bleeding, swelling, or bruising to the head?
  • Are they able to stand/mobilise/ weight bear?
• How long did it take to get help?
  • Were they lying on the floor for a long time? (this can be linked to rhabdomyolysis, a serious condition whereby there is extensive muscle breakdown and possible kidney damage).

Environmental Hazards

Several environmental hazards can contribute to mechanical falls; some examples might include uneven floor surfaces, wet floors, inadequate lighting, and wearing shoes with inadequate grip.

It is important to assess these conditions to help prevent future falls. Often, this is done by an occupational therapist by visiting the patient's home as part of a post-fall assessment.

Systems to Review in the History

Essentially, we must be able to work out whether the fall was mechanical or caused by an acute medical problem. As the differentials for falls are broad, we can start by reviewing the systems that are most commonly associated with falls.

The Neurological System

The Central Nervous System

• Is the patient known to have a neurological condition that could impair their balance or coordination?
• Could this be the first presentation of one of these conditions? Are there any associated features, for example:
  • Parkinson's disease: tremors, rigidity, bradykinesia, shuffling gait.
  • Epilepsy: seizure activity, e.g. limb jerking, tongue biting, incontinence, confusion after the fall.
  • Stroke: limb weakness, slurred speech, visual impairment, facial drooping, confusion, headache.
• Cognitive impairment may lead to poor judgment, poor spatial awareness, and lapses in attention during movement.

The Peripheral Nervous System

The following problems with the peripheral nervous system can increase the risk of falls:

• Peripheral neuropathy: paraesthesia or reduced foot sensation, which is common in diabetic patients, can impair posture and balance.
• Vertigo: Patients might experience a feeling as though the room is spinning, which can lead to problems with balance.
• Visual impairment: This may contribute to misjudgement in spatial awareness.

The Cardiovascular System

The blood supply to the brain may be inadequate for numerous reasons, e.g. aortic stenosis, myocardial infarction, hypovolaemic shock, arrhythmias, etc. These conditions can lead to dizziness and, hence, fainting and falls. Therefore, it is essential to review symptoms related to the cardiovascular system, e.g. chest pain, dizziness, palpitations, and shortness of breath.

The Musculoskeletal System

A sedentary lifestyle can lead to reduced muscle strength and increased frailty, which over time can result in an increased risk of falls.

General Review

• Fevers/ night sweats (Are any infective or inflammatory processes occurring?). If an infective cause is suspected, further review of other systems is required to help identify the source of the infection, e.g. the urinary and respiratory systems etc.). Infection is commonly associated with delirium in elderly patients and can increase the risk of falls.
• Weight loss (could there be an underlying cancer or chronic illness?).
• Lethargy (could anaemia be contributing to the falls?)

Past Medical History

• Ask about medical history, including any history of cardiovascular, neurological disease and diabetes. As previously discussed, these all increase the falls risk.
• Ask about previous falls. Establish the frequency/cause and any complications associated with the falls. Is there a pattern to the falls? Are there ways the falls could have been prevented? Has the patient been referred to a falls clinic?

Drug History

• When seeing a patient following a fall, always ask if they are taking anticoagulation medication, e.g. warfarin or DOACs. This puts them at higher risk of a subdural haemorrhage if they have hit their head during the fall but also longer bleeding times from sustained injuries.
• Many medications have side effects such as dizziness, drowsiness, and instability, which can, in turn, increase falls risk.
• Polypharmacy is also another common reason for patients to be at increased risk of falls. It is important that medications are regularly reviewed and stopped if appropriate to help reduce the risk of falls.

Family History

Enquire about the history of genetic conditions that might be associated with falls, e.g. Parkinson's disease, multiple sclerosis, vascular dementia, cardiovascular disease, etc.

Social History

• Where does the patient live? e.g. Do they have stairs? Is there a lift?
• Do they need any help with activities of daily living?
• Does the patient have caring responsibilities?
• Is there a support network? These questions are particularly important when considering what help might be needed when a patient is admitted or discharged from the hospital.
• Ask about alcohol intake, as substance abuse can contribute to impaired coordination and hence increase the risk of falls.
• Ask about recreational drug use, as some drugs cause dizziness, cardiac complications, and neurotoxicity.
• Ask about exercise, as a sedentary lifestyle can reduce muscle mass and strength. This can, in turn, increase the risk of falls in elderly patients.

Examination

• A comprehensive examination should be undertaken to assess for medical causes of the fall, site/s of injury and other complications arising from the fall.
• Always assess for head injuries.
• Examine all systems that could potentially be related to the fall, e.g. a full neurological exam, vascular exam, cardiovascular, joint examinations, and other relevant systems dependent on the history, e.g. mental state examination in a confused patient.

Management

This will depend on the severity of the fall, the likely cause of the fall and examination findings.

In the case of Mable, she is at high risk of having sustained a hip fracture and, therefore, would require hospital admission for pain management, further assessment, and imaging. She would likely be a suitable candidate for surgical management. She may require a CT head if there is any evidence of a head injury. This is especially important to consider due to her being on warfarin.

Future Planning, Support and Falls Prevention

Recovery from a serious fall generally requires a multidisciplinary approach. This is likely to include the following:

• Appropriate pain management.
• Rehabilitation programmes to assist patients with strength and mobility.
• Functional assessment, e.g. can the patient wash, dress and manage their daily needs?
• Follow up in fracture clinics if applicable.
• Referral to a relevant specialist, e.g. a falls clinic, care of the older person clinic, or neurology clinic, for further assessment and management.
• Falls clinic assessment typically involves:
  • Medication review.
  • Blood pressure review to check for postural hypotension.
  • Assessment of strength, balance, and gait.
  • Screening and management of osteoporosis.
  • Examination of relevant systems to look for medical causes of falls.
• Additional tests appropriate to the examination findings for example, an echocardiogram (ECG).
• Home assessment: Prevention is crucial for anyone who has sustained a fall. This will likely involve a risk assessment of the home environment and sometimes providing assistance with walking aids or installation of specialist equipment, e.g. bath rails, stair lifts, etc.

Summary

The multifactorial nature of falls can make them difficult to assess and manage. By having a systematic and comprehensive approach to history taking and examination, we can effectively diagnose and assist in falls prevention. Falls management often requires a multidisciplinary team approach, including referral to relevant medical teams and involvement of allied healthcare professionals to assist with rehabilitation and home assessment.

References

1. BMJ (2019) Assessment of falls in the elderly. BMJ Best Practice. http://www.bestpractice.bmj.com
2. NICE (2013a) Falls in older people: assessing risk and prevention. Clinical guideline 161. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
3. NICE (2013b) Falls: assessment and prevention of falls in older people (NICE guideline). Clinical guideline 161. for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]

OSCE Course

If you liked this article, take a look at my OSCE course. I have broken down how to tackle different types of OSCE stations and included all my top examiner tips and advice. This is what I cover in the course:

• How to Prepare for OSCEs
• History Taking
• Information Giving
• Clinical Examinations
• Procedural Skills
• How to Effectively Summarise
• How to Answer Examiner Questions
• Worked Examples

The Essential OSCE Guide 

Master Your OSCE Exam Technique and Excel in Your Exams

I want this!