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Approach to falls in the older patient

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Head injury on anticoagulation: scan generously
    • Hip fracture: the fall that changes a life's trajectory
    • The fall as a symptom: sepsis, MI, stroke, and bleeds all present as 'found on floor'
    • A long lie: rhabdomyolysis, pressure injury, hypothermia

  2. History that discriminates

    • Mechanism honestly reconstructed: trip (environment) versus collapse (syncope) versus legs gave way
    • Witness account; loss of consciousness is often underreported
    • The medication list: sedatives, antihypertensives, anticholinergics, hypoglycemics
    • Pattern: first fall or recurrent faller; fear of falling since

  3. Examination

    • Injury survey first: head, C-spine, hips, wrists
    • Orthostatic vitals; rate and rhythm
    • Gait and balance watched, not asked about: the timed up-and-go
    • Vision, feet, footwear, and cognition

  4. Problem representation

    A recurrent faller on nine medications with orthostatic drop and a shuffling gait (multifactorial, medication-heavy) versus a single unexplained collapse without prodrome (syncope workup, not a falls pathway).

  5. Differential, by mechanism

    Intrinsic

    • Orthostatic hypotension
    • Arrhythmia and syncope
    • Sarcopenia and deconditioning
    • Neuropathy
    • Parkinsonism
    • Cognitive impairment
    • Vision loss

    Extrinsic

    • Polypharmacy
    • Alcohol
    • Environment: rugs, lighting, stairs

    The fall as symptom

    • Infection
    • MI
    • Stroke
    • GI bleed
    • Hypoglycemia

  6. Investigations

    • ECG on every unexplained fall
    • Basic bloods: CBC, electrolytes, glucose, creatinine; CK after a long lie
    • CT head by head-injury rules, low threshold on anticoagulants
    • Bone health assessment: this fall predicts the next fracture

  7. Interpretation

    • 'Mechanical fall' written without a mechanism is a diagnosis avoided, not made
    • Distinguishing trip from collapse redirects the entire workup

  8. Next steps

    • Deprescribe deliberately: the medication review is the highest-yield intervention
    • Strength and balance referral, home assessment, vision and footwear fixes
    • Treat the bones: falls plus fragility equals fracture prevention

Connected

ApproachWhen the fall was a faintApproachApproach to confusionScriptDelirium illness script

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