Key Facts

Falls in older people are rarely due to a single cause. A comprehensive multifactorial assessment is essential to identify and address modifiable risk factors.

Epidemiology

• One in three people >65 falls each year; increases to one in two >80
• Falls cause >250,000 fractures per year in the UK
• Approximately 30% of falls result in injury; 5% result in fracture
• Hip fracture: approximately 66,000 per year in the UK; 30-day mortality ~8%
• Annual NHS cost of falls in older people: approximately £2.3 billion

Aetiology

Falls are usually multifactorial:

• Intrinsic factors: muscle weakness, gait/balance problems, visual impairment, cognitive impairment, postural hypotension, syncope, peripheral neuropathy, arthritis, vestibular dysfunction
• Extrinsic factors: environmental hazards (loose carpets, poor lighting, uneven surfaces), inappropriate footwear
• Medications: sedatives, antihypertensives, anticholinergics, opioids, polypharmacy (≥4 medications)

Pathophysiology

• Age-related decline in muscle mass (sarcopenia), proprioception, vestibular function, and visual acuity
• Postural hypotension: impaired baroreceptor reflex sensitivity
• Cognitive impairment: reduced hazard awareness and reaction time
• Osteoporosis: does not cause falls but increases fracture risk from falls

History

• Circumstances of fall (where, when, what doing)
• Preceding symptoms (dizziness, palpitations, blackout, trip/slip)
• Frequency of falls
• Fear of falling (major contributor to reduced mobility and further falls)
• Medication history
• Functional history (ADLs, mobility aids, living situation)

Examination

• Gait and balance assessment (Timed Up and Go test, Berg Balance Scale)
• Lying and standing BP (postural hypotension)
• Cardiovascular examination (murmurs, arrhythmias)
• Visual acuity
• Neurological examination (power, sensation, cerebellar signs)
• Musculoskeletal assessment (joint range, deformity)
• Cognitive assessment (AMT, 4AT for delirium)
• Footwear assessment

Red Flags

• Loss of consciousness (syncope vs mechanical fall)
• Head injury (subdural haematoma risk, especially if anticoagulated)
• Focal neurological signs (stroke)
• New-onset heart failure or arrhythmia
• Long lie (>1 hour on the floor — risk of rhabdomyolysis, hypothermia, pressure injury)

Bedside

• Lying and standing BP (1 and 3 minutes standing): postural drop ≥20mmHg systolic or ≥10mmHg diastolic
• ECG: arrhythmia, heart block, QT prolongation
• Timed Up and Go (TUG): >12 seconds suggests increased falls risk
• 4AT: screening for delirium
• Urinalysis (UTI as precipitant)
• Blood glucose

Bloods

• FBC (anaemia), U&Es (dehydration, AKI from long lie), calcium (hypercalcaemia)
• TFTs, vitamin D, B12/folate
• CK (rhabdomyolysis if long lie)
• HbA1c (diabetes)
• Bone profile (if fracture suspected)

Imaging

• X-ray: if fracture suspected (hip, wrist, spine)
• CT head: if head injury, anticoagulated, or neurological signs
• DEXA scan: fracture risk assessment
• Echocardiography: if murmur or suspected cardiac cause

Special Tests

• 24-hour ECG (Holter): if arrhythmia suspected
• Tilt table test: for suspected vasovagal syncope
• Home hazard assessment by occupational therapist
• Visual acuity testing
• FRAX/QFracture: 10-year fracture risk assessment

Non-pharmacological

• Strength and balance training: Otago Exercise Programme or equivalent (30-40% fall reduction)
  • ≥3 sessions/week for ≥12 weeks (NICE CG161)
• Home hazard assessment and modification (occupational therapy): grab rails, improved lighting, remove loose rugs
• Footwear advice: well-fitting, low-heeled, non-slip soles
• Visual correction: cataract surgery if indicated; avoid bifocal/varifocal glasses when walking
• Assistive devices: walking frame, stick, personal alarm
• Education: falls prevention awareness, strategies to get up after a fall

Pharmacological

• Medication review: reduce/stop high-risk medications
  • Stop/reduce: benzodiazepines, Z-drugs, sedating antihistamines, anticholinergics, opioids
  • Review: antihypertensives (reduce if postural hypotension), diuretics, alpha-blockers
• Vitamin D supplementation: 800-1,000 IU daily (especially if deficient or housebound)
• Treat postural hypotension: reduce offending drugs; consider fludrocortisone 50-200mcg OD or midodrine 2.5-10mg TDS if persistent
• Osteoporosis treatment: alendronate 70mg weekly, risedronate, denosumab (to reduce fracture risk from falls)

Surgical/Interventional

• Cataract surgery: if visual impairment contributing to falls (reduces falls risk by 34%)
• Cardiac pacemaker: if falls due to bradycardia, carotid sinus hypersensitivity, or complete heart block
• Hip protectors: reduce hip fracture risk in care home residents

Referral Criteria

• All older people presenting with a fall: multifactorial falls risk assessment
• Recurrent falls (≥2 in 12 months): falls prevention service
• Unexplained falls with LOC: cardiology/syncope assessment
• Injurious falls in care home: community falls team
• Osteoporosis identified: fracture liaison service

• Multicomponent interventions reduce falls rate by 30-40% in community-dwelling older adults
• Fear of falling affects 50% of fallers; contributes to activity restriction and further decline
• Hip fracture: 30-day mortality ~8%; 1-year mortality ~30%
• Long lie (>1 hour): associated with 50% mortality at 6 months
• Falls are the leading cause of injury-related death in older adults
• Most falls are preventable with appropriate multifactorial intervention

NICE CG161 Multifactorial Falls Assessment Components

Timed Up and Go (TUG) Test