Around a third of elderly patients living in the community fall annually with 5-15% of falls resulting in significant injuries such as fractures and head trauma.  In the UK there is 1 fall associated death every 5 hours.  So, falls in the elderly pose a significant health problem.


The cause of a fall may not always be straight forward and may be multifactorial.  Risk factors include increasing age, living in residential care and chronic disease.

Intrinsic Causes











Environmental Causes



Stroke, cerebellar disorders, visual impairment, Parkinsonism, seizures

MI, arrhythmia, orthostatic hypotension

Hypoglycaemia, hypothyroidism, dehydration

Diarrhoea, bleeding

Arthritis, muscular weakness

Incontinence, nocturia

Delirium, dementia, depression

Polypharmacy, antihypertensives, diuretics, alcohol


Poor lighting, steps, ice, shoes, rugs, walking aids


The Fall

Depending on the circumstances, it may be necessary to obtain a collateral history.

  • Environmental cause e.g. fall down stairs
  • What can they remember before and after: retrograde and anterograde amnesia are worrying symptoms of head injury
  • What were they doing at the time: a fall after standing from sitting or lying is suggestive of postural hypotension
  • Symptoms before fall e.g. dizziness
  • Loss of consciousness: suggestive of head injury or epilepsy
  • Symptoms after fall
  • Associated injuries


Past Medical History

A detailed past medical history may indicate the cause. Specifically ask about:

  • Previous falls
  • Recent infection
  • Recent vomiting and diarrhoea


Drug History

  •  Beta blockers and diuretics can cause postural hypotension


Social History

  • Alcohol history
  • Mobility
  • Use of adaptions e.g. walking aids, handrails
  • Housing
  • Care



  • Conscious level
  • Orientation: consider MMSE
  • Muscle bulk, tone, power, coordination and sensation
  • Visual acuity and visual fields



      • Pulse: arrhythmias
      • Postural BP



        • Signs of arthritis e.g. deformities, crepitus
        • Range of movement


        The mnemonic I HATE FALLING can be used to remind you of the common treatable causes of falls which may be apparent on physical examination.

        Inflammation of joints


        Auditory and visual abnormalities

        Tremor (e.g. Parkinson's)

        Equilibrium problems

        Foot problems

        Arrhythmia, heart block or valvular disease

        Leg-length discrepancy

        Lack of conditioning (generalised weakness)


        Nutrition (e.g. poor, weight loss)

        Gait disturbance


        • FBC: macrocytosis may point to alcoholism, anaemia may suggest blood loss
        • U&Es
        • LFTs
        • TFTs
        • Random blood glucose
        • Urinalysis
        • ECG

          Indications for Immediate CT Scan

          • GCS <13 on presentation
          • GCS <15 2 hours after injury
          • Suspected open or depressed skull fracture
          • Any sign of basal skull fracture e.g. 'panda' eyes, CSF coming from ear or nose
          • Post-traumatic seizure
          • Focal neurological deficit
          • >1 episode of vomiting
          • >30 minutes of retrograde amnesia
          • Some loss of consciousness/amnesia and either >65, coagulopathy or dangerous mechanism of injury e.g. RTA

          Gait and Balance Assessment

          An assessment of balance and gait could include:

          •  Observation of sitting to standing
          •  Observation of transfers
          •  Romberg test
          •  Tandem walking
          •  Timed walk


          Falls should be managed by firstly treating the underlying cause.  The involvement of a multidisciplinary team including physiotherapists and occupational therapists is useful.


          Modification of risk factors

          •  Weight bearing exercise
          •  Balance training
          •  Hip protectors
          •  Home visits e.g. to assess need for handrails, improved lighting

          Algorithm for the Investigation and Management of Falls


          The complications of falls can vary and include:

          •  Fractures
          •  Soft tissue damage
          •  Subdural haemorrhage
          •  Loss of confidence and independence
          •  Decreased quality of life
          •  Death

          Bibliography and Further Reading

          Akyol AD.  Falls in the elderly: what can be done? International Nursing Review 2007;54:191–196.

          Clark M, Kumar P.  Kumar & Clark’s Clinical Medicine.  7th ed. pp 1096-7.  London: Saunders Elsevier, 2009.

          Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR.  Oxford Handbook of Clinical Medicine.  8th ed. p 26.  New York: Oxford University Press, 2010.

          National collaborating centre for acute care. Head injury: Triage, assessment, investigation and early management of head injury in infants, children and adults. NICE, September 2007.


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