Falls in the elderly

Falls are common in older adults and are associated with significant morbidity and mortality.
Causes are usually multifactorial — orthostatic hypotension, polypharmacy, gait/balance impairment, cognitive impairment, environmental hazards.
A stepwise, structured assessment identifies modifiable risk factors and directs the patient to the appropriate service.
Orthostatic hypotension alone causes ~10% of syncope and is associated with a 2× risk of death.

Primary care assessment

History

Detailed account of the fall (before, during, after) — witness account if possible.
Number of falls in the last 12 months.
Loss of consciousness, injury, ability to get up unaided.
Symptoms of orthostatic hypotension: light-headedness on standing, visual disturbance, "coat-hanger" posterior neck pain, syncope, fatigue, worse in mornings/heat/after meals.
Medication review (see common culprits below).
Cognitive screen, continence, vision, footwear, alcohol.

Examination

Cardiovascular and neurological examination.
Lying & standing BP (see protocol below).
ECG.
Gait and balance observation (e.g. Timed Up & Go).
Clinical Frailty Score (Rockwood) — see Appendix.

Bloods (if indicated)

FBC, U&E, HbA1c, Vitamin D, TSH.

Lying & Standing BP — RCP/FFFAP protocol

Patient lies down for at least 5 minutes, then BP recorded.
Stand patient (assist if needed); BP within first minute of standing.
Repeat BP at 3 minutes standing.
If BP still falling, repeat until stable.
Use a manual sphygmomanometer if possible (definitely if automatic device fails).
Document symptoms: dizziness, light-headedness, pallor, visual disturbance, weakness, palpitations.

Positive result (any one):

Drop in systolic BP ≥20 mmHg (± symptoms)
Drop to systolic BP <90 mmHg on standing (± symptoms, even if drop <20)
Drop in diastolic BP ≥10 mmHg with symptoms

Primary care managemnt

Medication review — common culprits

Antihypertensives (especially alpha & beta blockers), diuretics, vasodilators (nitrates, calcium-channel blockers).
Anti-Parkinson's medication.
Antidepressants (TCAs, SSRIs).
Opiates, sedatives, anticholinergics.
Insulin in diabetics with autonomic dysfunction.
Amiodarone, chemotherapy (autonomic neuropathy).

Stop, reduce or substitute where possible. Reassess BP and symptoms after change.

Conservative management of orthostatic hypotension

Avoid triggers: prolonged standing, heat, alcohol, large/heavy meals, prolonged bed rest.
Fluid intake 2–4 L/day (if no contraindication).
Frequent small meals.
Regular gentle exercise.
Raise head of bed by ~10°.
Consider added dietary salt and compression stockings/abdominal binder (if not contraindicated).
Patient education: recognise prodrome and sit/lie immediately.

Self-management when symptomatic

Sit down; drink ~500 ml water as a rapid bolus to raise BP.
Physical counter-pressure manoeuvres: hand gripping, calf raises, leg crossing, squatting, whole-body tensing.
If unresolved: lie down with legs raised against a wall.

Drug treatment

✓ Specialist Initiation Only Fludrocortisone, midodrine and pyridostigmine should normally be initiated in secondary care after refractory symptoms despite the above measures.

Driving (DVLA)

Group 1: need not notify DVLA for orthostatic hypotension if symptoms occur only on standing.
Group 2: must stop driving and notify DVLA for any syncope.
Always check current DVLA guidance.

Who to refer

Pathway

Criteria

Route

Falls MDT Clinic
Geriatrician + Physio + OT + Nurse
Mountain Hall Treatment Centre
Twice monthly, up to 90 min
Family encouraged

≥2 falls in the last 12 months AND one of:

Clinical Frailty Score >4 (Rockwood)
Injury requiring medical or surgical treatment
Loss of consciousness with the fall
Unable to get up independently after the fall

SCI Gateway → Geriatrics

Physiotherapy ± Occupational Therapy

Does not meet MDT criteria but has gait or balance impairment

HomeTeams referral

DG Doing More

Has fallen in the last year without gait or balance impairment

DG Doing More referral

Refer urgently / consider admission if:

Suspected cardiac syncope (exertional syncope, syncope without prodrome, abnormal ECG, family history of sudden cardiac death).
Significant injury (head injury on anticoagulant, suspected fracture, # NOF).
Acute neurological deficit, suspected TIA/stroke.
Sepsis, GI bleed or significant volume depletion as cause of fall.

Who not to refer

Single fall with clearly identified, fully reversible cause (e.g. mechanical trip, no injury, no gait/balance issue) — manage in primary care with safety-netting.
Patients whose orthostatic hypotension resolves with medication review and conservative measures, with no ongoing falls or gait impairment.
Patients in the last days of life (CFS 8–9) where the goal is comfort — consider Anticipatory Care Planning rather than MDT referral.
Routine referral to MDT for patients not meeting the ≥2 falls + criteria threshold — use Physio/OT or DG Doing More instead.

Appendix - Rockwood score

Score