Red flags
- Head strike + anticoagulation/antiplatelet - CT brain even if GCS 15
- Syncope preceding fall (not mechanical trip) - cardiac/neurological work-up
- Inability to rise unaided ('long lie' >1 hour) - rhabdomyolysis, pressure injury, hypothermia, AKI, pneumonia risk
- New focal neurology, severe headache
- Fracture with minimal trauma - occult NOF, vertebral, wrist
- Recurrent falls with no clear mechanical cause - cardiac arrhythmia, seizure
Differential by mechanism
Intrinsic
- Cardiovascular - orthostatic hypotension, arrhythmia, carotid sinus hypersensitivity, aortic stenosis, vasovagal
- Neurological - stroke/TIA, Parkinson's, peripheral neuropathy, cervical myelopathy, cognitive impairment/delirium, seizure
- Musculoskeletal - sarcopenia, myopathy, foot deformity/footwear, joint disease
- Sensory - visual impairment, vestibular disease, peripheral neuropathy (proprioception)
- Metabolic - hypoglycaemia, hyponatraemia, dehydration
Extrinsic
- Polypharmacy - psychotropics, antihypertensives, sedatives, opioids (single strongest modifiable risk factor)
- Environmental hazards - lighting, rugs, stairs, unfamiliar setting
- Inappropriate aids/footwear
Situational
- Acute illness (infection, dehydration) precipitating deconditioning or delirium
- Post-prandial or micturition syncope
Focused history
- Circumstances: witnessed/unwitnessed, activity at time, prodrome (dizziness, palpitations, chest pain), loss of consciousness, ability to recall the event
- Frequency - single vs recurrent (recurrent = higher risk, needs full multifactorial assessment)
- Injury sustained, time on floor
- Medication review - psychotropics, antihypertensives, hypoglycaemics, opioids, anticholinergics; recent changes
- Alcohol use
- Fear of falling - restricts activity, worsens deconditioning
- Home environment, mobility aids, footwear
- Continence (nocturia -> night-time falls), vision, hearing
- Cognitive symptoms, mood
Focused examination
- Lying-to-standing BP at 1 and 3 minutes
- Cardiovascular - pulse rate/rhythm, murmurs (AS), carotid sinus massage if suspected
- Gait and balance - Timed Up and Go (>=12s = high risk), gait speed, tandem stance
- Vision - acuity, visual fields
- Neurological - focal signs, parkinsonism, peripheral sensation/proprioception, cerebellar signs
- Musculoskeletal - lower limb strength, joint ROM, feet
- Cognitive screen (MMSE/MoCA)
- Postural stability, footwear check
Investigation strategy
- ECG in all - arrhythmia, conduction disease
- Bloods - FBE, UEC, calcium, glucose, B12, TFT, vitamin D
- Lying-standing BP (bedside, not a lab test but mandatory)
- CT brain if head strike + anticoagulant, focal signs, reduced GCS, or unwitnessed with cognitive impairment
- Bone health - DEXA if fracture or high fracture risk
- Further cardiac work-up (Holter, echo, tilt-table) only if syncope/arrhythmia suspected clinically - not routine for mechanical falls
- Home OT assessment for environmental hazards
Management
Sequence
1. Single fall, no injury, low risk - brief screen (gait, vision, medications), advice, safety-net
2. Recurrent falls, injury, or high-risk gait/balance test - full multifactorial falls risk assessment (2025 guidance consolidates this as the standard of care)
Multifactorial assessment domains
- Gait, balance and mobility; muscle strength
- Medication review and deprescribing - highest-yield single intervention; target psychotropics, benzodiazepines, >=4 medications
- Postural BP; cardiovascular disease screen
- Vision and hearing
- Footwear and home hazards (OT home visit)
- Cognition, mood, fear of falling
- Continence, vitamin D/calcium status, bone health (fracture risk assessment)
Targeted interventions
- Exercise - individually tailored balance and strength programme (e.g. Otago), the single best-evidence intervention
- Vitamin D - correct deficiency; supplementation without correcting deficiency does not reduce falls
- Vision - cataract surgery, updated glasses (single-vision preferred over multifocals outdoors)
- Home modification following OT assessment
- Cardiac pacing if cardioinhibitory carotid sinus hypersensitivity confirmed
- Hip protectors, alarm pendants for high-risk community-dwellers
- Multifactorial interventions are offered selectively based on assessment findings, not applied as a blanket package
Traps
- Attributing a fall to "mechanical"/"just tripped" without excluding syncope or arrhythmia
- Not checking lying-standing BP at 1 AND 3 minutes - delayed OH is missed on a single reading
- Treating dipstick bacteriuria as the fall's cause - asymptomatic bacteriuria is common and rarely causative
- Missing polypharmacy as the dominant modifiable factor because attention goes to imaging
- Vitamin D supplementation alone, expecting a falls benefit, without addressing gait/strength or replacing deficiency
- Failing to screen for fear of falling, which independently drives deconditioning and further falls
Talk track
Every fall needs syncope excluded first (postural BP at 1 and 3 min, ECG, cardiac history) before calling it mechanical. Recurrent falls or high-risk gait testing triggers a full multifactorial assessment - medications (biggest modifiable factor), vision, home hazards, strength/balance, bone health. Management is individually tailored exercise plus deprescribing plus targeted correction of what the assessment finds, not a blanket bundle.
8 of 8 sections written · drafted 2026-09-13