Environmental hazards e.g. slipping, tripping
Postural instability e.g. knees, hips, Parkinson
Visual e.g. glaucoma, macular degeneration
Alcohol: acute or chronic
Medication esp. iatrogenic
Serious disorders not to be missed
Cerebral insufficiency incl. TIAs, stroke
Acute coronary syndromes
Cardiac arrhythmias e.g. sick sinus syndrome
Subdural or extradural haematoma
Parkinson disease—early onset
Labyrinthine e.g. BPPV, labyrinthitis
Diabetes: hypoglycaemia; neuropathy
Thyroid/other endocrine: Addison D, hypothyroid?
Spinal dysfunction esp. myelopathy
Urinary tract infection—nocturia
Is the patient trying to tell me something?
Highly likely, consider conversion reaction.
A careful history is required including an interview with family members and any witnesses to the fall. Investigate the onset, environment and circumstances of the fall.
Consider seizure and loss of consciousness, and situational factors such as rushing to bathroom, climbing stairs or ladder. Incl. accounts of any witnesses to the fall.
Questions should incl. any premonitory or associated symptoms e.g. vertigo, lightheadedness, palpitations, chest pain dyspnoea, visual disturbance, possible unusual or disturbed behaviour. Gather past and recent medical history incl. diabetes, hypertension, cerebrovascular disease; as well as a drug history, esp. alcohol or illicit drugs, prescription agents esp. sedatives antidepressants, hypotensives, hypoglycaemics, antipsychotics, diuretics, NSAIDs. Check thyroid status.
General features: appearance of patient incl. central cyanosis, hydration status, vital signs incl. pulse, BP (supine and standing) and temperature
Look for and exclude obvious extrinsic causes of falls
Comprehensive CVS examination
Examine ears, eyes, oral cavity, head and neck, spine, extremities esp. feet
Neurological examination including muscle features, sensation, coordination, balance and gait
Mini mental state examination
Consider others according to history and findings:
spinal X rays
CT or MRI if indicated