Based on the transcript, a typical scenario involves an elderly patient presenting after a fall at home. The patient likely has multiple comorbidities, is on several medications (e.g., a benzodiazepine like Temazepam for sleep, antihypertensives), and may consume alcohol. The fall may have occurred during a postural change, like getting up from a chair. The core task is to identify the multiple contributing factors and explain them clearly to the patient, formulating a comprehensive management plan.

During the reading time for a station on falls in the elderly, your approach should be:

1. Identify Patient & Task: Elderly patient, post-fall. The task is likely a combination of focused history, requesting examination findings, and counselling/management planning. Note any specific instructions, like “explain the likely causes.”
2. Prioritise Differentials: The primary “diagnosis” is a multifactorial fall. However, you must actively rule out sinister specific causes. Think “SPLINTS” or a similar mnemonic for falls:
   • Syncope (Cardiac: arrhythmia, structural; Vasovagal)
   • Postural Hypotension
   • Loco-motor/Gait/Balance issues (Arthritis, frailty, Parkinson’s)
   • Illness (Acute infection like UTI, pneumonia)
   • Neurological (Stroke/TIA, seizure, vestibular issues)
   • Treatments (Medications: polypharmacy, psychoactives, antihypertensives)
   • Sight/Sensory deficits & Situational factors (Environment)
3. Structure the Consultation:
   • History: Start with open questions about the fall itself (“Tell me what happened”). Use the SPLINTS mnemonic to guide your focused questions (e.g., “Did you feel dizzy or lightheaded beforehand?”, “Any palpitations?”, “What medications are you taking?”). Remember to ask about the “long lie” (time spent on the floor) and any injuries sustained.
   • Examination Plan: Mentally list the key findings to request: Vitals (including lying and standing blood pressure), cardiovascular exam, neurological exam (including gait, balance, and cognition), and musculoskeletal assessment.
   • Explanation Plan: Based on the transcript’s advice, plan to state upfront that the fall is likely due to a combination of factors. List them first, then elaborate on each one as time permits.

When an older person presents after a fall, consider the following, ordered by likelihood in a typical primary care setting:

• Most Likely – Multifactorial Fall: The fall is a result of the cumulative effect of multiple, often subtle, intrinsic and extrinsic factors (e.g., combination of poor vision, osteoarthritis, polypharmacy, and a loose rug). This is the default and most common diagnosis.
• Common – Specific Triggers:
  • Orthostatic (Postural) Hypotension: A drop in blood pressure upon standing, leading to cerebral hypoperfusion and dizziness/fall. Often exacerbated by antihypertensives, dehydration, or prolonged bed rest.
  • Medication-Related Fall: A direct consequence of a drug’s side effect, such as sedation from a benzodiazepine (Temazepam), diuretic-induced volume depletion, or alpha-blocker induced postural drop.
  • Acute Intercurrent Illness: An underlying infection (e.g., Urinary Tract Infection, pneumonia) causing delirium, weakness, or hypotension, leading to a fall.
• Not-to-Miss – Potentially Life-Threatening:
  • Cardiac Syncope: Fall caused by a sudden loss of consciousness from a cardiac cause. Suspect if there are palpitations, chest pain, no prodrome, or a family history of sudden death. Key causes are arrhythmias (e.g., VT, heart block) or structural heart disease (e.g., aortic stenosis).
  • Stroke / Transient Ischaemic Attack (TIA): A fall accompanied by focal neurological signs (e.g., unilateral weakness, facial droop, speech disturbance).
  • Seizure: A fall with features of a seizure, such as tonic-clonic movements, tongue biting, incontinence, or a prolonged post-ictal state.
• Less Common:
  • Vestibular Dysfunction: Conditions like Benign Paroxysmal Positional Vertigo (BPPV) or vestibular neuritis causing severe vertigo and imbalance.
  • Severe Anaemia: Gradual onset of weakness and postural dizziness leading to a fall.

What it is (Definition)

A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. In the elderly, falls are rarely due to a single cause. A multifactorial fall is one that results from the combined, interacting effects of multiple risk factors. The assessment and management must address this complexity.

Epidemiology (Australian Context)

• Falls are a major public health issue in Australia. Approximately 1 in 3 people aged 65 and over living in the community fall at least once a year.
• Falls are the leading cause of injury-related hospitalisation and death in people aged 65 and over.
• In 2019-20, there were 229,000 hospitalisations due to injury for older Australians, with 45% of these being due to falls. Hip fractures are a common and devastating consequence.

Etiology and Pathophysiology

The risk of falling arises from a complex interaction between intrinsic (person-specific), extrinsic (environmental), and situational factors.

• Intrinsic Factors:
  • Age-Related Physiological Changes: Decreased muscle mass (sarcopenia), slower reaction time, impaired gait and balance, reduced proprioception, and impaired vision.
  • Cardiovascular: Orthostatic hypotension (a drop in SBP ≥20 mmHg or DBP ≥10 mmHg within 3 minutes of standing), carotid sinus hypersensitivity, arrhythmias.
  • Neurological & Cognitive: Previous stroke, Parkinson’s disease, dementia/cognitive impairment, peripheral neuropathy, vestibular disorders.
  • Musculoskeletal: Osteoarthritis (especially in hips/knees), foot problems (e.g., bunions, ulcers), frailty.
  • Medications (Polypharmacy): The risk increases with the number of medications. Key culprits include: Psychoactives, Antihypertensives, and drugs with Anticholinergic effects.
  • Other: Acute illness (UTI, pneumonia), depression, fear of falling, alcohol use.
• Extrinsic (Environmental) Factors:
  • Poor lighting, loose rugs or carpets, slippery floors, clutter, unsafe stairs, and lack of handrails.

Investigations

The goal is to identify reversible or treatable contributing factors.

Laboratory (Bloods)

• Full Blood Count (FBC): To rule out anaemia.
• Urea, Electrolytes, Creatinine (U&E/Cr): To assess for dehydration and renal impairment.
• Blood Glucose Level (BGL): To screen for hypo- or hyperglycaemia.
• Thyroid Stimulating Hormone (TSH): Hypo- or hyperthyroidism can contribute.
• Vitamin D: Deficiency is common and associated with muscle weakness.

Other

• Electrocardiogram (ECG): Essential to look for arrhythmias, heart block, or evidence of ischaemia.
• Urinalysis: To screen for a urinary tract infection.
• Imaging: Indicated by specific clinical findings (e.g., CT Brain for head injury, X-rays for suspected fractures).

Management Principles (Australian Guidelines Focus)

Management is multidisciplinary and multifactorial.

1. Treat Injuries & Acute Illness: Address any fractures, wounds, or underlying infections first.
2. Multifactorial Risk Assessment: Every older person presenting with a fall should have this assessment.
3. Key Interventions:
   • Strength and Balance Training: The single most effective intervention.
   • Medication Review (Deprescribing): A crucial and examinable step.
   • Home Environment Assessment & Modification: Usually performed by an Occupational Therapist (OT).
   • Management of Postural Hypotension: Patient education, hydration, medication adjustment.
   • Vision Assessment & Optimisation.
   • Footwear & Podiatry Review.
   • Vitamin D Supplementation.

• Verbalise Your Approach: When requesting examination findings, be systematic. “I would first like the vital signs, including temperature, heart rate, respiratory rate, oxygen saturation, and importantly, a lying and standing blood pressure.”
• Think Out Loud: When formulating your diagnosis, it’s okay to say, “Based on the history of dizziness on standing and the medications, postural hypotension is a major factor. However, the slow reaction time from the temazepam and the poor lighting in the hallway also likely contributed. Therefore, my leading diagnosis is a multifactorial fall.”
• Be Patient-Centred: Frame the management plan around the patient’s goals. “Our main goal is to work together to reduce your risk of another fall so you can stay confident and independent at home. To do this, I suggest we…”
• Close the Loop: Always end by summarising the plan and asking, “Does that make sense? What questions do you have for me?” This demonstrates good communication and patient-centred care.

• Title: Preventing falls and harm from falls in older people: Best practice guidelines for Australian residential aged care facilities 2018
  URL: https://www.safetyandquality.gov.au/sites/default/files/migrated/Guidelines-RACF.pdf
• Title: Australian Institute of Health and Welfare – Falls
  URL: https://www.aihw.gov.au/reports/injury/falls