Introduction
Falls in older adults are a major public health issue, frequently leading to injury, loss of independence, and hospital admission. Conducting a thorough falls assessment elderly UKMLA candidates must master is therefore a core competency, particularly relevant for the practical skills tested in the CPSA. Understanding the multifactorial nature of falls and applying a structured assessment framework are essential for identifying risks and implementing effective prevention strategies.
This guide provides a comprehensive 6-step approach to assessing an older person who has fallen, designed specifically for UKMLA candidates preparing for the CPSA. We will cover detailed history taking, targeted examination, functional assessment, and the principles of multidisciplinary management, linking theory to the practical skills required in stations simulating General Practice Essentials for UKMLA or acute care settings.
Key Takeaways
Falls are Multifactorial: Rarely due to a single cause; a comprehensive assessment must cover intrinsic (patient-related) and extrinsic (environmental) factors.
History is Key: A detailed falls history (using a mnemonic like SPLATT or similar structure) provides crucial clues to the underlying cause(s).
Targeted Examination: Focus examination on systems commonly implicated in falls: cardiovascular (postural hypotension), neurological (balance, gait, cognition, peripheral neuropathy), musculoskeletal (strength, joint issues), and vision.
Functional Assessment Matters: Directly observing gait, balance (e.g., Timed Up and Go test), and assessing fear of falling are essential components.
Multidisciplinary Approach: Management is often multidisciplinary (MDT), involving physiotherapy, occupational therapy, medication review (deprescribing), and potentially specialist referral.
Why Falls Assessment Elderly UKMLA CPSA Stations Demand Excellence
Falls are not an inevitable part of ageing, and many can be prevented with appropriate assessment and intervention. Your ability to perform this assessment demonstrates core clinical skills vital for the UKMLA.
The Scale of the Problem: Falls in Older Adults in the UK
Around 1 in 3 adults over 65, and 1 in 2 over 80, fall at least once a year.
Falls are the leading cause of injury-related death in older adults.
They frequently result in fractures (especially hip fractures), head injuries, and subsequent fear of falling, leading to reduced mobility and social isolation.
The cost to the NHS is significant, estimated at over £2 billion annually.
UKMLA Relevance (AKT questions on risk factors/causes; CPSA station focus)
AKT: Questions may test your knowledge of common risk factors for falls (e.g., polypharmacy, postural hypotension, visual impairment), causes of falls (e.g., syncope, environmental hazards), and initial management steps.
CPSA: Falls assessment is a classic station. You may be required to take a focused history from a simulated patient or carer, perform relevant physical examinations (e.g., lying/standing blood pressure, gait assessment), interpret findings, and formulate a management plan, often involving MDT referrals.
Preparing for the Assessment: Initial Steps & Safety
Before starting, ensure a safe and appropriate environment.
Environment and Equipment
Ensure the room is well-lit and free from hazards.
Have necessary equipment ready: Stethoscope, BP machine (manual preferred for postural BP), pen torch, tendon hammer, tuning fork, measuring tape (for TUG test), patient’s walking aid (if used).
Establishing Rapport and Consent
Introduce yourself clearly.
Explain the purpose of the assessment sensitively. Falls can be embarrassing or frightening for patients.
Obtain informed consent before proceeding with history and examination.
The 6-Step Framework for Comprehensive Falls Assessment
A systematic approach ensures all key areas are covered.
Step 1: Detailed Falls History (SPLATT Mnemonic)
This is often the most revealing part of the assessment.
Symptoms before fall: Any warning? Dizziness, light-headedness, palpitations, chest pain, shortness of breath, visual disturbance, aura? (Suggests syncope, arrhythmia, seizure). Loss of consciousness?
Previous falls: How many falls in the last year? Circumstances of previous falls? Any injuries?
Location of fall: Where did it happen? Indoors/outdoors? Specific room? Environmental hazards (rugs, poor lighting, stairs)?
Activity at time of fall: What was the patient doing? Walking, turning, standing up from sitting/lying, reaching?
Time of day: Any pattern? (e.g., Nocturia leading to falls at night).
Trauma sustained: Any injuries? Specifically ask about head injury, loss of consciousness after the fall, inability to get up (‘long lie’ – risk of rhabdomyolysis, pressure sores, hypothermia).
Step 2: Review Past Medical History & Risk Factors
Relevant Conditions: Check for known diagnoses increasing fall risk: Cardiovascular (IHD, arrhythmias, HF, postural hypotension), Neurological (Stroke, Parkinson’s, dementia, peripheral neuropathy, epilepsy), Musculoskeletal (Osteoarthritis, osteoporosis, muscle weakness, foot problems), Sensory (Visual impairment, hearing loss), Genitourinary (Incontinence, nocturia), Psychological (Depression, anxiety, fear of falling).
Intrinsic vs. Extrinsic Factors: Categorise risks (See Table 1).
Step 3: Comprehensive Medication Review (Deprescribing Focus)
Action: Obtain a full medication list (prescribed, OTC, supplements). Polypharmacy (≥4 or 5 drugs often cited) is a major risk factor.
Identify Culprit Drugs: Focus on classes known to increase falls risk (psychotropics, antihypertensives, etc.). For a detailed approach, see Tackling Polypharmacy: A 7-Step Guide to Deprescribing in the Elderly for UKMLA.
Assess Appropriateness: Is each drug still indicated? Is the dose appropriate? Could any be stopped or reduced? This links to Prescribing Safely for the UKMLA.
Step 4: Targeted Physical Examination
Focus on systems relevant to falls.
Cardiovascular:
Lying and Standing Blood Pressure: Measure BP after 5 mins lying, then at 1 min and 3 mins after standing. A drop in systolic BP ≥20mmHg or diastolic BP ≥10mmHg, or systolic <90mmHg on standing, confirms postural hypotension.
Pulse: Rate and rhythm (check for bradycardia, irregularity like AF).
Auscultate: Murmurs (especially aortic stenosis).
Neurological:
Cognition: Brief screen (e.g., AMTS, MoCA) if concerns.
Gait & Balance: Observe walking (see Step 5). Check Romberg’s test.
Tone, Power, Coordination: Assess lower limbs primarily. Check for Parkinsonian features (tremor, rigidity, bradykinesia).
Sensation: Check peripheral sensation (light touch, proprioception), especially feet (neuropathy).
Vision: Gross visual acuity assessment.
Musculoskeletal:
Inspect feet and footwear.
Check lower limb joint range of motion, look for pain/deformity (esp. hips, knees, feet).
Assess muscle strength (e.g., timed chair stands).
Step 5: Functional Assessment
Directly observe the patient’s mobility. Ensure safety during assessment.
Gait Assessment: Observe walking speed, step height, stride length, symmetry, turning stability, use of walking aids. Look for shuffling (Parkinson’s), broad-based gait (cerebellar/sensory ataxia), foot drop.
Balance Tests:
Timed Up and Go (TUG) Test: Time taken to stand from a chair, walk 3 meters, turn, walk back, and sit down. >12-15 seconds suggests increased falls risk. A key procedural skill concept.
Romberg’s Test: Assesses proprioception/balance. Patient stands feet together, eyes open then closed. Excessive sway/instability with eyes closed is positive.
Assessing Fear of Falling: Ask directly – has the fear of falling made them limit their activities?
Step 6: Formulating an Initial Management Plan (MDT Approach)
Summarise: Bring together findings from history, examination, and functional assessment.
Immediate Safety: Provide advice on environmental hazards, appropriate footwear, getting up safely if they fall again.
Investigations: Plan necessary tests (see next section).
Referrals: Identify appropriate MDT members:
✓ Physiotherapy: Essential for strength and balance training.
✓ Occupational Therapy (OT): For home hazard assessment, equipment/adaptations.
✓ Medication Review: By GP, geriatrician, or pharmacist (deprescribing).
✓ Specialist Referral: Geriatrician (complex cases/frailty), Cardiologist (suspected arrhythmia/syncope), Neurologist (Parkinson’s, stroke), Optometry/Ophthalmology.
Table 1: Common Intrinsic vs. Extrinsic Risk Factors for Falls
| Intrinsic Factors (Patient-Related) | Extrinsic Factors (Environmental/Situational) |
|---|---|
| Previous Falls | Poor Lighting |
| Gait/Balance Problems (e.g., Parkinson’s, Stroke) | Loose Rugs / Clutter |
| Muscle Weakness (Sarcopenia) | Slippery/Uneven Surfaces (Wet floors, Ice) |
| Visual Impairment | Stairs (Poorly maintained, No handrails) |
| Cognitive Impairment (Dementia, Delirium) | Inappropriate Footwear |
| Foot Problems / Inappropriate Footwear | Unfamiliar Environment |
| Postural Hypotension | Lack of/Incorrect Use of Walking Aids |
| Chronic Diseases (Arthritis, Diabetes, CVD) | Rushing (e.g., to toilet due to urgency) |
| Medications (Polypharmacy, Psychotropics) | Hazards (Trailing wires, Pets) |
| Fear of Falling | – |
Key Investigations Following a Falls Assessment
Investigations are guided by the history and examination findings.
Routine Bloods
FBC: Anaemia (can cause dizziness/weakness).
U&Es: Dehydration, electrolyte disturbances (esp. Na+, K+) which can cause confusion or arrhythmias. Check renal function (AKI?).
Calcium/Phosphate/ALP: Bone profile, relevant for osteoporosis risk/bone mets.
Glucose/HbA1c: Hypo/hyperglycaemia, screening for diabetes (neuropathy risk).
TFTs: Hypo/hyperthyroidism can affect balance/cognition.
B12/Folate: Deficiency can cause peripheral neuropathy/sensory ataxia.
ECG
Essential to look for arrhythmias (AF, bradycardias, heart block), previous MI, or features suggesting structural heart disease, linking to Cardiology Essentials.
Further Investigations (Based on Clinical Suspicion)
24-hour ECG (Holter): If intermittent arrhythmia or symptomatic palpitations/dizzy spells suspected.
CT Head: If head injury sustained, new focal neurology, suspected stroke/bleed.
Echocardiogram: If significant murmur (e.g., aortic stenosis) or suspected heart failure.
Carotid Sinus Massage: If carotid sinus hypersensitivity suspected (specialist procedure).
Tilt Table Testing: If recurrent unexplained syncope.
Management Strategies & The Multidisciplinary Team (MDT)
Management focuses on addressing identified risk factors, often involving an MDT approach as outlined in NICE Guideline NG249.
Physiotherapy
Crucial for strength and balance training programs, proven to reduce falls.
Gait re-education and advice on appropriate walking aids.
Occupational Therapy
Home hazard assessment and recommendations for modifications (e.g., removing rugs, improving lighting, installing grab rails).
Provision of equipment (e.g., walking frames, pendant alarms).
Strategies for managing activities of daily living safely.
Medication Review / Deprescribing
Systematic review aiming to stop or reduce doses of culprit medications (see Step 3 and Table 1). Involve pharmacists where available.
Managing Specific Causes
Treating underlying medical conditions (e.g., correcting anaemia, managing heart failure, pacemaker for complete heart block, optimizing Parkinson’s treatment).
Vision correction.
Podiatry for foot problems.
Vitamin D supplementation (often recommended, especially if deficient or housebound).
Patient and carer education are vital components. Resources like Age UK’s falls prevention advice can be helpful.
Table 2: Key Components of the Falls-Focused Examination
| System | Key Examination Components |
|---|---|
| Cardiovascular | Lying & Standing BP (Postural check), Pulse rate & rhythm, Heart sounds (murmurs), JVP. |
| Neurological | Cognitive screen (if indicated), Vision (acuity), Gait & Balance (inc. TUG), Tone/Power/Coordination (esp. lower limbs), Sensation (esp. feet proprioception/vibration), Romberg’s test, Cerebellar signs, Parkinsonian features. |
| Musculoskeletal | Inspect feet & footwear, Lower limb joint range of motion/pain/deformity (Hips, Knees, Ankles, Feet), Assess muscle strength (e.g., timed chair stands), Check spine. |
| General | Look for injuries from fall, General frailty assessment, Hydration status. |
Putting It All Together: A UKMLA CPSA Scenario Example
Scenario: Assessing an Elderly Patient on the Ward After a Fall
Brief: You are the FY1 doctor asked to assess Mr. Smith, an 82-year-old man admitted with pneumonia, who slipped and fell in the bathroom overnight. He did not hit his head or lose consciousness but felt dizzy beforehand.
Approach (Simulated):
Safety/Intro: Ensure safe environment, introduce self, confirm patient identity, gain consent.
History: Take a focused SPLATT history (Dizzy before fall? Previous falls? Location – bathroom, wet floor? Activity – standing up from toilet? Time – night? Trauma – hip pain?). Review PMH (Hypertension, BPH on Tamsulosin) and drug chart (Tamsulosin, Ramipril, recent antibiotics).
Examination: Check vital signs. Perform lying/standing BP (significant postural drop identified). Perform targeted Neuro exam (Gait/Balance may be limited by illness/setting, check power/sensation). Check Cardiovascular system. Check hydration.
Functional: May not be appropriate if acutely unwell, but ask about usual mobility.
Plan: Summarise findings (Likely multifactorial fall – postural hypotension exacerbated by dehydration/acute illness and alpha-blocker, plus potential environmental factor). Immediate plan: Hold Tamsulosin temporarily? Ensure adequate hydration. Request physio assessment when medically stable. Discuss medication review with senior/pharmacist. Ensure safe mobility on ward (call bell, supervision).
Concise Presentation Structure (SBAR format):
Situation: “Assessed Mr. Smith, 82, post-fall overnight in the bathroom. No significant injury reported.”
Background: “Admitted with pneumonia. PMH: Hypertension, BPH. Meds: Ramipril, Tamsulosin. Felt dizzy before fall.”
Assessment: “SPLATT history suggests pre-syncope. Lying/Standing BP shows postural drop of 30mmHg systolic. Likely multifactorial: postural hypotension exacerbated by acute illness/possible dehydration and alpha-blocker (Tamsulosin). Environment (bathroom) also a factor.”
Recommendation: “Plan: Hold Tamsulosin for now? Ensure adequate hydration via IV/oral fluids. Maintain ward safety measures (call bell, assist mobility). Request physio assessment for mobility/balance once medically fitter. Needs formal medication review before discharge.”
Frequently Asked Questions (FAQ) about Falls Assessment in the Elderly
While all components are important, the detailed falls history (using a framework like SPLATT) is often the most crucial part. It provides vital clues about the likely mechanism (e.g., syncope, trip, weakness), potential triggers, and relevant risk factors that guide the subsequent examination and investigations.
Ask the patient to lie down comfortably for at least 5 minutes. Measure their blood pressure and heart rate while lying. Then, ask the patient to stand up. Measure the BP and HR again immediately (within 1 minute) and then again after 3 minutes of standing. A drop in systolic BP of ≥20 mmHg or diastolic BP of ≥10 mmHg at either time point confirms postural (orthostatic) hypotension. Ensure patient safety during standing.
The TUG test is a simple functional mobility assessment. The patient starts seated in a standard chair, stands up, walks 3 meters (10 feet) at their normal pace, turns around, walks back to the chair, and sits down again. The time taken is recorded. A time of 12-15 seconds or longer is generally considered indicative of an increased risk of falling and warrants further assessment, typically by physiotherapy.
Several drug classes significantly increase falls risk:
Psychotropic medications: Benzodiazepines, Z-drugs, Antipsychotics, Antidepressants (especially TCAs).
Antihypertensives: Especially diuretics, alpha-blockers, and multiple agents causing postural hypotension.
Opioids: Due to sedation, dizziness, and constipation.
Anticholinergics: Cause confusion, blurred vision, and sedation.
Polypharmacy (simply taking multiple drugs, e.g., ≥4 or 5) itself is a major independent risk factor.
No, describing a fall as purely ‘mechanical’ (e.g., a simple trip) without considering underlying factors is often an oversimplification in older adults. While trips and slips do happen, underlying issues like poor vision, slow reaction times, gait instability, unsafe footwear, or environmental hazards often contribute. A comprehensive assessment should still explore potential intrinsic factors even if an apparent external cause is identified.
Vitamin D deficiency is common in older adults and is associated with muscle weakness (proximal myopathy) and impaired balance, increasing falls risk. It’s also crucial for bone health (preventing osteoporosis and fractures if a fall occurs). UK guidelines often recommend routine Vitamin D supplementation (e.g., 800 IU daily) for adults aged 65 and over, particularly those who are housebound or in care homes, although specific recommendations on testing and dosage can vary.
Fear of falling is common after a fall and can lead to a vicious cycle. Patients may restrict their activity and become deconditioned, leading to further muscle weakness and balance impairment, paradoxically increasing their risk of future falls. Addressing this fear through confidence-building exercises (physiotherapy) and psychological support is an important part of management.
Simple immediate advice includes:
Ensuring adequate lighting, especially at night (e.g., night lights).
Removing trip hazards like loose rugs, clutter, and trailing wires.
Using non-slip mats in the bathroom.
Wearing well-fitting shoes or slippers with good grip.
Taking time when standing up from sitting or lying.
Keeping frequently used items within easy reach.
Considering a pendant alarm if living alone.
Referral to a Geriatrician or specialist falls clinic is appropriate for patients with:
Recurrent falls (>2 in 12 months).
Falls causing significant injury.
Falls associated with loss of consciousness or syncope of unclear cause.
Gait or balance disorders requiring specialist assessment.
Complex multimorbidity and polypharmacy contributing to falls.
Failure to respond to initial primary care/MDT interventions.
The definitive UK guideline is NICE Guideline NG249 – Falls: assessment and prevention in older people and in people 50 and over at higher risk. This provides comprehensive recommendations on risk identification, multifactorial assessment, and interventions. Patient-friendly resources are available from Age UK.
Conclusion
Conducting a thorough falls assessment elderly UKMLA candidates need requires a blend of systematic history taking, targeted examination, functional evaluation, and clinical reasoning. Recognising falls as a multifactorial geriatric syndrome and utilising a structured 6-step approach helps ensure key contributing factors are identified. Addressing polypharmacy through careful medication review and deprescribing is a particularly high-yield intervention.
Remember that management is often multidisciplinary, involving physiotherapy and occupational therapy to address mobility, balance, and environmental risks. By mastering this comprehensive assessment process, you will be well-prepared for UKMLA CPSA stations and equipped to improve the safety and well-being of your older patients in clinical practice.
Your Next Steps
Memorise the 6 Steps: Commit the assessment framework (History, PMH/Risks, Meds, Exam, Function, Plan) to memory.
Practice SPLATT: Use the mnemonic (or similar) to structure your falls history taking in clinical encounters or simulated scenarios.
Master Postural BP: Practice the technique for measuring lying and standing blood pressure accurately.
Learn Functional Tests: Understand how to perform and interpret the Timed Up and Go (TUG) test.
Review High-Risk Drugs: Revisit the medication classes most likely to cause falls in the elderly and consider deprescribing principles (Deprescribing Guide).
Consult Guidelines: Familiarise yourself with the key recommendations in NICE NG249 regarding multifactorial assessment and interventions.
