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REVIEWPract Neurol 2007; 7: 158–171
Why old peoplefall (and how tostop them)N C Voermans, A H Snijders, Y Schoon, B R Bloem
N C VoermansSenior Registrar
A H SnijdersSenior Registrar
B R BloemConsultant Neurologist and Head
of the Parkinson Center Nijmegen
Department of Neurology,
Radboud University Nijmegen
Medical Centre, the Netherlands
Y SchoonConsultant Geriatrician and Head
of the Falls & Syncope Clinic
Department of Geriatrics, Radboud
University Nijmegen Medical
Centre, the Netherlands
Correspondence to:
Dr B R Bloem
Parkinson Centre Nijmegen (ParC),
Department of Neurology, 935,
Radboud University Nijmegen
Medical Centre, PO Box 9101, 6500
HB Nijmegen, the Netherlands;
Falls in older people are a common,
dangerous and frequently incapacitat-
ing problem. They are often perceived
as being untreatable—but this is an
overly negative perspective. In any event, in
the next few decades we will increasingly be
confronted with elderly fallers as life expec-
tancy continues to rise. This applies particu-
larly to general practitioners, emergency
department staff, geriatricians and neurolo-
gists. In this review, we will underscore the
clinical significance of falls in the elderly and
then outline a practical approach for their
management. Core elements of this approach
include:
N ascertaining whether or not the patientactually fell
N reliably classifying the nature of the falls
N identifying the causes and associated riskfactors for falls
N tailoring an individualised treatment tothe identified contributing factors, inorder to reduce falls and fall-relatedinjuries, or even to prevent themaltogether.
158 Practical Neurology
10.1136/jnnp.2007.120980
WHY ARE FALLS IMPORTANT?Falls in the elderly are a major health problem,
first and foremost for the affected individuals
whose quality of life is markedly reduced, and
also for the public health system because of
the immense costs associated with falls and
the resultant injuries. The risk of falls increases
with age: about one third of those over 65
years of age fall at least once a year, and about
half of them even more often.1 Apart from age,
prominent risk factors include previous falls,
female gender, concomitant neurological dis-
ease, living in a nursing home, fear of recurrent
falling, and regular alcohol intake.2, 3
Falling is serious, for several reasons:
N Falls may cause severe injury, and in upto 25% of elderly fallers this requiresmedical attention.4 Hip fractures arecommon and widely feared, and second-ary complications due to immobility arefrequent.
N Secondary immobility after a fall iscommon, and can be devastating in itsown right as this promotes osteoporosis,which in turn increases the risk offractures following future falls. A drivingfactor behind immobility is a fear ofrecurrent falls, which is regularly experi-enced by elderly fallers and may occur
even after a single and seeminglyinnocent fall. For some patients, this fearof falling is appropriate because theirbalance is severely disturbed, but forothers the degree of fear is dispropor-tionate and leads to unnecessary immo-bility, loss of independence and evensocial isolation.
N Up to 50% of elderly fallers are unable toget up after a fall, not only as a result ofinjury, but more commonly because ofphysical frailty and proximal muscleweakness. Patients who lie on the groundfor a long time may develop dehydration,pressure sores , rhabdomyolys i s ,hypothermia or pneumonia, all of whicheventually may be fatal.
N Falling and fall-related injuries are a pro-minent reason for nursing home admission.
N Falls are often a marker for an underlyingdisease, progression of which may con-tribute directly to the increased mortality,for example in patients with cardiovas-cular or cerebrovascular disease.5
N Not surprisingly, quality of life amongelderly fallers is markedly impaired.6
N Recurrent falls may reduce life expectancy,either directly (for example, subduralhaematoma following head trauma) orindirectly due to complications of the fall.
About one third ofthose over 65 yearsof age fall at leastonce a year
Figure 1The vicious circle of falling in the
elderly. Modified from Bloem BR, van
Vugt JP, Beckley DJ. Postural instability
and falls in Parkinson’s disease. AdvNeurol 2001;87:209–23,
159Voermans, Snijders, Schoon, et al
www.practical-neurology.com
A vicious circle of falling, balance problems,
fear of falling, immobilisation and isolation
mainly occurs in those who have recurrent
falls, or who lie on the ground for a long time
after their fall (fig 1).
THE CLINICAL APPROACH TOFALLINGBackgroundMany clinicians regard falls as an unavoidable
accompaniment to normal ‘‘ageing’’. However,
up to 20% of very old individuals still have a
completely normal gait and do not fall despite
their age—indicating that balance and gait
disorders are certainly not an inevitable
consequence of ageing. Indeed, falls in the
elderly should always initially be regarded as
pathological and therefore require the identi-
fication of some underlying disease or risk
factor. Falls tend to deter doctors because of
their complex underlying pathophysiology,
and clinicians are often frustrated in their
approach to elderly fallers because their
accounts, and even those of eyewitnesses,
are often incomplete. Too often falls in the
elderly are perceived as untreatable, and
therefore deemed unsatisfactory to deal with.
We hope this review will remove some of
these false preconceptions so that clinicians
come to regard elderly fallers as a gratifying
challenge, rather than as a frustration.
Bedside history and examinationAs ever, the approach to elderly fallers
requires a thorough history (table 1), careful
review of medical records, eyewitness reports
and fall diaries, as well as a detailed physical
examination.2 Questions should not only
focus on the falls per se, but also on their
consequences; hip fractures are typically
caused by lateral falls, bilaterally damaged
patellas by drop attacks, and wrist fractures
by a fall on the outstretched hand suggesting
that consciousness was preserved while fall-
ing. The medical records should contain a lot
of relevant and readily available information,
including medical history, home circum-
stances and, importantly, use of sedative
drugs or other predisposing medications.
Physical examination (table 2 and fig 2)
should include a careful gait and balance
assessment, preferably using ‘‘functional’’
tests which focus on the performance of
everyday activities, a search for underlying
risk factors, and any physical injuries.2
Evaluation of gait is mandatory because
any walking problems increase the risk of
falling: a shuffling gait increases the risk of
stumbling over obstacles, and episodic gait
disorders commonly lead to falls because
patients are caught unprepared. For example,
freezing of gait, where patients suddenly feel
as if their feet have become glued to the
floor7 is seen in Parkinson’s disease, as well as
other parkinsonian disorders. Assessment of
freezing is notoriously difficult because it is
so often absent in the examination room.
TABLE 1 Key elements of the history in elderly fallers
Classification of fallsl Present falll Earlier falls43
Cause of the falll Nonel Environment (eg, loose carpet)l (Sudden) change of posturel Performing several activities simultaneouslyl Hazardous behaviourl Inappropriate footwearSymptoms preceding the falll Light-headedness or vertigol Loss of consciousnessl Palpitations/chest pain/breathlessnessl Sudden weakness of the legsSymptoms after the falll Inability to stand upl Loss of consciousnessl Physical injuryl Fear of fallingSecondary immobilityUse of walking aidsl Prescribed by whom?l Difficulties in use?l If none, why not?Medical historyl Prior/current diseasesl (Psychoactive) medication and drug combinationsl Intoxication (alcohol)Domestic situationl Stairs, lighting, loose rugs, etc.l Support (partner, relatives, friends)Protective factorsl Exercise levell Adaptive behaviour/activities
Modified from Bloem BR, Boers I, Cramer M, et al. Falls in the elderly.I. Identification of risk factors. Wien Klin Wochenschr 2001;113:352–62.
160 Practical Neurology
10.1136/jnnp.2007.120980
Helpful aids are the use of specific freezing
questionnaires, interviewing the spouse, or
demonstrating to the patient what freezing
actually looks like. Useful tricks to provoke
freezing include asking patients to initiate
gait, to negotiate a narrow passage, and to
walk while performing a ‘‘dual task’’ (for
example, answering questions, or carrying an
object). Perhaps the best test is to ask patients
to turn around 360 ,̊ first in their preferred
direction, and then in the opposite direction—
the latter will provoke freezing much more
often. Recognition of freezing requires insight
into the three different clinical phenotypes:
shuffling with small steps; ‘‘trembling in
place’’ (rapid shuffling movements of the
feet, but without the patient moving for-
ward); or (more rarely) akinesia with complete
inability to start or continue walking.
Standardised rating scales such as the
Tinetti Mobility Index8 and the Berg Balance
Scale9 are useful tools to describe most aspects
of balance and gait, and we also value the
opinion of an experienced physiotherapist who
can review the patient more extensively in
various circumstances, and also judge how
well patients can use their walking aids.
Timed tests (for example, the 6-minute
walking test, timed up and go test, single leg
stance duration) have the advantage of
providing quantitative information, and
scores beyond established cut-off values
may help to predict the risk of falls (table 2).10
Orthostatic hypotension is detected by
measuring blood pressure, first in a recum-
bent position (preferably after a rest), and
again after 1, 3 and 5 minutes of standing.
Meanwhile, the patient should be observed
for signs and symptoms of orthostatic
hypotension such as ‘‘dizziness’’, pallor,
perspiration and stumbling. Note that clini-
cally relevant orthostatic hypotension can be
missed if the blood pressure is only measured
once, and continuous blood pressure record-
ing while patients are passively tilted upright
may even be required.11
Assessment of vision with and without
correction is important because many falls are
related to visual impairment. Paradoxically, poor
vision is probably worse than no vision at all;
poor vision provides false feedback and leads to
incorrect movement planning, while no vision
can at least be replaced by the intact remaining
senses (for example, proprioceptive and vestib-
ular) thanks to the physiological redundancy
between these three afferent systems.
The need for cognitive testing is under-
scored by the accumulating evidence of a
TABLE 2 Key elements of the physical examination in elderly fallers
Physical injuries General inspection (patient undressed)Risk factors Cardiovascular examination
Joints (ankles, knees, hips)Orthostatic hypotension*Carotid sinus hypersensitivityCognitionVision (with/without correction)Vestibular testsStrength of the legsProprioception in the lower limbs
Gait and balance analysis Quiet standingRetropulsion testFunctional tasks:l simple walkingl turning while walkingl rising from chair and sitting downl getting out of bedl picking up objects from floor or cupboardl climbing stairsl tandem gaitl narrow passageMultitasking:12, 44
l cognitive task while walking (eg, talking)l motor task while walking (eg, carrying an
object)l combinations of cognitive plus a motor
task (eg, talking while carrying an object)Quantifiable tests (cut-off values forquantifiable tests are shown in italics):{l ‘‘6-minute walking distance’’45
l ‘‘sit-to-stand test’’46
l ‘‘functional reach’’ test47 ,17 cmassociated with increased risk of falling
l ‘‘get-up and go test’’48,49 .13.5 sassociated with increased risk of falling
l ‘‘one-leg balance test’’50
Standardised rating scales:l Tinetti mobility index8 score ,19
represents high risk of falls and 19–24a moderate risk
l Berg balance test9
*Consider tilt table testing and non-invasive blood pressure recordings whenbedside examination for orthostatic hypotension is negative and where there isa high index of clinical suspicion.{For normal values please see Isles et al10 and Steffen et al.51 A more extensivelist of quantifiable tests and scales can be found on the PrOFaNE website(http://www.profane.eu.org/eu_map/map_views.php).
161Voermans, Snijders, Schoon, et al
www.practical-neurology.com
close relation between falls and cognitive
decline (fig 3). For example, falls are related to
being unable to walk and talk at the same
time; inability to perform such seemingly
simple tasks simultaneously has proven to be
a good predictor for future falls.12 Moreover,
some elderly people loose their ability to deal
with complex ‘‘multitask’’ circumstances and
fail to give priority to the most important task
(maintaining balance) at the expense of an
increased risk of falling.13 Falls are common in
patients with cognitive decline caused by
Alzheimer’s disease (for example)14 and they
are exceptionally common in disorders that
combine motor impairment with cognitive
decline, such as progressive supranuclear
palsy. Cognitively impaired people are also
more frequently exposed to dangerous situa-
tions due to their inability to estimate the risk
of falling, and their loss of control of gait
velocity.15 A global impression of cognitive
function can be obtained during the history,
and formal tests for frontal executive dys-
function are particularly important in patients
with gait disorders.16 Additional bedside and
sometimes more elaborate neuropsychologi-
cal tests should be used to detect underlying
conditions such as Alzheimer’s disease or
vascular dementia.
Ancillary investigationsQuantitative gait and balance assessments
(for example, static or dynamic posturo-
graphy) are interesting scientific tools, but
their use in daily practice is generally
precluded by their high costs and insufficient
individual diagnostic value.17 Brain imaging,
preferably with MRI, should be considered in
patients with unexplained falls, mainly to
detect treatable disorders such as hydroce-
phalus, or disorders which might at least
explain the falling even if they are not easily
Figure 2Useful gait and balance tests.
Figure 3Pathophysiology of falling.
162 Practical Neurology
10.1136/jnnp.2007.120980
treatable such as periventricular white matter
changes.18, 19 Other tests must be tailored to
the clinical suspicions raised during the
history and examination, and serve to identify
underlying disorders. A more elaborate
work-up may be required for patients whose
falls were preceded by transient loss of
consciousness:
N blood tests to detect electrolyte andglucose disturbances
N electrocardiography for suspectedcardiac syncope, with 24-h monitoringif necessary
N electroencephalography when seizuresare in the differential diagnosis
N carotid sinus massage to detect thecarotid sinus syndrome
N tilt table testing to provoke syncopeunder controlled conditions is useful inthe diagnostic work-up of patients withsuspected orthostatic syncope (commonin the elderly) or vasovagal syncope (rarein the elderly).
DID THE PATIENT REALLY FALL?This question can sometimes be surprisingly
difficult to answer, and it can help to have a
definition for falls: ‘‘any sudden, unexpected
event that caused the person to unintention-
ally land on any lower surface (object, floor or
ground), regardless of any sustained injury’’.
Many older people do not mention their falls,
simply because they accept falling as part of
their ageing process. Others forget their falls,
even if injury occurred, partly because of the
association between memory impairment and
falling.20 And even if patients do recall their
falls, they often find it difficult to recall
exactly under what circumstances the fall
occurred.2 Asking patients and/or their carers
to keep a dedicated falling diary is useful to
record the number and circumstances of the
falls,21 and a ‘‘falls hotline’’, where patients
can report and discuss their falls immediately
after they have occurred, is also helpful.
Whether a fall was preceded by loss of
consciousness can be difficult to ascertain
because syncopal falls are often associated
with amnesia for the fall, even in cognitively
intact elderly people. A useful trick is to ask
the patients whether they recall hitting the
ground after their fall. If not, consider
transient loss of consciousness, even when
patients deny it. Eyewitness accounts should
be helpful, but are commonly unavailable or
incomplete.22
WHAT SORT OF FALL(S) DID THEPATIENT HAVE?Once it has become clear that a patient really
has fallen, the next step is to classify the
nature of the fall(s), which provides the basis
for tailored treatment (fig 4).
A single fall or recurrent falls?This is important, because single falls with an
obvious extrinsic cause (like ice on the
pavement) merely require treatment of any
associated injuries, without further analysis
into the cause of the fall. But if no obvious
extrinsic cause can be found, or if a patient
has had recurrent falls, further investigations
are justified.
Is there a pattern to the falls?For patients with recurrent falls, the next step
is to identify any stereotypical pattern. For
example, patients may say their falls occur
exclusively immediately after rising from
sitting or lying, and so they could have
orthostatic hypotension, or severe balance
impairment leading to insecure transfers.
Identification of fall patterns also has ther-
apeutic consequences. For example, adapting
the house is a useful approach for patients
who only fall due to trips over doorsteps, or
while climbing stairs. When patients present
with different types of falls, each fall type
should be scrutinised separately.
Were extrinsic or intrinsic riskfactors (or both) involved?The next step is to decide whether the falls
were predominantly related to ‘‘intrinsic’’
(patient-related) factors (yellow boxes in fig 3)
or ‘‘extrinsic’’ (in the environment) factors
(orange box in fig 3). And this process should
Did the patient really fall?
l Ask family or other carers about the falls.l For patients with suspected loss of consciousness obtain an eyewitness
report.l Ask patients to keep a falls diary.l Consider implementing a falls ‘‘hotline’’.
Falling in theelderly is typically amultifactorialproblem, wheremultiple risk factorsjointly contribute tofalls in eachindividual patient
163Voermans, Snijders, Schoon, et al
www.practical-neurology.com
also focus on identifying specific protective
factors (which will be discussed in the
following paragraph), because this determines
the net risk of falling (green box in fig 3). Note
that falling in the elderly is typically a
multifactorial problem, where multiple risk
factors jointly contribute to falls in each
individual patient. And that falling often
results from interactions between intrinsic
and extrinsic factors. For example, a doorstep
might only create problems when step height
is diminished, as in patients with Parkinson’s
disease or a dropped foot due to ankle extensor
weakness. Therefore, physicians should not
stop when a single risk factor has been
identified, but instead pursue a systematic
search for multiple intrinsic and extrinsic risk
factors, as well as any protective factors.
Extrinsic (environmental) factorsExtrinsic risk factors include freshly polished
floors, wet bathroom tiles, stairs, loose carpets,
uneven pavements, poor lighting, stepping
onto escalators, and dogs or cats in the
household.3 Inappropriate footwear (high heels,
slippery soles or loosely fitting shoes) is another
common extrinsic factor. The risk of falling
indoors is also associated with walking bare-
foot, or in socks. Modern buses and trains with
their fast acceleration and automatic doors can
cause considerable difficulty for elderly people
who may fall before they can find a seat.
Intrinsic (patient-related) factorsMany elderly people cannot identify clear
extrinsic determinants for their fall, and have
repeated falls in seemingly harmless situations.
They merit a thorough work-up of intrinsic risk
factors as there is a high risk of recurrent falls.2
Intrinsic risk factors often include one or more
underlying disorders, in combination with
drugs, alcohol or both (table 3; fig 3).
Use of medication is a prominent risk
factor in the elderly. The underlying
Figure 4A diagnostic algorithm to classify falls.
TLOC, transient loss of consciousness;
COM, centre of mass; BOS, base of
support.
164 Practical Neurology
10.1136/jnnp.2007.120980
pathophysiological mechanisms may include
a combination of sedation, cognitive impair-
ment, carotid sinus syndrome, orthostatic
hypotension, urinary incontinence, beha-
vioural abnormalities, extrapyramidal adverse
effects, ataxia, and muscle weakness.
Particularly notorious are benzodiazepines
and antidepressants,23 recent initiation of
new medication and polypharmacy.
Neuroleptics, antihypertensive medication,
and anti-arrhythmics also increase the risk
of falls.24 In Parkinson’s disease, dopaminergic
medication may paradoxically increase the
falling frequency by causing violent dyskine-
sias, sudden freezing of gait, orthostatic
hypotension or confusion.25
Many chronic diseases are associated with
falls (table 3), both acute disorders (for
example, delirium, urinary tract infection with
urge incontinence) and a wide range of
chronic conditions. Note that physical impair-
ments such as urine incontinence or visual
impairment are more important than the
diseases themselves in predicting recurrent
falls. One important example is diabetes
mellitus, which may contribute to the risk of
falling by various mechanisms, including
hypoglycaemia, diabetic retinopathy, poly-
neuropathy, foot ulcers and stroke. Urge
incontinence is also associated with falls,
partly because the underlying disease may
cause incontinence and falls (for example,
stroke), and partly because night-time visits
to the toilet in darkness provide ideal falling
circumstances.26, 27 Osteoporosis should be
suspected in patients who have low-impact
fractures, in nursing home residents, in frail
elderly people and those taking steroids.
Were the falls associated with atransient loss of consciousness?For patients with intrinsic falls, the next step
is to clarify whether they were preceded by
transient loss of consciousness (distinguished
from loss of consciousness occurring after
the fall—for example, due to head injury). If
so, their diagnostic and therapeutic work-up
is completely different from patients who fell
with preserved consciousness; epilepsy, syn-
cope and psychiatric disorders all need to be
considered (table 4).
A major category is syncope, where—by
definition—loss of consciousness is caused by
failure of the cerebral circulation, itself almost
always due to a failure of the systemic blood
circulation. The falls are mostly backwards,
either flaccidly or stiffly. Syncope is typically
preceded by presyncopal features, such as
blurred vision and loss of colour vision
(‘‘greying out’’), loss of control over eye and
other movements, constriction of the field of
vision, and hearing loss. The loss of con-
sciousness usually lasts less than 20 seconds,
and involuntary multifocal jerky movements
may be seen, but in contrast with epileptic
seizures, these are non-rhythmic and asyn-
chronous involving various body parts.11
Urinary incontinence is common (so this does
not differentiate syncope from epilepsy) but a
lateral tongue bite is rare (this does suggest
epilepsy). Patients recover promptly and
spontaneously, with rapid improvement of
behaviour and cognition. In the elderly
however, syncope can present in a less typical
way without all the usual features, and
retrograde amnesia is common. Orthostatic
TABLE 3 Chronic diseases that are often associated with falls, withoutany preceding loss of consciousness
Category ofdisorder Impairment Example of disorder
‘‘Afferent’’disorder
Visual impairment CataractDiabetic retinopathy
Vestibular dysfunction Benign paroxysmal positionalvertigoVestibular neuronitis
Disturbedproprioception
Sensory polyneuropathyVitamin B1, B6 and B12 deficiency
‘‘Efferent’’disorder
Pyramidal Motor strokeExtrapyramidal Parkinson’s diseaseCerebellar Alcohol abuseLower motor neuron Motor polyneuropathyNeuromuscularjunction
Myasthenia gravis
Muscles Steroid myopathySarcopenia
Joints ArthritisCentralprocessingdisorder
Cognitive slowing/decline
Alzheimer’s disease
Impaired alertness Subcortical white matter lesionsMedication Various Psychoactive cardiovascular
combinationsIntoxication Alcohol, benzodiazepines
Modified from Bloem BR, Boers I, Cramer M, et al. Falls in the elderly. I.Identification of risk factors. Wien Klin Wochenschr 2001;113:352–62.
165Voermans, Snijders, Schoon, et al
www.practical-neurology.com
hypotension and the carotid sinus syndrome
are the most common causes of syncope in
the elderly,28, 29 and it is most important to
identify cardiac syncope because mortality is
doubled due to the underlying heart disease
(we refer to a recent review for further details
of syncope11).
Epilepsy is a less common cause of falls in
the elderly. Eyewitness reports are crucial for
the diagnosis. The characteristic tonic-clonic
with massive, synchronous jerking move-
ments of face and limbs usually occur after
the patient has fallen to the floor. The
duration of the actual seizures is generally
brief, often only a few minutes. However,
unlike syncope, postictal confusion and ante-
rograde amnesia are distinctive features,
typically for at least several minutes, but
often much longer. Seizures in old age call for
a search for an underlying cause, such as a
brain tumour or other focal lesion. Note that
epilepsy is sometimes the result of a fall,
rather than its cause—for example, in the case
of brain concussion or intracranial haema-
toma. Electroencephalography may confirm
the clinical suspicion of epilepsy and help
classify the seizure type, but it is often normal
in the inter-ictal phase. More importantly,
EEG can assist in predicting the risk of
recurrent seizures.
Was the fall preceded by a‘‘funny turn’’?When preceding loss of consciousness is ruled
out, the next step is to ascertain whether the
fall was preceded by a ‘‘funny turn’’ of some
kind. Many elderly people report ‘‘dizziness’’
as the cause of their falls. Try to clarify
precisely what they mean: was it vertigo
(spinning sensations, usually accompanied by
nausea) or light-headedness (perhaps with
presyncopal features)? Ask patients to specify
whether their dizziness was ‘‘in the head’’
(suggesting syncope or vertigo), ‘‘in the eyes’’
(suggesting poor vision) or ‘‘in the legs’’
(suggesting venous insufficiency, or sensory
ataxia due to polyneuropathy). Note that falls
preceded by funny turns do often turn out to
be caused by syncope, even when loss of
consciousness is denied.
Is there any balance or gaitdisturbance?If the fall was the result of an intrinsic factor,
but not preceded by loss of consciousness or
some funny turn, the next question is
whether the patient’s balance or gait is
sufficiently disturbed to explain it. If these
are normal or only minimally impaired, falls
might be caused by drop attacks or, in
younger people, by cataplexy or hyperek-
plexia.11 Note that patients may have episodic
gait disturbances that are easily missed in the
office, but which are notorious causes of falls
because their episodic nature makes it
difficult for patients to adapt their walking
behaviour—for example, freezing of gait in
parkinsonian disorders, and neurogenic clau-
dication due to lumbar stenosis.7
‘‘Base-of-support’’ or ‘‘centre-of-mass’’ falls?Falls caused by balance or gait disturbances
can be subdivided into two categories:
TABLE 4 Falls associated with transient loss of consciousness
SyncopeN Reflex syncope Vasovagal syncope
Postprandial syncopeSituational faintCarotid sinus syndromeCough syncope
N Orthostatic syncope Autonomic failure:l primary autonomic failurel secondary autonomic failure
(drugs, alcohol)Hypovolaemia
N Cardiac or cardiopulmonary syncope Cardiac arrhythmiasCardiac structural abnormalities(with obstruction of outflow)
Non-syncopalN Epileptic seizuresN Metabolic disorders Hypoxia
HypoglycaemiaHyperventilation
N IntoxicationsN Cerebrovascular disordersN MigraineN Vascular—eg, subclavian steal syndrome (rare)
Modified from Bloem BR, Overeem S, van Dijk G. Syncopal falls, dropattacks and their mimics. In: Bronstein AM, Brandt T, Woollacott MH, et al,eds. Clinical disorders of balance, posture and gait. Arnold, London, 2004.(Reproduced in adapted form by permission of Edward Arnold (Publishers) Ltd.)
166 Practical Neurology
10.1136/jnnp.2007.120980
N ‘‘base-of-support falls’’ caused by displa-cement of the feet (for example, slips, ortripping over obstacles)
N ‘‘centre-of-mass falls’’ related to trunkinstability, either during self-inducedperturbations (for example, bending,reaching or turning) or caused by exter-nally applied perturbations (for example,a push or collision).30
Making this distinction helps to identify the
underlying problem: base-of-support falls
occur in patients with lower leg weakness
(dropped foot) or distal sensory loss caused
by polyneuropathy. Centre-of-mass falls are
common in parkinsonian patients. This dis-
tinction also has implications for treatment,
because frequent base-of-support falls could
justify a home visit by the occupational
therapist to remove obstacles from the floor.
Conversely, centre-of-mass falls call for
optimised treatment of the underlying bal-
ance deficit in trunk control.
What if patients think they fellspontaneously?What to do when the physician is unable to
pinpoint even a single risk factor for
apparently spontaneous falls is a common
problem:
N One diagnosis to consider is drop attacks,typically in middle-aged women who fallspontaneously during walking, and onlyrarely while just standing, without loos-ing consciousness.11 Men are rarelyaffected. The typical story is of sudden,unexpected falls without preceding lossof consciousness, and without prodromalor postictal symptoms. There is norelation to change in posture, headmovement or any other specific precipi-tating event. Patients typically fallstraight down or forward onto theirknees. Unlike syncope and epilepsy, thereare no associated involuntary move-ments. If no injury occurs, the patientscan get up immediately and resume theiractivities. Most of these drop attacksremain cryptogenic.11
N A second possibility is that the patient didin fact fall due to loss of consciouseness,but failed to recognise this (see above).
N A third option is freezing of gait, whichwe described above. Not all patients canproperly identify their freezing episodes,but instead report ‘‘spontaneous’’ falls.
Asking about the direction of falls can provide
a diagnostic clue: forward falling suggests
freezing of gait in Parkinson’s disease;
(sudden) backward falling suggests progres-
sive supranuclear palsy; and vertical (down-
ward) falling suggests syncope or drop
attacks. Lateral falls have little diagnostic
value, but have great clinical relevance
because these cause hip factures. Inability to
stand up after a fall may suggest a preceding
epileptic seizure or stroke.
HOW TO PREVENT RECURRENTFALLSPrevention of falls and subsequent injuries
requires treatment of any underlying disorder
and elimination of the associated risk factors.
Primary prevention focuses on elderly
people who have not yet fallen, and aims to
eliminate risk factors that are common in the
elderly such as lack of exercise, or unneces-
sary use of psychoactive drugs. Tackling risk
factors that are only weakly associated with
falls, such as inappropriate footwear, may still
be rewarding if they are sufficiently prevalent
in the general population. Preventing osteo-
porosis reduces the chance of fracture should
the patient fall. Various exercise pro-
grammes—walking, Tai Chi and dancing—can
clearly improve strength, endurance and
balance, and several controlled trials have
shown a significant reduction in falling.31
Secondary prevention focuses on elderly
people who have fallen at least once and aims
to avoid recurrent falls. Here, the emphasis is
more on treatment of specific underlying
disorders and eliminating intrinsic or extrinsic
risk factors that are strongly associated with
falls.
What sort of fall(s) did the patient have?
l Did the patient fall once or recurrently?l Is there a pattern to the falls?l Which intrinsic and extrinsic risk factors are involved?l Were the falls preceded by loss of consciousness?l Was the fall preceded by a ‘‘funny turn’’?l Is there a balance or gait disturbance?l Can the falls be characterised as ‘‘base-of-support’’ or ‘‘centre-of-mass’’
induced?l Did the patient think he/she fell spontaneously?
167Voermans, Snijders, Schoon, et al
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Tertiary prevention concerns measures that
benefit elderly people who fall very often,
have sustained recurrent injuries, and who
have risk factors for falls that are hardly
amenable to secondary prevention. This
includes frail elderly people in nursing homes,
demented patients, and patients with severe
motor handicaps—for example, end-stage
parkinsonism. Here the aim is to limit the
impact of falls using hip pads, installing
personal alarm systems, or home surveillance
of solitary elderly people.32
Falls prevention should involve a multi-
disciplinary falls team,33 including a clinician
with appropriate skills and experience or
a specialist (for example, geriatrician,
neurologist), physiotherapist, occupational
therapist and specialist nurse. The proposed
interventions should be practical and easy to
implement, and this calls for optimal coop-
eration with the patient and their family.
Patients should receive both verbal and
written information on the preventive mea-
sures. Table 5 lists possible strategies for
secondary prevention.32, 34, 35
Several measures deserve specific attention:
N Drug combinations of any type should beavoided in elderly fallers, and the phar-macist can play an active role here. Arecent randomised controlled trialshowed that when a pharmacist reducedthe number of drugs in elderly care homeresidents, the number of falls wasreduced by 40%.36 Psychoactive drugs(mainly benzodiazepines and antidepres-sants) should be stopped or minimised.Drugs in high doses or with long half-times should particularly be avoided.
N Promoting the use of walking aids alsodeserves specific attention. Many elderlypeople do not use them, either becausethey are not recommended to do so orbecause they are ashamed or embar-rassed. For many older people, the use ofwalking aids can be unsafe but if those atrisk are instructed properly, they are oftenpleased with their regained confidence,mobility and independence. Physio-therapists or occupational therapistscan assist in selecting the appropriatewalking aids, and train patients howto use them properly.37 Physiotherapistscan also teach people to make safertransfers and increase their physicalfitness.
TABLE 5 Possible strategies for secondary prevention
Risk factor/disorder Possible intervention/therapy
Environmental riskfactors
Assessment by occupational therapistRemove loose rugs and doorstepsHandgripsImprove lighting in vital areas (staircase, bathroom)Handrails, stair rails and anti-slip material (toilet,bathroom)Higher chairs and bedsMove to ground floor house
Psychoactive drugs Stop or reduce doseNon-pharmacological treatment of sleep problems
Drug combinations Avoid when possibleVisual impairment Corrective lenses; avoid multifocal lenses while
walkingCataract surgery
Proprioceptiveimpairment
Treat underlying cause if possibleIncrease proprioceptive input with assistive deviceor appropriate footwear
Decreased musclestrength
Referral to physiotherapist for assistive devices andfor gait and progressive balance training
Orthostatichypotension
Stop or reduce causative drugsAdequate hydrationElevate head of the bed (at least 30 )̊Avoid precipitating circumstancesAnti-orthostatic manoeuvres (standing with crossedlegs or regular ‘‘tip-toeing’’)Elastic compression stockingsSodium chloride tabletsFludrocortisoneExercise
Osteoporosis Promote physical exerciseAnti-osteoporotic treatment
Footwear Avoid high and narrow heelsSturdy shoes with leather soleAnkle bracesRefer to chiropody in case of foot abnormalities
Cardiovascular disease Treat hypertensionTreat hypercholesterolaemiaStop smokingDaily exercise/physiotherapy
Balance problems Treat cause if possiblePhysiotherapyPromote walking aidsProvide external support (eg, handrails or walkingaids)
Urge incontinence Treat underlying cause if possibleSymptomatic treatment (eg, oxybutinine)
Cognitive impairment Treat cause if possibleRestrain activities if untreatable dangerousbehaviour
Postural vertigo PhysiotherapyPositional manoeuvres: habituation exercises,Epley’s manoeuvre
168 Practical Neurology
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N Home visits by occupational therapistscan reduce domestic hazards. In addition,medical and behavioural risk factors forfalls can be screened at the same time,and replacing unsafe footwear also helpsto reduce the number of falls. However,poor compliance limits the success ofhome visits. Many elderly are reluctant tochange their house or their behaviour, ordoubt that doing so will reduce their fallfrequency. Therefore, their agreement toany preventive measure is essential.38
Another aspect to consider is that homevisits are generally costly and timeconsuming.39
N Prevention of falls associated with loss ofconsciousness mainly involves treatmentof the underlying disorder.11
– Orthostatic hypotension patients shouldbe advised to avoid precipitating cir-cumstances, such as rapid changes inposture or prolonged recumbence. Inaddition, they can be trained to useanti-orthostatic manoeuvres such asstanding with crossed legs or regular‘‘tip-toeing’’, or elastic compressionstockings. A simple pharmacologicalintervention is sodium chloride tablets.If this fails, fludrocortisone and sym-pathomimetics can be used, but onlywhen there are severe disturbances ofblood pressure regulation, because oftheir adverse effects in the elderly.
– Elderly fallers with urge incontinenceshould be scrutinised for vasculardementia, spinal cord compression, ornormal pressure hydrocephalus.
– Proper lighting should be installed forthose who frequently fall during night-time visits to the toilet. A commodenext to the bed or a condom catheterfor men may be needed.
– For benign paroxysmal positional ver-tigo, an Epley manoeuvre (to eliminatethe debris from the semicircular canals)may dramatically improve the debilitat-ing complaints, but is often difficult toperform in elderly people. When thismanoeuvre fails, habituation exercisescan be tried. There are no drugs withproven anti-vertigo efficacy.
– Prevention of osteoporosis is re-commended for elderly fallers.Promoting physical activity increasesbone mineral density and reduces therisk of hip fractures. Oral provitamin
Risk factor/disorder Possible intervention/therapy
Gait impairment Treat underlying cause if possibleGait training/physiotherapyUse of walking aids
Disproportionate fearof falling
Group treatment using behavioural-cognitivetherapyPhysiotherapy to regain confidence
Syncope Treat cause if possibleReferral to cardiologist if necessary
Vascular stealsyndrome
Instruction on reduced arm exerciseStent placement if possible
Epilepsy Symptomatic treatmentAlcohol abuse Stop drinking
Refer to community psychiatric nurseHypoglycaemia Adjust anti-diabetic medication
Refer to diabetic nurseHyperventilation Search for underlying cause, such as renal
insufficiencyBreathing instruction
Basilar migraine Symptomatic treatment
Modified from Bloem BR, Boers I, Cramer M, et al. Falls in the elderly. I.Identification of risk factors. Wien Klin Wochenschr 2001;113:352–62.
TABLE 5 Continued
Useful websites
l http://www.cochrane.org/index0.html http://www.merck.com/mrkshared/mmg/sec2/sec2.jsp (Mercks Manual
chapters on falling)l http://falls-and-bone-health.org.uk/ (Falls-and-bone-health group of the
British Geriatrics Society)l http://www.americangeriatrics.org/products/positionpapers/Falls.pdf
(American Geriatric Association with guidelines on falling)l http://www.icservices.nhs.uk/datasets//pages/falls.asp (UK National Health
Service, with NICE guidelines (National Institute of Clinical Health andEffectiveness) and Older People NSF (National Service Framework)guidelines)
l http://216.119.65.75/members/sig-IPTOP.cfm (American physical therapistson falling)
l http://www.mednwh.unimelb.edu.au/VFCC/VFCC_guidelines.htm (VictorianFalls Clinics Collaboration with guidelines)
l http://www.mednwh.unimelb.edu.au/VFCC/VFCC_References.htm (VictorianFalls Clinics Collaboration with references and abstracts)
l http://mqa.dhs.state.tx.us/qmweb/Falls.htm (Quality Matters Institute, aGeriatric Collaboration in Texas, USA)
l http://www.profane.eu.org/phpBB2/faq.php?mode = falls (Prevention ofFalls Network Europe (ProFaNE). Offers a list of many assessmentmeasures)
169Voermans, Snijders, Schoon, et al
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1a-hydroxyvitamin D3, calcium supple-mentation and alendronate/raloxifenearrest progression of osteoporosis andreduce hip fractures.40
Tertiary preventive measures focus on the
fear of falling and the resulting immobilisation
or social isolation. An electronic warning
system around the neck or wrist can limit
complications in patients who are unable to
stand up after a fall. Fear of falling can of
course be reasonable in patients with severe
balance impairment, and the resultant restric-
tion of mobility can actually serve as an
adequate tertiary preventive measure.
However, for many, the fear is disproportional
to the actual degree of balance impairment and
risk of falls. Reduction of fear and regaining
confidence is important for these people,
because it helps restore mobility and promotes
independence. Group treatment using a beha-
vioural-cognitive approach to change attitudes,
as well as training with a physiotherapist,
might also help. In addition, physiotherapists
play a central role in restoring balance
confidence and reducing the fear of falls.41
However, this positive effect wanes as the
patient becomes more frail.42 An entirely
different approach is required for cognitively
impaired patients who can be too confident
and inappropriately overrate their own balance
ability, resulting in risky behaviour and falls. For
them, restriction of activities might be the best
solution to prevent recurrent falls.
ACKNOWLEDGEMENTSDr Bloem was supported by a ZonMw VIDI
research grant (number 016.076.352), and a
research grant from the National Parkinson
Foundation. We would like to thank Dr J E
Visser for the artwork in figures 1 and 4. This
article was reviewed by Heine Mattle, Berne,
Switzerland.
REFERENCES1. Nevitt MC, Cummings SR, Kidd S, et al. Risk factors
for recurrent nonsyncopal falls. A prospective
study. JAMA 1989;261:2663–8.
2. Bloem BR, Boers I, Cramer M, et al. Falls in the
elderly. I. Identification of risk factors. Wien KlinWochenschr 2001;113:352–62.
3. Pluijm SM, Smit JH, Tromp EA, et al. A risk profile
for identifying community-dwelling elderly with a
high risk of recurrent falling: results of a 3-year
prospective study. Osteoporos Int 2006;17:417–25.
4. Luukinen H, Koski K, Honkanen R, et al. Incidence of
injury-causing falls among older adults by place of
residence: a population-based study. J Am GeriatrSoc 1995;43:871–6.
5. Bloem BR, Gussekloo J, Lagaay AM, et al. Idiopathic
senile gait disorders are signs of subclinical disease.
J Am Geriatr Soc 2000;48:1098–101.
6. Tinetti ME, Williams CS. Falls, injuries due to falls,
and the risk of admission to a nursing home.
N Engl J Med 1997;337:1279–84.
7. Snijders AH, van de Warrenburg BP, Giladi N, et al.Neurological gait disorders in elderly people:
clinical approach and classification. Lancet Neurol2007;6:63–74.
8. Tinetti ME. Performance-oriented assessment of
mobility problems in elderly patients. J Am GeriatrSoc 1986;34:119–26.
9. Berg KO, Maki BE, Williams JI, et al. Clinical and
laboratory measures of postural balance in an
elderly population. Arch Phys Med Rehabil1992;73:1073–80.
10. Isles RC, Choy NL, Steer M, et al. Normal values of
balance tests in women aged 20–80. J Am GeriatrSoc 2004;52:1367–72.
11. Bloem BR, Overeem S, van Dijk JG. Syncopal falls,
drop attacks and their mimics. In: Bronstein AM,
Brandt T, Nutt JG, et al, eds. Clinical disorders ofbalance, posture and gait. Second edition. London:
Arnold, 2004:286–316.
12. Lundin-Olsson L, Nyberg L, Gustafson Y. ‘‘Stops
walking when talking’’ as a predictor of falls in
elderly people. Lancet 1997;349:617.
13. Bloem BR, Grimbergen YA, van Dijk JG, et al. The
‘‘posture second’’ strategy: a review of wrong
priorities in Parkinson’s disease. J Neurol Sci2006;248:196–204.
14. Horikawa E, Matsui T, Arai H, et al. Risk of falls in
Alzheimer’s disease: a prospective study. InternMed 2005;44:717–21.
15. van Iersel MB, Verbeek LM, Bloem BR, et al. Frail
elderly patients with dementia go too fast. J NeurolNeurosurg Psychiatry 2006;77:874–6.
16. Giladi N, Bloem BR, Hausdorff JM. Gait
disturbances and falls. In: Schapira AH, ed.
Neurology and clinical neurosciences. Philadelphia:
Mosby Elsevier, 2007:455–70.
17. Bloem BR, Visser JE, Allum JH. Posturography. In:
Hallett M, ed. Handbook of clinicalneurophysiology. Amsterdam: Elsevier Science BV,
2003:295–336.
PRACTICE POINTS
l Falls in the elderly are common and can be devastating.l Falls are not an inevitable accompaniment of ageing, but warrant a
systematic search for underlying disorders and associated risk factors.l Fear of falling is common and should be actively dealt with.l Preventing falls depends on an adequate classification of the type of falls,
usually achieved with a systematic approach as outlined in this review.l An important distinction is whether or not falls were preceded by transient
loss of consciousness, because this determines the diagnostic work-up andtreatment strategies.
l Most falls in the elderly are multifactorial, so clinicians should not abandontheir diagnostic work-up when a single risk factor has been identified.
l Optimal prevention of falls calls for a multifactorial and multidisciplinarytreatment approach.
170 Practical Neurology
10.1136/jnnp.2007.120980
18. Kerber KA, Enrietto JA, Jacobson KM, et al.Disequilibrium in older people: a prospective study.
Neurology 1998;51:574–80.
19. Syrjala P, Luukinen H, Pyhtinen J, et al. Neurological
diseases and accidental falls of the aged. J Neurol2003;250:1063–9.
20. Graafmans WC, Ooms ME, Hofstee HMA, et al. Falls
in the elderly: a prospective study of risk factors
and risk profiles. Am J Epidemiol1996;143:1129–36.
21. Mackenzie L, Byles J, D’Este C. Validation of self-
reported fall events in intervention studies. ClinRehabil 2006;20:331–9.
22. Shaw FE, Kenny RA. The overlap between syncope
and falls in the elderly. Postgrad Med1997;73:635–9.
23. Ensrud KE, Blackwell TL, Mangione CM, et al.Central nervous system-active medications and risk
for falls in older women. J Am Geriatr Soc2002;50:1629–37.
24. Ziere G, Dieleman JP, Hofman A, et al. Polypharmacy
and falls in the middle age and elderly population.
Br J Clin Pharmacol 2006;61:218–23.
25. Bloem BR, Bhatia KP. Gait and balance in basal
ganglia disorders. In: Bronstein AM, Brandt T,
Nutt JG, et al, eds. Clinical disorders of balance,posture and gait. Second edition. Arnold: London,
2004:173–206.
26. Brown JS, Vittinghoff E, Wyman JF, et al. Urinary
incontinence: does it increase risk for falls and
fractures? Study of Osteoporotic Fractures
Research Group. J Am Geriatr Soc 2000;48:721–5.
27. Balash Y, Peretz C, Leibovich G, et al. Falls in
outpatients with Parkinson’s disease: frequency,
impact and identifying factors. J Neurol2005;252:1310–15.
28. Anpalahan M. Neurally mediated syncope and
unexplained or nonaccidental falls in the elderly.
Intern Med J 2006;36:202–7.
29. Humm AM, Mathias CJ. Unexplained syncope-is
screening for carotid sinus hypersensitivity
indicated in all patients aged .40 years? J NeurolNeurosurg Psychiatry 2006;77:1267–70.
30. Maki BE, McIlroy WE. Postural control in the older
adult. Clin Geriatr Med 1996;12:635–58.
31. Gillespie LD, Gillespie WJ, Robertson MC, et al.Interventions for preventing falls in elderly
people. Cochrane Database Syst Rev2001;3:CD000340.
32. Boers I, Gerschlager W, Stalenhoef PA, et al. Falls in
the elderly. II. Strategies for prevention. Wien KlinWochenschr 2001;113:398–407.
33. American Geriatrics Society, Britisch Geriatrics
Society, and American Academy of Orthopaedic
Surgeons Panels on Falls Prevention. Guideline for
the prevention of falls in older persons. J AmGeriatr Soc 2001;49:664–72.
34. Tinetti ME. Clinical practice. Preventing falls in
elderly persons. N Engl J Med 2003;348:42–9.
35. Kannus P, Sievanen H, Palvanen M, et al. Prevention
of falls and consequent injuries in elderly people.
Lancet 2005;366:1885–93.
36. Keller RB, Slattum PW. Strategies for prevention of
medication-related falls in the elderly. ConsultPharm 2003;18:248–58.
37. Steultjens EM, Dekker J, Bouter LM, et al.Occupational therapy for community dwelling
elderly people: a systematic review. Age Ageing2004;33:453–60.
38. Cumming RG, Thomas M, Szonyi G, et al. Adherence
to occupational therapist recommendations for
home modifications for falls prevention. Am J OccupTher 2001;55:641–8.
39. Robertson MC, Devlin N, Gardner MM, et al.Effectiveness and economic evaluation of a nurse
delivered home exercise programme to prevent
falls. 1: Randomised controlled trial, BMJ2001;322:697–701.
40. Close P, Neuprez A, Reginster JY. Developments in
the pharmacotherapeutic management of
osteoporosis. Expert Opin Pharmacother2006;7:1603–15.
41. Hauer K, Rost B, Rutschle K, et al. Exercise training
for rehabilitation and secondary prevention of falls
in geriatric patients with a history of injurious falls.
J Am Geriatr Soc 2001;49:10–20.
42. Faber MJ, Bosscher RJ, Chin APM, et al. Effects of
exercise programs on falls and mobility in frail and
pre-frail older adults: A multicenter randomized
controlled trial. Arch Phys Med Rehabil2006;87:885–96.
43. Ganz DA, Bao Y, Shekelle PG, et al. Will my patient
fall? JAMA 2007;297:77–86.
44. Bloem BR, Valkenburg VV, Slabbekoorn M, et al. The
Multiple Tasks Test. Strategies in Parkinson’s
disease. Exp Brain Res 2001;137:478–86.
45. Lord SR, Castell S, Corcoran J, et al. The effect of
group exercise on physical functioning and falls in
frail older people living in retirement villages: a
randomized, controlled trial. J Am Geriatr Soc2003;51:1685–92.
46. Gross MM, Stevenson PJ, Charette SL, et al. Effect
of muscle strength and movement speed on the
biomechanics of rising from a chair in healthy
elderly and young women. Gait Posture1998;8:175–85.
47. Duncan PW, Weiner DK, Chandler JM, et al.Functional reach: a new clinical measure of
balance. J Gerontol Med Sci 1990;45:M192–M197.
48. Mathias S, Nayak USL, Isaacs B. Balance in elderly
patients: the ‘‘get-up and go’’ test. Arch Phys MedRehabil 1986;67:387–9.
49. Podsiadlo D, Richardson S. The timed ‘‘Up & Go’’: a
test of basic functional mobility for frail elderly
persons. J Am Geriatr Soc 1991;39:142–8.
50. Vellas BJ, Wayne SJ, Romero L, et al. One leg
balance is an important predictor of injurious falls
in older persons. J Am Geriatr Soc 1997;45:735–8.
51. Steffen TM, Hacker TA, Mollinger L. Age- and
gender-related test performance in community-
dwelling elderly people: Six-Minute Walk Test, Berg
Balance Scale, Timed Up & Go Test, and gait speeds.
Phys Ther 2002;82:128–37.
171Voermans, Snijders, Schoon, et al
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