Falls with No Loss of Consciousness
Many falls are genuine trips – so sorting out trip hazards is one of the most effective strategies to advise. Possible medical contributors are numerous and may combine in elderly patients with recurrent falls. NOTE: The term ‘drop attacks’ is inconsistently defined in the literature as ‘falls with no loss of consciousness’, ‘falls with loss of consciousness’ or may be regarded as a distinct diagnostic entity rather than a symptom. It is a term best left unused.
Differential diagnosis
Common Diagnoses
- Orthostatic Hypotension
- Parkinson’s Disease
- Iatrogenic (e.g. Phenothiazines, Hypoglycaemics, Tricyclics and Hypotensives)
- Postural Instability (Osteoarthritis, Muscular Weakness and General Frailty)
- Any Acute Illness (e.g. Sepsis, CVA)
Occasional Diagnoses
- Peripheral Neuropathy (Various Causes)
- Lack of Concentration (Tripping over Mats, etc.)
- Visual Disturbance
- Acute Alcohol Intoxication and Chronic Alcohol Misuse
- Cardiac Arrhythmias
- Any Cause of Vertigo (e.g. Vestibular Neuritis, Ménière’s Disease) or Non-specific Dizziness (e.g. Anaemia)
- Hypoglycaemic Episodes
- Dementia
Rare Diagnoses
- Hypothyroidism
- Hydrocephalus
- Third Ventricular Tumour
- Diabetic Autonomic Neuropathy
- Aortic Stenosis
- Painless (‘Silent’) Myocardial Infarction
Ready reckoner
Key distinguishing features of the most common diagnoses
| Orthostatic Hypotension | Parkinson’s Disease | Iatrogenic | Postural Instability | Acute Illnes | |
|---|---|---|---|---|---|
| Joint Stiffness | No | No | No | Possible | No |
| On Standing up | Yes | Possible | Possible | Possible | Yes |
| Confused | No | No | Possible | No | Possible |
| Polypharmacy | Possible | Possible | Possible | No | No |
| On Turning Head | No | No | No | No | Possible |
Possible investigations
Likely: Urinalysis, FBC.
Possible: TFT, U&E, B12 and folate, fasting glucose or HbA1c, serum electrophoresis, vitamin D, LFT, ECG (or 24 h ECG/event monitor).
Small Print: CT scan, echocardiography.
- Urinalysis for glucose may reveal underlying diabetes: A major cause of autonomic or peripheral neuropathy – or evidence of UTI.
- FBC: Anaemia will exacerbate any cause of postural hypotension, or may itself cause dizziness. Sepsis is suggested by a raised WCC. A high MCV may be a useful pointer to alcohol misuse, B12 or folate deficiency, or hypothyroidism.
- TFT: Hypothyroidism is common in the elderly and develops insidiously.
- Fasting glucose or HbA1c: To confirm or detect diabetes.
- U&E, B12 and folate, serum electrophroresis: Renal failure, B12/folate deficiency or myeloma may cause a peripheral neuropathy.
- Vitamin D: Deficiency may cause muscular weakness.
- LFT: For evidence (γGT) of alcohol misuse.
- ECG or 24 h ECG/event monitor is useful to identify an arrhythmia, conduction defect or MI.
- CT scanning (e.g. for tumours or hydrocephalus) or echocardiography (for aortic stenosis) may be arranged by the specialist after referral.
Top Tips
- Failure to observe the patient’s gait may mean that significant diagnoses, such as Parkinson’s disease, are missed.
- Recurrent falls in the elderly are often caused by a combination of factors, such as failing vision, poor lighting and trip hazards at home. A home assessment may give valuable clues.
- In the acute situation, management may depend more upon the ability of the patient to remain safely at home (e.g. social support) rather than the precise diagnosis.
- Don’t underestimate the importance of prescribed medications in causing morbidity. Attempt to reduce polypharmacy and review therapy regularly.
- Recurrent falls in the frail elderly are a real concern with the prospect of significant injury and recurrent admission. They can also be fiendishly difficult to pin down and resolve – so use your local multidisciplinary falls team if you have one.
Red Flags
- In dealing with this problem, don’t forget to look for cause and effect – the aetiology of the falls and any significant injuries sustained.
- Sudden onset of falls in the previously well elderly patient is likely to represent acute pathology – have a low threshold for investigation or admission.
- Gradual onset of recurrent falls is often multifactorial in the elderly; in younger patients, specific underlying disease is more likely, so refer for investigation.
- Evidence of injury (e.g. bruises or fractures) and multiple attendance slips from A&E department indicate either a very frail, vulnerable elderly person or significant underlying illness.