Family medicine
Falls In The Elderly
Falls in the elderly are unintentional events in which an older adult comes to rest on the ground or a lower level, often resulting from the interplay of intrinsic factors (such as muscle weakness, impaired balance, polypharmacy, and cognitive decline) and extrinsic environmental hazards.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Multifactorial / age-related falls (environmental + gait/balance impairment + polypharmacy) | Multiple minor risk factors, no single medical cause; >65 y/o | 「你覺得係咪行路唔穩加上屋企環境嘅問題？」 |
| Drug-related falls (sedatives, anti-HT, polypharmacy) | Temporal link to new/changed medication | 「你幾時開始食呢隻藥？同跌倒有冇時間上嘅關係？」 | |
| Serious Not To Miss | Cardiac syncope (arrhythmia, aortic stenosis) | LOC, palpitations, exertional syncope, ejection systolic murmur | 「跌之前有冇暈低、心跳亂？」/ Auscultation: ejection systolic murmur at aortic area |
| Stroke / TIA | Focal neurological deficit, sudden onset | 「跌之前有冇手腳突然冇力、講嘢唔清楚？」 | |
| Subdural haematoma (post-fall complication) | Headache, confusion, progressive deficit days after fall; on anticoagulant | 「跌完之後有冇頭痛、精神變差？食緊薄血丸？」 | |
| Hip / vertebral fracture | Inability to weight-bear, bony tenderness, shortened & externally rotated leg | 「跌完之後行唔行到路？有冇痛到企唔到？」 | |
| Pitfalls | Postural hypotension | Symptoms on standing; BP drop ≥20/10 mmHg | Lying-to-standing BP: 「我幫你量下瞓低同企起身嘅血壓」 |
| Peripheral neuropathy (esp. diabetic) | Stocking-pattern sensory loss, unsteadiness in dark | 「你對腳有冇痺、好似著咗襪咁嘅感覺？」 | |
| Cervical spondylotic myelopathy | Spastic gait, hyperreflexia, neck pain | 「有冇條頸痛？行路有冇覺得對腳硬硬地？」 | |
| Masquerades | Depression → psychomotor retardation, inattention | Low mood, loss of interest, poor concentration, social withdrawal | 「你心情點呀？有冇對嘢冇晒興趣？」 |
| Parkinson's disease | Bradykinesia, resting tremor, rigidity, shuffling gait [4] | 「你行路有冇越行越細步？手有冇震？」/ Exam: cogwheel rigidity, festinating gait | |
| Diabetes (neuropathy, hypoglycaemia) | Known DM, hypo episodes, sensory loss in feet | 「你有冇糖尿？有冇試過血糖低頭暈？」 | |
| Anaemia | Fatigue, pallor, exertional dizziness | 「你有冇覺得特別攰、面色差？」 | |
| Drugs (sedatives, anticholinergics, opioids) | Temporal association, polypharmacy | Review drug list using STOPP criteria [3] | |
| Trying to Tell Me Something? | Fear of losing independence / being institutionalised | Reluctance to admit falls; family pressure to move to nursing home | 「你有冇擔心要搬去老人院？屋企人有冇俾壓力你？」 |
| Elder abuse / neglect | Unexplained injuries, fearfulness, poor nutrition | 「你同屋企人相處點呀？有冇人對你唔好？」 | |
| Social isolation / loneliness | Living alone, reduced social contact | 「你平時有冇朋友探你？會唔會覺得孤獨？」 |
Clinical Test Game Plan
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好呀，我係X醫生，今日由我同你傾下。請問我可以點樣稱呼你呀？」「你今日嚟睇醫生，最想傾啲咩呀？」 | Interpersonal marks: greeting, preferred name, open-ended opening |
| 0:30–1:30 | HPI: Falls history — circumstances, frequency, timing, mechanism, injuries, loss of consciousness, preceding symptoms | 「可唔可以同我講下你跌倒嗰陣嘅情況？」「跌之前有冇頭暈、眼前發黑、心跳快嘅情況？」「有冇撞親頭？有冇受傷流血？」 | Chief complaint & HPI accuracy; red-flag screening |
| 1:30–2:30 | Targeted systems review & risk factors — medications (sedatives, anti-HT, polypharmacy), vision, hearing, gait aids, home environment, alcohol, footwear | 「你而家食緊啲咩藥？有冇食安眠藥、血壓藥？」「你對眼睇嘢清唔清楚？」「屋企有冇啲地毯、門檻容易絆倒？」 | DDx discrimination; identifies modifiable risk factors |
| 2:30–3:30 | PMHx, FHx, Social Hx, Functional assessment — chronic diseases (DM, PD, stroke, osteoporosis), walking aids, ADLs, living situation, carer support | 「你平時行路使唔使用拐杖或者助行架？」「你自己一個住定係有人照顧？」「你日常自己煮飯、沖涼搞唔搞到？」 | Biopsychosocial completeness; functional impact |
| 3:30–4:30 | ICE + Hidden agenda — Ideas, Concerns, Expectations; ask "Why today?" | 「你自己覺得點解會跌？」(Idea) 「你最擔心嘅係咩呀？」(Concern) 「你今日嚟，最希望醫生可以幫到你啲咩？」(Expectation) 「點解揀今日嚟睇醫生呢？」(Hidden agenda) | Marks heavily weighted on ICE; hidden agenda often = fear of fracture, loss of independence, or pressure from family |
| 4:30–5:15 | Summarise & check understanding | 「等我總結返，你最近跌咗X次，冇暈低過，食緊呢幾隻藥，你最擔心係...，我有冇漏咗啲咩？」 | Interpersonal marks: summarising, inviting correction |
| 5:15–6:00 | Plan, safety net, close | 「我會安排幫你驗下血同埋做返身體檢查。如果你再跌倒、頭暈、或者企唔穩，記得即刻返嚟或者打999。」「你有冇嘢想問我？多謝你今日嚟。」 | Safety-net line; empathetic close |
- "Why today?" is critical. The patient may have come because: a family member is worried, they fear losing independence (e.g. being sent to a nursing home), they had a near-miss fall with an injury, or they are afraid of hip fracture.
- Ask: 「係咪有啲嘢令你特別擔心，所以今日先嚟睇醫生？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think of |
|---|---|---|---|---|
| Fall details | How many falls? When? Where? What were you doing? | 「你跌咗幾多次？喺邊度跌？嗰陣做緊咩？」 | Distinguishes mechanical vs medical cause | Recurrent → multifactorial assessment needed [1] |
| Mechanism | Did you trip/slip or did you just go down? | 「你係絆倒定係突然間腳軟跌低？」 | Trip = extrinsic; spontaneous = intrinsic | Spontaneous → syncope, postural hypotension, arrhythmia |
| LOC / Pre-syncope | Did you black out? Any dizziness, palpitations, chest pain before the fall? | 「跌之前有冇暈低、眼前發黑、心跳快、胸口痛？」 | Red flag: cardiac syncope | Arrhythmia, aortic stenosis, PE |
| Post-fall | Could you get up? How long on the floor? | 「跌完之後你自己起唔起到身？喺地下瞓咗幾耐？」 | "Long lie" → rhabdomyolysis, hypothermia, functional decline | >1 hr on floor → urgent Ix |
| Injuries | Any fractures, head injury, bruising? | 「有冇撞親頭？有冇骨折、瘀傷？」 | Identifies complications | Subdural haematoma, fracture |
| Gait & balance | Any difficulty walking? Using aids? | 「行路穩唔穩？有冇用拐杖/助行架？」 | Gait and balance assessment is the single most important part of fall evaluation [1][2] | Parkinsonism, cerebellar disease, peripheral neuropathy |
| Vision | Any recent change in eyesight? | 「你睇嘢有冇差咗？幾時驗過眼？」 | Visual impairment is a major modifiable risk factor [2] | Cataracts, macular degeneration |
| Medications | What medications? Any new ones? Sedatives, BP drugs, pain meds? | 「你食緊啲咩藥？最近有冇轉過藥？有冇食安眠藥、止痛藥？」 | Polypharmacy (≥4 drugs) and psychotropic drugs are major modifiable fall risk factors [1][3] | Drug-related falls (benzodiazepines, anti-HT, opioids, anticholinergics) |
| Postural symptoms | Dizzy when standing up? | 「你起身企嗰陣有冇頭暈？」 | Postural hypotension | Anti-HT drugs, autonomic neuropathy (DM) |
| Alcohol | How much alcohol? | 「你有冇飲酒？飲幾多？」 | Alcohol → gait impairment, neuropathy | Alcohol-related falls |
| PMHx | DM, stroke, Parkinson's, heart disease, osteoporosis, arthritis? | 「你有冇糖尿病、中風、柏金遜、心臟病、骨質疏鬆、關節炎？」 | Each increases fall risk differently | DM → neuropathy; PD → postural instability; stroke → hemiparesis |
| Home environment | Stairs, rugs, lighting, bathroom grab bars? | 「屋企有冇樓梯？廁所有冇扶手？夜晚夠唔夠光？」 | Environmental hazards are modifiable [2] | Home modification referral |
| Fear of falling | Are you afraid of falling again? Avoiding activities? | 「你有冇驚再跌？有冇因為驚跌而唔敢出街？」 | Fear of falling → activity restriction → deconditioning → ↑falls (vicious cycle) [1] | Psychological problem for biopsychosocial |
| Functional status | Can you manage daily activities? Bathing, cooking, shopping? | 「你日常沖涼、煮飯、買嘢自己搞唔搞到？」 | ADL impairment = social problem | Need for carer/home help |
| Social | Who do you live with? Any carer? | 「你同邊個住？有冇人照顧你？」 | Assesses support network | Social isolation → delayed help after fall |
| Continence | Any rushing to toilet? Incontinence? | 「你有冇急住去廁所嘅情況？有冇漏尿？」 | Urgency incontinence → rushing → falls | Urge incontinence as contributing factor |
Case Report Form Answer Builder
- CC: Recurrent falls / a fall in a [age]-year-old [gender]
- HPI must capture:
- Number of falls, timing, location, activity at time
- Mechanism: trip/slip vs spontaneous
- Preceding symptoms: LOC, dizziness, palpitations, focal neurology
- Injuries sustained
- Ability to get up; duration on floor
- Current medications (especially sedatives, anti-HT, polypharmacy)
- Gait/balance baseline; use of walking aids
- Relevant PMHx (DM, PD, stroke, osteoporosis, arthritis, visual impairment)
- Likely RFC examples:
- "Patient fell at home yesterday and daughter is worried about recurrence"
- "Recurrent falls over past 3 months, now afraid to walk alone"
- "Fall with hip pain, worried about fracture"
- Best single answer: State the trigger event + the underlying concern, e.g. "Recurrent falls over the past 2 months causing fear of falling and functional decline, prompted to attend by concerned daughter."
| Component | Likely Content | Example Wording for CRF |
|---|---|---|
| Ideas | "I think it's just old age" / "Maybe my blood pressure pills" / "My legs are weak" | Patient attributes falls to aging and leg weakness. |
| Concerns | Fear of hip fracture; fear of losing independence; fear of nursing home; worry about burdening family | Patient is worried about breaking a hip and having to move to a nursing home. |
| Expectations | Wants medication review; wants referral for physiotherapy; wants reassurance; wants home assessment | Patient hopes for a check-up to find the cause and prevent further falls. |
- Multifactorial falls (environmental hazards + gait/balance impairment + polypharmacy/medication side effects) in the majority of FM station scenarios
- Minimum supporting evidence: Age >65, ≥2 falls, identifiable risk factors (e.g. polypharmacy, impaired vision, environmental hazard), abnormal Timed Get Up and Go test [2]
- If the stem strongly suggests a single cause (e.g. clear syncope with LOC → cardiac cause; classic tremor + shuffling → PD), shift the most likely diagnosis accordingly
| DDx | Key Discriminator |
|---|---|
| 1. Postural (orthostatic) hypotension | Symptoms on standing; BP drop ≥20 systolic / ≥10 diastolic on lying-to-standing |
| 2. Cardiac syncope (arrhythmia / aortic stenosis) | LOC, palpitations, exertional symptoms, murmur |
| 3. Parkinson's disease | Resting tremor, bradykinesia, rigidity, shuffling gait |
(Adjust based on the specific case stem — e.g. if DM is prominent, substitute diabetic peripheral neuropathy)
| Domain | Problem |
|---|---|
| Biological | Polypharmacy contributing to falls risk; osteoporosis increasing fracture risk |
| Psychological | Fear of falling leading to activity avoidance and deconditioning; possible depression |
| Social | Loss of functional independence (difficulty with ADLs); social isolation if living alone; carer burden on family |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Multifactorial falls (most likely Dx) | Timed Get Up and Go (TUG) test abnormal | Ask patient to stand from chair without using arms, walk 3m, turn, walk back, sit down. Time it. Abnormal if >12 seconds or unsteady [2] | Demonstrates impaired gait and balance — the strongest predictor of future falls [1] |
| Postural hypotension | Orthostatic BP drop ≥20/10 mmHg | Measure BP lying (after 5 min supine) then standing (at 1 and 3 min) | Confirms orthostatic hypotension as fall mechanism |
| Cardiac syncope (aortic stenosis) | Ejection systolic murmur, loudest at aortic area, radiating to carotids | Auscultate with diaphragm at right 2nd intercostal space; patient sitting forward | Suggests aortic stenosis causing exertional syncope |
| Parkinson's disease | Cogwheel rigidity at wrist | Passively flex/extend patient's wrist while they perform contralateral hand movement (Froment's manoeuvre) [4] | Cardinal sign of PD; supports diagnosis when combined with bradykinesia and tremor |
| Peripheral neuropathy | Reduced sensation to monofilament/vibration in stocking distribution | 10g monofilament on plantar foot; 128Hz tuning fork on great toe | Loss of proprioception → sensory ataxia → falls |
Exam Discriminators and Traps
Must-Not-Miss Red Flags — Urgent Referral
- LOC / true syncope → ECG, consider Holter, echocardiogram; refer cardiology if cardiac cause suspected
- New focal neurological deficit → suspect stroke/TIA → urgent CT brain, refer A&E
- Head injury on anticoagulant → urgent CT brain to rule out subdural/extradural haematoma
- Inability to weight-bear after fall → X-ray hip/spine → suspect fracture
- Progressive confusion after fall → consider subdural haematoma (especially if on warfarin/DOAC)
- Unexplained injuries / signs of abuse → safeguarding referral
| Trap | How to Avoid |
|---|---|
| Forgetting to ask about medications (especially sedatives, anti-HT) | Always do a drug history — polypharmacy (≥4 drugs) is one of the most important modifiable risk factors [1][3] |
| Not distinguishing mechanical fall from syncope | Always ask about LOC, preceding symptoms |
| Ignoring postural BP | This is a key physical sign and commonly tested |
| Forgetting ICE | Allocate specific time; use exact phrases |
| Writing only biological problems in biopsychosocial | Must include psychological (fear of falling, depression) and social (isolation, ADL limitation, carer burden) |
| Not asking about home environment | Environmental modification is a key evidence-based intervention [2] |
| Missing the hidden agenda | Ask "Why today?" — often family pressure or a recent scary near-miss |
From GC slides [1][5]: A Comprehensive Geriatric Assessment (CGA) approach is essential for falls — assess medical, functional, psychological, and social domains simultaneously. Falls are rarely due to a single cause.
- Safety net (say to patient): 「如果你再跌倒、頭暈、暈低、或者企唔穩行唔到路，記得即刻打999或者去急症室。」
- Brief management plan to mention if asked:
High Yield Summary
What to ASK: Fall circumstances (mechanism, LOC, preceding Sx), medications (sedatives/anti-HT/polypharmacy), vision, gait/balance, home environment, PMHx (DM/PD/stroke/osteoporosis), functional status, fear of falling, ICE, and "Why today?"
What to WRITE: CC = recurrent falls in elderly; Most likely Dx = multifactorial falls; Best physical sign = Timed Get Up and Go test or orthostatic BP; DDx = postural hypotension, cardiac syncope, Parkinson's disease; Biopsychosocial = polypharmacy (Bio), fear of falling (Psych), loss of independence/social isolation (Social).
What NOT TO MISS: LOC (→ cardiac syncope), head injury on anticoagulant (→ SDH), new focal neurology (→ stroke), medication review (STOPP criteria), and the hidden agenda (fear of nursing home / loss of independence).
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: The Patient Who Falls - Tinetti ME 2010 (JAMA).pdf [2] Lecture slides: Management of Falls in Older Persons - Moncada LV 2011 (AAFP).pdf [3] Lecture slides: GC 079 (supp-2)STOPP-START-V3.pdf [4] Senior notes: Ryan Ho Neurology.pdf (Parkinson's disease section, p119-122) [5] Lecture slides: GC 038. Comprehensive geriatric assessment and rehabilitation in older people.pdf [6] Lecture slides: GC 031. Back pain in an elderly woman_osteoporosis and related fractures.pdf [7] Senior notes: Ryan Ho Fundamentals.pdf (Elderly patients history checklist, p7) [8] Senior notes: Maksim Medicine Notes.pdf (Geriatrics section, p113) [9] Lecture slides: GC 054. Frailty in the older people.pdf [10] Lecture slides: GC 037. Common neurological problems in older people.pdf
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