11/13/24, 8\:09 PM Guide | Fall history

Fall history

Table of contents

Background

1
Falls are common in older people, with around 50% of patients over 80 having at least one fall a year. Falls are a signi
cause of trauma and disability in older people and a common presentation in emergency departments.
1
Falls are often multifactorial, and many risk factors can contribute to someone having a fall. A thorough fall history is vital to
identify risk factors and help manage and prevent future falls.
Risk factors for falls are split into activity (what the person is doing), environment (where the person is, are there any safety
risks), and person (history of falls, advanced age, visual problems, muscle weakness, abnormal gait, impaired balance).
These risks can be managed by treating any underlying cause, making reasonable environmental adaptations, and
encouraging strength and balance training to prevent further falls.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
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“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
“ T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g.”
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , c a n y o u t e l l m e m o r e a b o u t t h e f a l l ?”
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

The purpose of a fall history is to
What happened to cause the fall?
What are the consequences of the fall?
Is there anything we could do to prevent further falls?
Covering these points will allow you to assess the fall fully. The best way to do this is to assess events before, during and after
the fall systematically.

Before the fall

Clarify when the fall occurred\:
" W h e n d i d y o u f a l l ? D o y o u r e m e m b e r t h e t i m e ?"
It is important to clarify when the fall happened, so we can determine a time scale for how long they were on the
could not get up.
Ask about activities before the fall\:
" W h a t w e r e y o u d o i n g j u s t b e f o r e y o u f e l l ?"
" T a l k m e t h r o u g h w h a t y o u w e r e d o i n g b e f o r e y o u f e l l"
Falls may be related to the activity (e.g. gardening, exercising, carrying shopping). It may also indicate underlying pathology (e.g.
standing up, suggesting postural hypotension)
Ask about warning signs and physical symptoms before the fall\:
“ D i d y o u t h i n k y o u w e r e g o i n g t o f a l l o v e r ?”
“ D i d a n y t h i n g f e e l d i
" D i d y o u h a v e a n y s y m p t o m s s u c h a s d i z z i n e s s o r p a l p i t a t i o n s b e f o r e t h e f a l l ?"
This is important for ascertaining any underlying pathology, which will be screened in more detail later in the consultation.

During the fall

Ask about the nature of the fall. This is an opportunity for the patient to describe the act of falling in as much detail as possible.
However, some patients may not be able to recall all the information, so closed questions can act as prompts\:
" H o w d i d y o u f a l l ?"
“ D i d y o u t r i p o v e r , o r d i d y o u j u s t f a l l ?”
“ C a n y o u r e m e m b e r w h a t d i r e c t i o n y o u f e l l ?”
“ D i d a n y t h i n g b r e a k y o u r f a l l ?”
“ D i d y o u h i t y o u r h e a d o r a n y o t h e r p a r t o f y o u r b o d y ?”
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Clarify how the patient landed (if they remember)\:
“ W h a t d i d y o u f a l l o n t o ?”
“ W h a t p o s i t i o n w e r e y o u i n w h e n y o u l a n d e d”
Ask about loss of consciousness\:
“ D i d y o u b l a c k o u t a t a n y p o i n t ? E i t h e r b e f o r e , d u r i n g, o r a f t e r y o u h a d f a l l e n ?”
“ D o y o u r e m e m b e r f a l l i n g ? W h a t a b o u t h i t t i n g t h e gr o u n d ?”
This question is particularly important as it can indicate the underlying pathology and the patient’s recollection of the events.
If they did lose consciousness, the patient may be unable to remember falling. Instead, they will remember
on the
Loss of consciousness can help distinguish a fall from an episode of transient loss of consciousness (TLOC). Loss of
consciousness is usually associated with hypotension, syncopal symptoms, cardiac causes, and neurological causes.
Ask what the patient did when they started to fall\:
" W h a t d i d y o u d o w h e n y o u f e l t y o u r s e l f f a l l i n g?"
" D i d y o u t r y a n d b r e a k y o u r f a l l ?"
Some patients try to re-position themselves as a natural re
something nearby.

After the fall

Clarify how long the patient was on the ground\:
" H o w l o n g w e r e y o u l y i n g o n t h e
This is a key question because it can give us a lot of information, both physically and from a social perspective. A fall with a
prolonged period lying on the ground ('fall with a long lie') is associated with complications, including rhabdomyolysis,
pressure damage and neurovascular compromise.
Asking this question may identify social or safeguarding issues (e.g. if the patient lives with people, was there a delay in
helping them up?).
Ask if the patient was able to get up by themselves\:
" D i d y o u m a n a g e t o g e t u p y o u r s e l f ?"
If the patient was unable to get up, ask how they sought help and who came to help\:
" D i d s o m e o n e c o m e t o h e l p y o u ?"
" D i d y o u c a l l s o m e o n e ? W h o ?"
" W a s i t a f a m i l y m e m b e r , n e i g h b o u r , o r c a r e r ?"
This can tell us a lot about the patient’s social background and support networks.
Explore how the patient felt after the fall\:
" H o w d i d y o u f e e l r i g h t a f t e r t h e f a l l ?"
" D i d y o u h a v e a n y p a i n ?"
" D i d y o u h a v e a n y o t h e r s y m p t o m s s u c h a s f e e l i n g s i c k , v o m i t i n g o r f e e l i n g d i z z y ?"
These symptoms can tell us about the consequences of the fall.

Now

Ask how the patient feels now\:
“ H o w a r e y o u f e e l i n g a t t h e m o m e n t ?”
Ask directly about speci
" D o y o u h a v e a n y p a i n a n y w h e r e ?"
" D o y o u h a v e a n y b r u i s i n g o r s w e l l i n g ?"
" D o y o u h a v e a n y w e a k n e s s ?"
This is a key screening question to identify injuries caused by the fall.
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Ask about further falls since the original fall. Depending on the setting of the consultation, the patient may have had further
falls since the main episode\:
" H a v e y o u h a d a n y f u r t h e r f a l l s s i n c e t h e n ? I f s o , Explore how the fall is a
h o w m a n y ?"
" H o w h a v e t h i n g s b e e n s i n c e t h e f a l l ?"
" H a v e y o u b e e n w o r r i e d a b o u t f a l l i n g a g a i n ?"
" H a v e y o u s t o p p e d d o i n g a n y a c t i v i t i e s y o u u s e d t o d o ?"
This is important when thinking about the risk of further falls. Fear of falling is important to identify as it can lead to a hesitant
gait, leading to muscle loss and an abnormal walking pattern, leading to further falls.
The patient may have lost con

Risk of future falls

The FRAT score can indicate an individual’s risk of falling and guide management. 2
later on in the history.
Some of these questions will be covered
FRAT Score
This determines the relative risk that a patient has of recurrent falls. There are speci
assessment\:
“Have you had any falls in the last year?”
“Are you on 4 or more medications per day?”
“Do you have a diagnosis of stroke or Parkinson’s disease”
“Do you have any problems with your balance?”
“Are you able to get up from a chair without using your arms?”
A patient gets a point for each question answered with "
yes"
. Interpretation\:
Less than 3 points\: lower risk
3-5 points\: higher falls risk

Previous falls

It may be appropriate to ask the patient if they have ever fallen before this episode, how that fall compares to this one, and how
often they fall if they have done so in the past.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
“ W h y d o y o u t h i n k y o u f e l l ?"
“ W h a t d o y o u t h i n k c a u s e d t h e f a l l ?”
Concerns
Explore the patient’s current concerns\:
“ I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?”
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“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
Expectations
Ask what the patient hopes to gain from the consultation\:
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
”
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
”
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
In a fall history, screening for any preceding illnesses that may have caused the fall is important (e.g. urinary tract infection or
chest infection).
Some examples of symptoms you could screen for in each system include\:
Systemic\: fever, night sweats, unintentional weight loss (infection or other systemic illness)
Cardiovascular\: chest pain, palpitations (cardiac syncope)
Respiratory\: productive cough, shortness of breath, pleuritic chest pain (chest infection)
Gastrointestinal\: diarrhoea, vomiting, abdominal pain (gastroenteritis, colitis)
Urinary\: dysuria, frequency, incontinence, haematuria (urinary tract infection, urinary retention)
Neurological\: confusion, abnormal movements (dementia, Parkinson's disease)

Assessing fracture risk

Depending on the context, it may be important to assess fracture risk. 3
The Fracture Risk Assessment Tool (FRAX®) tells us
the ten-year probability of having a major osteoporotic fracture and can guide treatment in high-risk patients.
Asking about the following can help determine the relative risk of osteoporotic fractures\:
Age
Sex\: women are more prone to osteoporosis and fractures
BMI\: a low BMI is associated with increased risk of fractures
Any previous fractures
Family history of fractures (in particular, a fractured hip)
Smoking status\: smoking is a risk factor for osteoporosis
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Steroid use\: this is a risk factor for osteoporosis
Rheumatoid arthritis
Conditions that can lead to secondary osteoporosis (type 1 diabetes, hyperthyroidism, premature menopause, chronic
malnutrition, or malabsorption)
Alcohol use (3 or more units per day)

Past medical history

Establishing a patient’s medical history is particularly important when assessing falls. This may help identify why the patient has
fallen and identify risk factors for injuries (e.g. osteoporosis increasing the risk of fractures).
Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
Ask if the patient has previously undergone any surgery (e.g. lower limb surgery, pelvic surgery, cancer surgery)\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e , a n d w h y w a s i t p e r f o r m e d ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Examples of relevant medical conditions
Relevant medical conditions in the context of a fall include\:
Conditions that abenign paroxysmal positional vertigo, Parkinson’s disease,
orthostatic hypotension, arthritis syndromes and sarcopenia
Conditions that adementia syndromes and other neurological conditions
Conditions that a
Conditions that a
Conditions that can lead to urgent movement (making it more likely for someone to fall)\: urinary conditions, including
urinary tract infection, incontinence and overactive bladder
Cardiovascular conditions\: aortic stenosis, atrial , pacemakers, other arrhythmias

Allergies

Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
anaphylaxis).

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
If the patient is taking prescribed or over the counter medications, document
the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side e
“ H a v e y o u n o t i c e d a n y s i d e e
“ D o y o u t h i n k y o u r f a l l s s t a r t e d a f t e r y o u b e g a n t a k i n g a n y o f y o u r c u r r e n t m e d i c a t i o n s ?”
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Polypharmacy
Polypharmacy, de
Medications to be aware of include\:
Antihypertensives (e.g. amlodipine, ramipril)\: multiple antihypertensives increase the risk of hypotension
Sedating drugs (e.g. benzodiazepines, antipsychotics, opioid analgesics, antihistamines and anti-epileptics) increase
the risk of falls
Diuretics (e.g. indapamide, furosemide)\: increase the risk of hypotension and electrolyte disturbances
Antidepressants (e.g. SSRIs)\: increase the risk of postural hypotension, sedation and electrolyte disturbances (e.g.
hyponatraemia)
Anticholinergic burden
Anticholinergic burden refers to drugs that decrease the action of the parasympathetic nervous system, particularly
acetylcholine.
A high anticholinergic burden can lead to adverse e
The mnemonic PC SOAP can be used to remember drugs with a high anticholinergic burden\:
Promethazine (antihistamine)
Cetirizine (antihistamine)
Solifenacin (used for overactive bladder)
Oxybutynin (used for overactive bladder)
Amitriptyline (used for depression and pain)
Prochlorperazine (antiemetic)

Family history

Ask the patient if there is any family history of relevant medical conditions\:
“ D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y m e d i c a l c o n d i t i o n s ?”
Clarify at what age the disease developed (disease developing at a younger age is more likely to be associated with genetic
factors).
Examples of conditions with a genetic component which may increase the risk of falls include cardiovascular disease and
autoimmune conditions (particularly those a

General social context
Explore the patient’s general social context including\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
If relevant, identifying any home hazards, such as upturned carpets, wires and cables, and furniture, is important. These
hazards may indicate a safeguarding concern and require referral to the adult safeguarding team.
Smoking
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Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years’ the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Excess alcohol consumption increases the risk of falls.
Fluid intake
Dehydration can lead to electrolyte imbalance, confusion, and falls. Quantifying how much
this has changed recently is important.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Rachel Murdoch
Consultant in Older Persons' Medicine

References

1. NICE CKS. Falls risk assessment. Available from\: [LINK]
2. HCPA StopFalls Campaign. FRAT Score. Published in 2018. Available from\: [LINK]
3. Centre for Metabolic Bone Diseases, University of SheLINK]
Source\: geekymedics.com
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