Services vary depending on geography (e.g. availability of day hospital, home assessment by physio etc). Please also refer to locality guidelines for MoE services and the above supporting pages.
Falls are increasingly common with age. There can be multiple causes for falls including acute illness, and falls can often co-exist with the onset of delirium. Falls can result in severe injury including fractures and head injuries, with associated consequent morbidity and mortality. Fear of falling can be debilitating for older people, and hard to treat. Realistic prescribing is important in older people; the risks of polypharmacy (including falls) increase with age.
It can be difficult to determine the reason for a fall, and one single reason may never be identified.
There are a number of risk factors; modifiable and non-modifiable. The purpose of a comprehensive geriatric assessment is to identify all risk factors and address as many of the modifiable risk factors as possible. Risk factors for falls include (but are not limited to):
| Age | Postural hypotension |
| Sarcopenia / low body weight | Syncope of any cause |
| Sensory impairments particularly eyesight | Medications (esp. high anticholinergic burden) |
| Dizziness and vertigo (central or peripheral cause) | Number of medications (polypharmacy) |
| Dementia | Incontinence |
| Neurological conditions e.g. Parkinsonism, stroke disease, neuropathy | Alcohol |
| Delirium of any cause | Metabolic disturbances (e.g. hypoglycaemia) |
| Pre-existing MSK injury or pain | Inappropriate walking aids |
| | Environmental factors (stairs, loose rugs etc.) |
The more information in the referral, the easier it is to triage to the appropriate service.
Who to refer:
Patients who have recurrent falls despite attempts to address identifiable risk factors, or where further expert advice is needed
Who not to refer:
Patients who solely require input from physiotherapy and/or occupational therapy should be referred to the local services directly
Patients who have clear red flags for cardiac syncope (definite loss of consciousness, abnormal ECG, facial injuries suggestive of LOC) – please consider referring directly to cardiology.
Please consider involving a pharmacist before referring if medication/polypharmacy review is the sole reason for referral.
Please consider contacting the Parkinson’s nurses instead of or alongside MOE referral if the patient has a diagnosis of PD.
How to refer:
If acutely unwell and Hospital at Home admission is appropriate, please refer to locality Hospital-at-Home team.
Patients should be referred via SCI Gateway to their local geriatric medicine service;
- North East Edinburgh: Leith Community Treatment Centre – Geriatric Medicine
- North West Edinburgh: Western General Hospital- Geriatric Medicine
- South Edinburgh: Liberton Hospital – Geriatric Medicine
- Midlothian: Liberton Hospital – Geriatric Medicine
- East Lothian:
- West Lothian: St John’s Hospital – Geriatric Medicine
In all older patients with falls, consider the possibility that this is the presenting symptom of an acute illness.
Appropriate history and examination therefore includes:
- Number and frequency of falls including time of day, preceding activities (step by step history helpful)
- Other associated symptoms coinciding with onset of falls (i.e. suggesting intercurrent illness)
- Light headedness on standing, loss of consciousness at any point preceding / during fall (if LOC please give appropriate driving advice as per DVLA)
- Injuries sustained following falls (facial injuries/failure to attempt rescue may indicate syncope more likely, injuries add to hazard risk of falls)
- Alcohol history
- Collateral history and witness account if possible (partner, family, carers)
- Cardiovascular, respiratory, abdominal, and neurological examinations as appropriate to identify intercurrent illness.
- Assessment of gait and mobility (e.g. Timed Up And Go test)
- Lying and standing blood pressures (after 5 min lying, immediately and again at 3 minutes)
- Full medication review (in particular considering anticholinergic burden and START/STOPP criteria)
- ECG
- FBC, U&E, LFT, Calcium, TFT, B12/folate/iron studies, random glucose, HbA1c in people with diabetes
- Consider osteoporosis risk using appropriate scoring system (Qfracture, FRAX).
How to measure lying and standing BP:
Polypharmacy guidance including information about anticholinergic burden:
Realistic prescribing: Polypharmacy-Guidance-2018.pdf
Qfracture: https://qfracture.org/
