A 79-year-old presents after her third fall in two months, one of which was witnessed and involved a brief loss of consciousness. How would you assess her?

Question

A 79-year-old woman on bisoprolol, amlodipine, doxazosin and sertraline presents after falling in the bathroom. A neighbour witnessed a previous episode with brief loss of consciousness and rapid recovery. ECG shows sinus rhythm at 52 bpm with first-degree AV block.

Accepted Answer

The witnessed loss of consciousness is the most important detail, because it moves this from a falls assessment to a syncope assessment and changes what I look for first. I would take a careful history from her and, crucially, from the neighbour who witnessed it: what she was doing and what position she was in, whether there was any prodrome such as palpitations, chest pain or light-headedness, how long she was unconscious, whether there was any jerking, tongue biting or incontinence, how quickly she recovered, and whether she was confused afterwards. Rapid recovery with no post-ictal phase points away from seizure. I would examine her cardiovascularly, look for a murmur suggesting aortic stenosis, and do a lying and standing blood pressure myself with measurements at one and three minutes, because postural hypotension is the commonest reversible cause and is frequently not measured properly. Her ECG already shows sinus bradycardia at 52 with first-degree block while she is on bisoprolol, so I would want ambulatory monitoring, and if episodes are infrequent I would discuss an implantable loop recorder with cardiology. Her drug chart is probably the biggest single contributor: bisoprolol, amlodipine, doxazosin and sertraline together represent a substantial hypotensive and falls burden, and I would use STOPP/START to plan a structured, staged reduction rather than stopping everything at once. Alongside the cardiovascular work I would do a full multifactorial falls assessment covering gait and balance, vision, cognition, continence, footwear and home hazards, and refer to physiotherapy and occupational therapy for strength and balance training and a home assessment. I would assess her bone health with a fracture risk tool and DXA, check calcium and vitamin D, and start treatment if indicated, because the goal is to prevent the fracture as well as the fall.

Recurrent Falls and Syncope in an Older Adult

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