The literature varies widely on the definition of falls, but typically falls are defined as unintentionally coming to rest on the ground or a lower surface. When evaluating a patient with falls, obtaining a detailed history of the fall from the patient and witnesses, if available, is imperative and a good starting point. This history should include the circumstances surrounding the fall, any preceding symptoms, such as dizziness or lightheadedness, whether the fall was witnessed or not, and whether there was loss of consciousness with the fall. A focused physical exam including a cognitive and functional assessment should also be completed. During the evaluation, it is important to remember that falls constitute a geriatric syndrome. As such, the cause of falling in an older patient is rarely the result of a single cause but instead the result of a complex interaction between intrinsic and extrinsic risk factors. In addition to a detailed history and physical exam, identifying and addressing these risk factors is at the core of a falls evaluation. Current guidelines emphasize assessing the following risk factors: (a) history of falls, (b) medications, (c) gait, balance, and mobility, (d) visual acuity, (e) other neurologic impairments, (f) muscle strength, (g) heart rate and rhythm, (h) postural hypotension, (i) feet and footwear, and (j) assessment of environmental hazards (Table 59–1). Medication classes to specifically identify in older adults with falls include anticonvulsants, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Because of their propensity to worsen postural hypotension, antihypertensive medications should also be evaluated.
Fainting is a common problem and encompasses any disorder associated with a real or perceived transient loss of consciousness. Nontraumatic transient loss of consciousness is further classified into syncope, epileptic disorders, psychogenic pseudosyncope, and rare miscellaneous causes, such as cataplexy or drop attacks. Syncope specifically refers to transient loss of consciousness caused by global hypoperfusion. Hallmark features of its presentation are sudden loss of consciousness with associated loss of postural tone and rapid spontaneous recovery. The causes of syncope can be classified into 3 broad categories: reflex-mediated syncope, syncope caused by orthostatic hypotension, and cardiac syncope (Table 59–2).
The initial goal of the evaluation of syncope is risk stratification, that is, to define those patients who warrant urgent cardiac evaluation because of the high short-term risk of recurrence of syncope. Approximately one-third of patients with syncope will have a recurrent event within 3 years. As with falls, the evaluation of the patient with syncope should start with obtaining a comprehensive history of the event and physical examination, including checking orthostatic vital signs. An electrocardiogram (ECG) should also be performed. Historical questions should be targeted to try to identify which class of syncope is most likely. A detailed history and physical examination combined with ECG findings can identify the cause of syncope in nearly 25% of patients. Patients in whom the cause of syncope is uncertain may warrant additional tests. These tests include, but are not limited to, echocardiography, stress testing, short-term or long-term ECG monitoring, electrophysiology study, tilt-table testing, and supine and upright carotid sinus massage. Similar to falls, older adults may have more than 1 factor contributing to their syncope. Physiologic changes associated with aging, such as inability to preserve sodium and water, decreased baroreceptor responsiveness and autonomic dysfunction all increase older adults’ risk for syncope. The use of multiple medications that affect blood pressure, heart rate, and volume status, such as diuretics and β blockers, also predispose older people to syncope. All of these factors should be kept in mind when evaluating the older adult with syncope.