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“Marked clinical overlap exists between falls, orthostatic hypotension, and dizzy spells, which may all present as syncope. Elderly patients may present with recurrent falls resulting from syncope.”

From the AHA/ACCF Scientific Statement on the Evaluation of Syncope (2006)

“Given that up to 70% of falls in older persons are not witnessed, these patients may present with a report of a fall rather than syncope.”

From the AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (2011)

General Principles in Older Adults

Falls and syncope are commonly encountered syndromes in older adults and both are associated with significant morbidity and mortality. It is often difficult to know when to consider syncope as the primary or a contributing cause to falls in older adults. This chapter provides some guidance for the clinician faced with the question, “Is this patient’s fall caused by syncope?”

Most studies estimate that one-third of community-dwelling older adults fall each year. Falls are the leading cause of injury among patients age 65 years and older. Twenty percent to 30% of falls among older adults result in moderate-to-severe injuries. Falls are associated with functional decline, increased risk for nursing home placement, decreased quality of life, and higher health care costs.

Syncope is also common among older adults. Its prevalence in the general population has a bimodal distribution peaking in people age 10–30 years and again in those older than age 65 years. Almost half of emergency room visits for syncope are made by persons 65 years of age or older. Because of underlying multiple comorbidities and increased prevalence of cardiovascular disease in older people, the morbidity and mortality associated with syncope is higher in older adults compared to younger adults.

General Approach to the Patient with Falls or Syncope

Falls

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 ...

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