reasons for elderly to fall. Differentials

Multifactorial fall etiology in older adults

Falls in older adults are usually multifactorial rather than due to a single cause. [1] [2]

A practical differential is organized into intrinsic (patient-related) and extrinsic (environment/behavior/device) contributors. American Geriatrics Society—Causes [3]

Intrinsic causes (patient factors)

Falls are associated with medication adverse effects such as dizziness, drowsiness, weakness, slowed reaction time, and visual changes. [4]
Falls risk increases with polypharmacy and psychotropic medication exposure. American Geriatrics Society—Causes [1]

Orthostatic hypotension is a common modifiable fall risk factor. [5]
Cardiovascular causes contributing to transient loss of consciousness should be considered in the differential when history suggests syncope. [3]

Neurologic and cognitive causes

Gait instability, weakness, balance impairment, and unsteady mobility increase fall risk. [1]
Cognitive impairment contributes to falls through impaired judgment, attention, and safe mobility behaviors. [1] [3]

Sensory impairment causes

Vision impairment increases fall risk. [2]
Hearing and other sensory deficits may contribute to balance and spatial orientation problems in older adults. [1]

Musculoskeletal and mobility causes

Lower-extremity weakness and impaired balance are common intrinsic contributors. [1]
Foot problems and improper footwear contribute to falls by reducing stability and traction. [5] [1]

Dehydration can lead to hypotension and increase fall risk. American Geriatrics Society—Causes
Alcohol use can increase fall risk via sedation and balance impairment. [6]

Extrinsic causes (environment, tasks, and equipment)

Home and activity environment causes

Environmental hazards such as clutter in walkways and stairs without appropriate supports increase fall risk. [7]
Falls risk increases with inadequate lighting and absence of safety equipment in the home setting. [6]

Incorrect or poorly used mobility aids can contribute to falls by causing instability. [5]
Poor shoe fit, lack of traction, or inadequate heel support increases fall risk. [5]

Clinical differentials based on fall presentation

“Mechanical fall” presentation

When the history suggests trip or slip, intrinsic gait/balance impairment and extrinsic hazards/footwear should be prioritized. [3] American Geriatrics Society—Causes

Presyncope or syncope presentation

When the history suggests dizziness, lightheadedness, or loss of consciousness, orthostatic hypotension and cardiogenic etiologies should be prioritized. [5] [3]

Medication change or dose escalation around the event

When onset followed medication initiation, dose change, or medication nonadherence, medication adverse effects and drug–drug interactions should be prioritized. [4] [1]

Vision- or environment-triggered pattern

When falls cluster in low lighting or unfamiliar spaces, vision impairment and home/environmental hazards should be prioritized. [2] [6]

Differential-driven evaluation framework

A multifactorial falls risk assessment is recommended after a fall or recurrent falls and with abnormal gait or balance. [3]

Common assessment domains include gait/strength/balance, mobility aid use, vision, orthostatic blood pressure, medication review, feet/footwear, vitamin D intake, home hazards, and cognition. [8]