Differential Diagnoses for Sensation of Impending Fall in Adults
When an adult reports feeling like they will fall, prioritize a systematic evaluation of balance disorders, functional impairment, visual deficits, cognitive impairment, and medication effects, as these represent the most common and reversible causes. 1
Primary Differential Categories
Neurological and Vestibular Causes
- Balance and gait disorders - the most frequently identified risk factor requiring immediate assessment through standardized gait and balance testing 1
- Peripheral neuropathy - particularly in diabetic patients where neuropathic changes affect proprioception and balance 1
- Cognitive impairment or delirium - screen for depression, B12 deficiency, and hypothyroidism as reversible causes 1
- Vestibular dysfunction - contributing to dizziness and imbalance 2
Cardiovascular Causes
- Orthostatic or postural hypotension - essential component of multifactorial risk assessment 1
- Cardiac arrhythmias - causing transient cerebral hypoperfusion 3
Medication-Related Causes
- Psychoactive medications - including benzodiazepines (OR 2.2), haloperidol (OR 2.8), and tricyclic antidepressants (OR 2.4) 4
- Anticonvulsants - particularly hydantoins (OR 3.3) and benzodiazepine anticonvulsants 4
- Antihypertensives - contributing to orthostatic changes 5
- Polypharmacy - cumulative effect of multiple medications 1
Musculoskeletal Causes
- Muscle weakness - particularly lower extremity weakness affecting gait stability 3
- Functional impairment - requiring assistive devices (OR 3.2) or person assistance (OR 2.1) for ambulation 4
- Foot problems and inappropriate footwear - modifiable risk factors 5
Sensory Deficits
- Visual impairment - requires specific assessment as part of multifactorial evaluation 1
- Proprioceptive deficits - often related to neuropathy or vitamin B12 deficiency 1
Metabolic and Endocrine Causes
- Hypothyroidism - associated with increased fall risk requiring thyroid function monitoring 6
- Vitamin D deficiency - both a cause and treatment target 6, 5
- Hypoglycemia - particularly in insulin-treated patients (OR 1.5) 4
Environmental and Situational Factors
- Home hazards - modifiable through environmental assessment 1
- Confusion or altered mental status (OR 2.4) - requiring urgent evaluation 4
- Urinary incontinence (OR 1.5) - associated with rushing to bathroom 1, 4
Risk Stratification Approach
High-Risk Indicators Requiring Immediate Multifactorial Assessment
- History of 2 or more falls in past year 1
- Single fall combined with gait or balance problems 1
- Presenting with acute fall 1
- History of prior falls (OR 2.7) 4
Essential Assessment Components
- Balance and mobility evaluation - using standardized testing 1
- Medication review - focusing on psychoactive medications, anticonvulsants, and polypharmacy 1
- Orthostatic blood pressure measurement - standing and supine 1
- Vision assessment - formal evaluation 1
- Cognitive evaluation - screening for delirium, dementia, depression 1
- Environmental hazard assessment - home safety evaluation 1
- Functional status - activities of daily living assessment 1
Treatment Algorithm
For All Patients with Fall Sensation
- Exercise intervention - balance, gait, and strength training components reduce fall risk by approximately 17% 6, 5
- Vitamin D supplementation - 800 IU daily for at least 12 months (number needed to treat = 10) 1, 6
- Medication withdrawal or minimization - particularly psychoactive medications 5
For High-Risk Patients
- Comprehensive multifactorial assessment with management - reduces fall risk by 25% in select populations 1
- Physical therapy referral - for significant gait or balance impairments 6
- Management of postural hypotension - if identified 5
- Foot problem management and footwear modification - recommend low heels and hard soles 6, 5
Critical Pitfalls to Avoid
- Do not dismiss patient reports - falls are frequently unreported and underdetected 1
- Do not perform superficial assessment - multifactorial assessment without comprehensive follow-up and management is ineffective 1
- Do not overlook reversible causes - depression, B12 deficiency, hypothyroidism, and medication effects are treatable 1
- Do not ignore urinary incontinence - associated with social isolation, depression, and increased fall risk 1
- Do not delay delirium evaluation - requires urgent assessment when identified 1