Differential Diagnosis Chart for Recurrent Falls in Elderly Patients (≥65 years)
For elderly patients with recurrent falls, organize your differential diagnosis into seven evidence-based domains: balance/mobility, sensory/neuromuscular, psychological, medical, medication, environmental, and cardiovascular causes, as these categories predict up to 53% increased risk of recurrent falls. 1
Category 1: Balance and Mobility Disorders (RR: 1.32)
Key Clinical Features to Assess:
- Gait instability: Perform Timed Up and Go test—time >12 seconds indicates increased fall risk and need for intervention 2, 3
- Impaired tandem stand: Inability to hold tandem stand for 10 seconds is associated with increased fall risk 2
- Previous falls: History of falls in past year is the strongest predictor (OR = 2.45) of recurrent falls 4
- Subjective unsteadiness: Patient reports feeling unsteady when walking (OR = 2.34 for recurrent falls) 4
- Assistive device dependence: Need for or advised to use cane/walker predicts adverse outcomes 4
Specific Diagnoses:
- Benign Paroxysmal Positional Vertigo (BPPV): 9% of geriatric clinic patients have undiagnosed BPPV, with 75% having fallen within 3 months 2
- Vestibular neuritis 2
- Age-related gait and balance instability: Present in 20-50% of community-dwelling elderly 2
Category 2: Sensory and Neuromuscular Impairments (RR: 1.51)
Key Clinical Features to Assess:
- Peripheral neuropathy: "Lost some feeling in their feet" predicts recurrent falls 4
- Visual impairment: Formal visual acuity testing is essential as vision impairment is a modifiable fall risk factor 3, 5
- Proprioceptive deficits: Test lower extremity peripheral nerves and proprioception 5
- Proximal motor weakness: Assess lower extremity strength 5
- Cerebellar dysfunction: Test for dysmetria, ataxia 2
Specific Diagnoses:
- Diabetic or other peripheral neuropathy 4
- Cataracts or macular degeneration 3
- Cervical myelopathy 5
- Multiple sclerosis 2
Category 3: Medication-Related Falls (RR: 1.53)
Key Clinical Features to Assess:
- Polypharmacy: Use of ≥5 medications is an independent fall risk factor 2, 5
- Psychotropic medications: Sedatives, hypnotics, antipsychotics significantly increase fall risk 3, 5
- Vestibular suppressants: Should be avoided in elderly patients 3
- Vasodilators and diuretics: Contribute to orthostatic hypotension 3
- Patient reports: "Take medication that makes them feel light-headed or more tired than usual" predicts adverse outcomes 4
High-Risk Medication Classes:
- Benzodiazepines and sedative-hypnotics 3, 5
- Antipsychotics 3
- Tramadol (causes dizziness, sedation, orthostatic hypotension) 5
- Antihypertensives causing orthostasis 3
Category 4: Psychological Factors (RR: 1.35)
Key Clinical Features to Assess:
- Cognitive impairment: Screen with Mini-Cog or Memory Impairment Screen—cognitive impairment significantly increases fall risk 3
- Depression: Screen with PHQ-2—late-life depression is common and contributes to falls 3
- Fear of falling: Ask "Do you worry about falling?"—positive response mandates broader assessment 2
- Dementia: Present in 5% of 65-year-olds and 20% of 80-year-olds, influences recall accuracy 2
Specific Diagnoses:
- Mild cognitive impairment or dementia 2, 3
- Major depressive disorder 3
- Anxiety disorders with fear of falling 2
Category 5: Medical Comorbidities
Key Clinical Features to Assess:
- Parkinson's disease: Assess for extrapyramidal signs, bradykinesia, rigidity 5
- Osteoarthritis: Evaluate lower extremity joint function and pain 5
- Cardiopulmonary disease: May be exacerbated by occult rib fractures from falls 6
- Frailty markers: Low body weight, creatinine clearance <50 mL/min 2
Specific Diagnoses:
- Parkinson's disease or parkinsonism 5
- Severe osteoarthritis limiting mobility 5
- Chronic obstructive pulmonary disease 6
- Chronic kidney disease 2
Category 6: Cardiovascular/Syncope Causes
Key Clinical Features to Assess:
- Orthostatic hypotension: Perform supine and upright blood pressure measurements—essential in all elderly fall patients 2, 3, 5
- Carotid sinus hypersensitivity: Perform supine AND upright carotid sinus massage (diagnostic response only present upright in one-third of patients) 2
- Syncope history: Document presence of loss of consciousness, near-syncope, or altered mental status 5
- Urge incontinence: "Have to rush to toilet" predicts adverse outcomes 4
Specific Diagnoses:
- Orthostatic hypotension (neurogenic or iatrogenic) 2, 3
- Carotid sinus syndrome (cardioinhibitory or vasodepressor): Accounts for up to 20% of symptoms in elderly 2
- Cardiac arrhythmias 2
- Brainstem or cerebellar stroke: 10% of cerebellar strokes present similar to peripheral vestibular process 2
- Vestibular migraine: Lifetime prevalence 3.2%, accounts for 14% of vertigo cases 2
Category 7: Environmental and Situational Factors
Key Clinical Features to Assess:
- Home hazards: Loose rugs, poor lighting, lack of grab bars 3, 5
- Footwear: Suboptimal footwear characteristics (recall P-SCHEME mnemonic) 2
- Lack of home support: Social isolation increases risk 2
- Environmental circumstances: Document location and specific cause of each fall 5
Specific Risk Factors:
- Person-environment interactions: Account for 31% of falls 2
- Inadequate lighting throughout home 3
- Absence of assistive devices when needed 3
Critical Pitfalls to Avoid
- Do not assume isolated injury: Perform complete head-to-toe examination even for seemingly isolated injuries—traumatic injuries may be occult in elderly 5, 6
- Do not miss high-risk injuries: Specifically evaluate for hip fractures, cervical spine injuries, and rib fractures 6
- Do not overlook amnesia for loss of consciousness: Up to one-third of events present as falls without clear syncope history 2
- Do not forget witness accounts: Pursue witness information as 40-60% of patients lack this critical data 2
- Do not perform only supine carotid sinus massage: One-third of diagnostic responses only present when upright 2
Immediate Screening Algorithm
Step 1: Ask three CDC screening questions 2, 3:
- Have you fallen in the past year? How many times?
- Do you feel unsteady when standing or walking?
- Do you worry about falling?
Positive response to ANY question = proceed to Step 2
Step 2: Perform objective testing 2, 3:
- Timed Up and Go test (>12 seconds = high risk)
- 4-Stage Balance Test (tandem stand <10 seconds = high risk)
- Orthostatic blood pressure measurements
Step 3: Apply P-SCHEME mnemonic for modifiable factors 2:
- Pain (axial or lower extremity)
- Shoes (footwear assessment)
- Cognitive impairment (Mini-Cog screening)
- Hypotension (orthostatic or iatrogenic)
- Eyesight (vision assessment)
- Medications (centrally acting drugs)
- Environmental factors
Any positive findings = initiate multifactorial intervention 3, 5