Falls and Drop Attacks

Falls and Drop Attacks—Introduction

Falling in childhood is part of growing up and usually medically insignificant, unless a serious childhood illness contributes. With advancing age, the potential for injury and other complications increases, and falling eventually develops into a dangerous burden for the elderly and the neurologically impaired. Quality of life can be severely affected by associated morbidity, immobilization, fear of falling (FOF), and growing dependency. Despite improved understanding of falls and their prevention, they remain a leading public health problem. The 2014 Behavioral Risk Factor Surveillance System (BRFSS) estimated that more than a fourth of adults older than 65 years have fallen, resulting in 29 million annual falls, more than 7 million injuries, and 800,000 hospital admissions in the United States. The corresponding cost to Medicare alone exceeded $31 billion and $50 billion for all medical care ( , August 17). Fall-related injuries belong to the 20 most costly medical conditions.

Clinically, a large number of etiologies of falls have to be considered. A useful initial approach is to determine whether a patient has suffered a drop attack or an accidental fall. In this discussion the term drop attack describes a sudden fall occurring without a prodrome that may or may not be associated with loss of consciousness and cannot be prevented by assistive devices. In contrast, falls reflect an inability to remain upright during a postural challenge. Potential etiologies of drop attacks include cardiac, epileptic, vascular, sleep, and vestibular disorders, as well as congenital brain abnormalities and intracranial masses. In neurological practice, falling is most commonly associated with chronic disorders such as neuropathies, stroke, multiple sclerosis (MS), parkinsonism, and dementia. Affected patients have impaired control of stability and gait due to functional declines in neuromuscular, sensory, vestibulocerebellar, and cognitive systems. Finally, the elderly, with their inevitable infirmities and accumulating functional deficits, frequently fall. These associations permit a classification of falls and drop attacks, as presented in Box 3.1 .

As is true for most neurological presentations, the medical history is essential in establishing the likely etiology of a patient’s fall. Aside from gender, age, medications, and neurological conditions, which all affect fall risk, answers to the following questions should be sought:

• What were the circumstances of the fall and has the patient fallen before?

• Did the patient lose consciousness? If so, for how long?

• Did lightheadedness, vertiginous sensations, or palpitations precede the event?

• Is there a history of a seizure disorder, startle sensitivity, excessive daytime sleepiness, or falls precipitated by strong emotions?

• Does the patient have headaches or migraine attacks associated with weakness?

• Does the patient have vascular risk factors, and were there previous symptoms suggestive of transient ischemic attacks (TIAs)?

• Are there symptoms of sensory loss, limb weakness, or stiffness?

• Is there a history of visual impairment, hearing loss, vertigo, or tinnitus?

The neurological examination identifies predisposing functional deficits. However, in the case of drop attacks, the examination is often normal, posing a diagnostic challenge. In such patients, neuroimaging is necessary. Further workup is tailored to the clinical circumstance and may include vascular imaging, cardiac and autonomic studies, electroencephalogram (EEG), nocturnal polysomnography, and, rarely, genetic and metabolic testing when related conditions are suspected. Psychogenic disorders of station and gait need to be considered in patients who frequently experience near falls without injuries.

Drop Attacks With Loss of Consciousness

Drop Attacks Without Loss of Consciousness