Why Falls Assessment Is a Core OSCE Station
Falls are the leading cause of injury-related hospital admission in the over-65 population in the UK. They appear in geriatric medicine, GP, and A&E OSCE circuits. The examiner wants to see you take a structured multi-system history that covers both why the patient fell and how to prevent the next fall — not just a simple account of what happened.
Immediate Safety First
Before the detailed history, check:
- Was there an injury? Head injury, possible fracture, loss of consciousness?
- Is the patient safe now? Can they mobilise independently?
- Prolonged lie on the floor? (risk of hypothermia, rhabdomyolysis, pressure injury)
History of the Fall: SPLATT
🧠 Mnemonic
SPLATT — take the history of every fall in this order
S — Symptoms at the time: dizziness, palpitations, chest pain, aura, visual disturbance?
P — Previous falls: how many in the last year? Any pattern?
L — Location: home, outdoors, on stairs, in the bathroom, at night?
A — Activity at the time: getting up from a chair, walking, reaching up, going to the toilet?
T — Time of day: morning (postural hypotension), after meals (postprandial hypotension), night (nocturia)?
T — Trauma and injury: head injury, fracture, soft tissue injury, prolonged lie?
Critical follow-up questions:
- "Did you have any warning before you fell — dizziness, blackout, or chest pain?"
- "Did you lose consciousness? Were you told how long for?"
- "Do you remember hitting the ground?" (No memory = likely LOC or seizure; clear memory = mechanical fall)
- "How long were you on the floor before you could get up or get help?"
Causes of Falls — Intrinsic vs Extrinsic
Intrinsic Factors (Patient-Related)
| System | Causes |
|---|---|
| Cardiovascular | Postural hypotension, arrhythmia, vasovagal syncope, aortic stenosis |
| Neurological | Parkinson's disease, stroke, peripheral neuropathy, cerebellar ataxia, dementia |
| Musculoskeletal | Arthritis, proximal muscle weakness, foot deformity, pain limiting mobility |
| Sensory | Visual impairment (cataracts, macular degeneration), peripheral neuropathy |
| Medications | Antihypertensives, diuretics, sedatives, opiates, anticholinergics, polypharmacy |
Extrinsic Factors (Environmental)
- Loose rugs, slippery floors, poor lighting
- Ill-fitting footwear or bare feet
- No grab rails in bathroom, bed too low or too high, cluttered walkways
💎 Clinical Pearl
Medications are the most modifiable fall risk factor. Always take a full drug history and specifically ask about antihypertensives, diuretics, benzodiazepines, zopiclone, tricyclic antidepressants, and any recent dose changes. Polypharmacy (4 or more medications) independently increases fall risk.
Differentiating Syncope from a Mechanical Fall
| Feature | Mechanical fall | Vasovagal syncope | Cardiac syncope |
|---|---|---|---|
| Warning | None (trip/slip) | Prodrome: pallor, sweating, nausea | None or very brief |
| Recall of fall | Remembers hitting ground | May not recall | No recall |
| Precipitant | Environmental | Prolonged standing, pain, emotion | Exertion, palpitations |
| Recovery | Immediate | Slow, fatigue, nausea | Often rapid |
⚠️ Red Flag
Syncope on exertion, associated with chest pain, or with a family history of sudden cardiac death warrants urgent cardiac investigation — 12-lead ECG and cardiology referral. Do not dismiss a fall as mechanical without cardiac screening.
Screening for Postural Hypotension
Ask:
- "Do you feel dizzy or lightheaded when you stand up from sitting or lying?"
- "Is it worse first thing in the morning or after a meal?"
Examine: lying and standing blood pressure — a drop of 20 mmHg or more in systolic, or 10 mmHg or more in diastolic, within 3 minutes of standing = orthostatic hypotension.
Functional Assessment
- "Before the fall, how far could you walk? Do you use a walking aid?"
- "Are you able to manage independently at home?"
- Fear of falling: "Has worrying about falling stopped you doing things you used to do?"
Timed Up and Go (TUG) test: patient rises from a standard chair, walks 3 metres, turns, walks back, and sits. Over 12 seconds = high fall risk.
Completing the Assessment
- Visual acuity (Snellen chart)
- Lying and standing blood pressure
- Neurological examination: gait, Romberg's, proprioception
- Musculoskeletal: muscle strength, joint range of motion
- Bloods: FBC (anaemia), U&E (dehydration), glucose (hypoglycaemia), B12/folate, TFTs, calcium
- ECG: arrhythmia, heart block, QTc prolongation
Frequently Asked Questions
"What does SPLATT stand for and how do I use it in a falls OSCE?"
SPLATT covers: Symptoms before the fall, Previous falls, Location, Activity at the time, Time of day, and Trauma sustained. Work through each domain in order. The symptoms question is the most important — it separates a mechanical trip from a syncopal episode or neurological event.
"What is the Timed Up and Go test?"
The TUG test assesses functional mobility and fall risk. The patient rises from a standard chair without using their arms if possible, walks 3 metres, turns, walks back, and sits down. A time of over 12 seconds indicates high fall risk. It requires no specialist equipment and takes under 2 minutes.
"How do I screen for postural hypotension in an OSCE?"
Ask about dizziness on standing, especially in the morning or after meals. Confirm clinically with lying and standing blood pressure: a drop of 20 mmHg or more in systolic pressure within 3 minutes of standing meets the diagnostic threshold for orthostatic hypotension.
"Which medications most commonly cause falls?"
The highest-risk medications are antihypertensives and diuretics (postural hypotension), benzodiazepines and Z-drugs (sedation, impaired balance), opiates (sedation, confusion), tricyclic antidepressants (postural hypotension, sedation), and antipsychotics. Polypharmacy — defined as four or more medications — is independently associated with fall risk regardless of specific agents.
"What is the difference between a syncopal fall and a mechanical fall?"
A mechanical fall involves tripping or slipping with no loss of consciousness — the patient remembers hitting the ground. A syncopal fall involves transient loss of consciousness: the patient typically has no memory of falling and may have had a prodrome (vasovagal) or no warning (cardiac arrhythmia). Witness accounts and ECG are essential for distinguishing syncopal falls.
Related guides: [How to Take a Cardiology History OSCE](/blog/how-to-take-a-cardiology-history-osce) · [Neurological Examination OSCE](/blog/neurological-examination-osce) · [A&E Assessment OSCE](/blog/ae-assessment-osce)