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.