Falls, Gait, and Balance Disorders
Epidemiology and mechanism
About one-third of community-dwelling adults over 65 fall each year. Falls are multifactorial: intrinsic factors (gait and balance impairment, sarcopenia, neuropathy, parkinsonism, visual impairment, orthostatic hypotension, cognitive impairment, fear of falling) and extrinsic factors (medications, footwear, home hazards, lighting). Medication classes most implicated include sedative-hypnotics, antipsychotics, antidepressants, opioids, antihypertensives, anticholinergics, and hypoglycemic agents.
Evaluation
After a fall, ask about circumstances (trip versus syncope versus unexplained collapse), loss of consciousness, prodrome, and ability to get up (a long lie predicts rhabdomyolysis, dehydration, pressure injury). Examine gait, strength, proprioception, vision, and orthostatic vital signs. Check for injury, especially hip fracture and intracranial hemorrhage - subdural hematoma can present days later with confusion, and anticoagulated patients warrant a low threshold for head imaging.
Management
The strongest evidence supports exercise interventions targeting balance and strength (e.g., Tai Chi, Otago program), medication review with deprescribing, vision optimization, home safety modification, and multifactorial intervention for high-risk patients. Vitamin D supplementation is not recommended as a stand-alone fall-prevention strategy; treat documented deficiency. Avoid physical restraints, which increase injury. Address fear of falling, since it drives deconditioning.
Gait patterns
The candidate should recognize parkinsonian gait (shuffling, festination, reduced arm swing), ataxic gait (wide-based, cerebellar), neuropathic/steppage gait, antalgic gait, and frontal gait apraxia (magnetic gait of normal pressure hydrocephalus or small vessel disease).
Trap and rule
A common trap is attributing a fall to "just tripping" without medication review or orthostatic measurement. Rule of thumb: any fall plus anticoagulation, head strike, or new confusion means image the head.