A 60-year-old diabetic, hypertensive, with CAD and depression on multiple drugs, presents with recurrent falls over one week — evaluate and manage Key insight for the examiner: falls clustering over one week in a previously stable patient indicate an acute precipitant superimposed on chronic risk factors — this is a “premonitory fall” pattern (Kane) and demands a search for acute illness, delirium or a recent drug change, not merely a routine falls assessment.

This patient has four independent fall risk domains: diabetes (neuropathy, retinopathy, hypoglycaemia, autonomic dysfunction), hypertension (drug-induced hypotension; orthostatic hypotension is commonest in uncontrolled hypertension), CAD (arrhythmia, low output, nitrates), and depression (antidepressants, poor concentration, deconditioning).

Polypharmacy is the dominant modifiable factor. More than four drugs, and use of psychotropic, analgesic, diuretic and antihypertensive drugs, are explicit fall risk factors.

An abrupt cluster of falls over one week signals a new event: acute illness (“premonitory fall”), delirium, a recent drug initiation or dose change, or a new cardiac or neurological event.

Take a detailed history of each fall — location and time of day, activity, whether alone or witnessed, and whether the patient was aware of the impending fall, tripped or slipped, or the fall was totally unexpected.

Ask about relationship to change of posture, turning of the head, cough, urination, a meal, or medication intake — each points to a different mechanism (orthostatic, carotid sinus, situational, postprandial hypotension, drug effect).

Ask for premonitory and associated symptoms: light-headedness, dizziness, vertigo, palpitations, chest pain, breathlessness, focal neurological symptoms (weakness, sensory disturbance, dysarthria, ataxia, aphasia), aura, incontinence of urine or stool.

Ask specifically about loss of consciousness, what is remembered immediately after the fall, whether the patient could get up and how long it took, and whether any witness can confirm loss of consciousness. Loss of consciousness suggests a cardiac event or seizure.

Obtain a complete drug chart including doses, recent changes, over-the-counter drugs and alcohol, and note any drug started or up-titrated in the preceding two weeks.

Vital signs first. Fever, tachypnoea, tachycardia or hypotension should prompt a search for acute illness — pneumonia or sepsis, myocardial infarction, pulmonary embolism, gastrointestinal bleeding.

Postural blood pressure and pulse supine, sitting, and after 1 and 3 minutes of standing are critical. A fall of more than 20 mmHg systolic is significant. Also check for postprandial hypotension if events occur within two hours of a meal.

If the history suggests carotid sinus sensitivity, gently massage the carotid for 5 seconds and observe for profound bradycardia (50% reduction in heart rate) or a long pause.

Cardiovascular examination for arrhythmia and aortic stenosis. Both are treatable, serious, and hard to detect clinically — refer for continuous monitoring and echocardiography if suspected. Syncope in aortic stenosis is an indication to evaluate for valve replacement.

Neurological examination: mental status, focal signs, muscle weakness, rigidity or spasticity, peripheral neuropathy especially posterior column signs (position and vibration sense) given diabetes, cerebellar signs (heel-shin, heel tapping), and features of Parkinson’s disease.

Visual acuity for uncorrected refractive error, cataract and diabetic retinopathy. Examine the feet for deformity, painful lesions (calluses, bunions, ulcers), neuropathic changes and poorly fitting or worn-out footwear.

Examine skin, extremities and painful soft-tissue areas for injury, and specifically consider subdural haematoma if there is head injury or new neurological signs days to weeks later.

Perform gait and balance assessment — more useful for finding remediable problems than the standard neuromuscular examination. Use the Get Up and Go test, and the STEADI trio of TUGT, 30-second chair stand and four-stage balance test.

Directed, not routine: capillary and fasting glucose, HbA1c; haemoglobin g/dL (occult GI bleed); sodium and potassium mEq/L; blood urea and creatinine mg/dL; calcium mg/dL; vitamin D; TSH; urine routine and culture; 12-lead ECG. Continuous cardiac monitoring and echocardiography only if clinically indicated; the arrhythmia must be temporally associated with symptoms before it is blamed.

Treat the acute precipitant first — infection, hypoglycaemia, dehydration, anaemia, electrolyte disturbance, delirium, ischaemia.

Deprescribe and rationalise: withdraw or reduce sedatives and hypnotics; review antidepressant choice and dose; reduce or space antihypertensives and diuretics if postural drop is present; review nitrates and alpha blockers; avoid sulfonylureas and reduce insulin to relax glycaemic targets in a faller; stop anticholinergics.

Correct the specific causes found: support stockings, leg elevation, slow staged rising and, if needed, mineralocorticoid or midodrine for postural hypotension; podiatry and correct footwear; ophthalmology referral; pacemaker if cardio-inhibitory carotid sinus hypersensitivity; antiparkinsonian drugs if indicated.

Rehabilitation and environment: refer to physiotherapy for gait and balance retraining and lower limb strengthening, and to occupational therapy for home hazard assessment. Prescribe and train in the correct use of a walking aid. Assess osteoporosis and start calcium and vitamin D; consider bone-specific therapy.

Ensure safety in this recurrent faller by urgent intervention, review response at short interval, and educate patient and family about the heightened risk in the days after any drug change.