Last Updated on August 19, 2026
Introduction
• Elderly tends to present ‘fall’ as a consequence of underlying etiology, while healthy and younger age group tend to present with fall/trauma first as the etiology which may later be complicated by stroke e.g. due to
intracranial bleed
Intracranial bleed (ICB)
| Age group | Etiology | Consequence |
| Younger age group | Fall / Trauma | Stroke |
| Elderly | Stroke | Fall |
Presentation
“74-year-old man with underlying DM, HTN and dyslipidaemia, presented to ED with wound at the forehead”
At Triage
Primary Triage
Key questions
• Age group?
• Any fall?
• Any slurred speech? Weakness? Facial asymmetry?
=====
Example:
Elderly + fall + slurred speech: allow skip secondary triage, assign patient to at least yellow zone for further assessment by doctor
History Taking
• What tine & date?
Prior to fall
• What the patient
did
e.g. walking, running, sitting Examples:
•
How
• Misstep
• Dizziness / Loss of consciousness / Vertigo
• Weakness of lower limbs
During fall
• Fall at which side? / Fall towards which
direction
e.g. fall forward, fall backward e.g. buttock landing on the floor first / head hitting the wall first e.g. forehead, occipital region, parietal region Important in documentation / requesting for CT brain / referring neurosurgical
•
Which site
• Fall hitting the head?
Which site
Post fall
• Any
retrograde amnesia
e.g. ask about what is the last thing patient remembers prior to fall e.g. occipital region / forehead / parietal region / temporal region
• Any loss of consciousness?
• Any abrasion / laceration wound? Any bleeding? Any ENT bleeding?
• Any head trauma? Any headache?
Which site
• Any neck pain?
• Any upper limbs pain: Shoulder? Arm? Forearm? Wrist? Fingers?
• Any lower limbs pain: Knee? Calf? Ankle? foot? Toes?
• Able to ambulate?
Relevant history
Co-morbidities • Risk of intracranial bleeding post fall, especially in elderly • Risk of intracranial bleeding post fall, especially in elderly • How is the compliance? Did the patient take extra dose? Did the patient have any meal after insulin injection? Types of insulin 🚪 Prandial insulin (Bolus) 🚪 Basal insulin 🚪 Premixed insulin Source: CPG Management of Type 2 Diabetes Mellitus • Did the patient take extra anti-hypertensive accidentally?
e.g. DM, HTN, dyslipidaemia, IHD, atrial fibrillation
Medications
Who takes care of patient’s medication?
•
Anticoagulant
• May indicate patient taking prophylactic medication for underlying atrial fibrillation
•
Antiplatelet
•
Insulin or oral anti-diabetic agents
• May cause hypoglycaemia → fall
• Short acting: Actrapid®, Humulin R, Insuman R, Insugen R
• Rapid analogue: Aspart (Novorapid®), Lispro (Humalog®), Glulisine (Apidra®)
• Intermediate-acting: Insulatard®, Hululin N, Insuman N, Insugen N
• Long-acting analogue: Glargine, Detemir, Degludec
• Mixtard 30, Humulin 30/30, Novomix 30, Humalog mix 25/75, Humalog mix 50/50
•
anti-hypertensive
• May cause hypotension → dizziness → fall
💡Notes
High risk of ICB post fall: elderly + on anticoagulant / antiplatelet
Causes of Fall
• Seizure (e.g. epilepsy)
• Alcoholics
Fall in elderly
• Stroke Pulmonary embolism
• Acute coronary syndrome
• Hypoglycaemia
• Sepsis
•
Pulmonary embolism
Complications of Fall
•
Intracranial bleed
Intracranial bleed (ICB)
Case Scenario
Example 1
67 years old man, presented with
4 hours
• When presenting a case, we should provide the duration (e.g. how many hours / how many days) instead of the exact timing (e.g. at 6 pm, on 25/2/2022) Risk factor of stroke Possible etiology of stroke • Could increase risk of intracranial bleeding especially after fall in elderly
Patient has underlying
HTN, DM, dyslipidaemia
Take Home Message
1. Fall in different age group can have different etiology and different consequences
2. When patient presented with multiple problems, we give priority to manage the dominant one(s)first.×the most life threatening and ongoing problem
Example: patient with resolved slurred speech and at the same time noted having VF, we must treat VF first, and CT brain can be done later