Falls in the Elderly: A Comprehensive MCCQE1 Guide

Introduction

For Canadian medical students and international medical graduates preparing for the MCCQE1, understanding Falls in the geriatric population is critical. Falls are one of the “Geriatric Giants” and represent a major cause of morbidity, mortality, and loss of independence in older adults.

In the context of the CanMEDS framework, managing falls requires a Medical Expert to diagnose etiologies, a Health Advocate to implement prevention strategies, and a Collaborator to work with multidisciplinary teams (physiotherapy, occupational therapy, pharmacy).

Pathophysiology and Etiology

Falls are rarely due to a single cause; they are typically multifactorial, resulting from a complex interaction between intrinsic factors (patient-related) and extrinsic factors (environment-related).

The Systems Approach

Stability requires the integration of sensory input (vision, proprioception, vestibular), central processing, and musculoskeletal output. A failure in any of these systems can lead to instability.

Mnemonics for MCCQE1

Use the mnemonic DAME to recall major categories of risk:

D - Drugs and alcohol
A - Age-related physiological changes
M - Medical problems
E - Environmental hazards

Clinical Assessment

The goal of the assessment is to identify modifiable risk factors and treat underlying pathologies.

Diagnostic Investigations

Investigations should be guided by the history and physical exam. Do not “shotgun” order tests without a clinical rationale.

Management and Prevention

Management must be multifactorial and interdisciplinary.

Acute Management

1. Treat immediate injuries (fractures, subdural hematoma).
2. Treat acute medical precipitant (UTI, pneumonia, dehydration).

Chronic Management & Prevention Strategies

Non-Pharmacological Interventions

• Exercise: Balance and strength training (e.g., Tai Chi, Otago Exercise Program).
• Environmental Modification: Home safety assessment by Occupational Therapy (remove rugs, improve lighting).
• Vision/Hearing: Cataract surgery, hearing aids.
• Footwear: Non-slip, closed-heel shoes.
• Hip Protectors: May reduce hip fractures in institutionalized elderly (evidence is mixed/compliance is low).

Canadian Guidelines

Familiarity with these guidelines is essential for the MCCQE1.

Choosing Wisely Canada

• Geriatrics: “Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.”
• Emergency Medicine: “Don’t order CT head for adults with minor head injury unless positive for a validated head injury clinical decision rule (e.g., Canadian CT Head Rule).”

Osteoporosis Canada

• Recommend Vitamin D supplementation for all Canadian adults year-round.
• Seniors (65+): 800–2000 IU daily.

Canadian Geriatrics Society (CGS)

• Emphasizes the “Geriatric 5Ms”: Mind, Mobility, Medications, Multicomplexity, Matters Most.

Key Points to Remember for MCCQE1

• Orthostatic Hypotension: Always measure lying and standing BP. It is a common, reversible cause of falls.
• Benzodiazepines: These are a major red flag in MCCQE1 questions. The correct answer often involves tapering/stopping them.
• TUG Test: Know that >12-15 seconds is abnormal.
• Vitamin D: Routine supplementation is standard care for falls/fracture prevention in Canada.
• Restraints: Physical restraints (tie-downs, lap belts) generally increase the risk of injury and are discouraged.
• Syncope vs. Fall: Differentiate clearly. Syncope involves loss of consciousness and loss of postural tone. A “drop attack” is sudden leg weakness without LOC.

Sample Question

Explanation

The correct answer is:

• C. Initiate a slow taper of lorazepam

Detailed Explanation: This patient presents with a likely mechanical fall compounded by orthostatic hypotension and medication side effects.

• C is correct: Lorazepam (a benzodiazepine) is a significant risk factor for falls in the elderly due to sedation, cognitive slowing, and impairment of balance. Choosing Wisely Canada strongly recommends against using benzodiazepines for insomnia in the elderly. Tapering this medication is a high-yield intervention to reduce fall risk.
• A is incorrect: A CT head is not indicated. She did not lose consciousness, has no focal deficits, and the fall occurred 2 days ago without deterioration (referencing the Canadian CT Head Rule principles).
• B is incorrect: While hip protectors may be considered, they do not prevent the fall itself. Removing the precipitating cause (medication) is higher priority.
• D is incorrect: The patient already demonstrates orthostatic hypotension (systolic drop of 25 mmHg). Increasing antihypertensives would worsen the orthostasis and increase fall risk.
• E is incorrect: While vision checks are part of a multifactorial assessment, there is no indication in the stem of acute visual pathology. The medication issue is the most glaring and immediate modifiable risk factor.

References

1. Public Health Agency of Canada. Seniors’ Falls in Canada: Second Report. Available at: https://www.canada.ca/en/public-health/services/health-promotion/aging-seniors/publications/publications-general-public/seniors-falls-canada-second-report.html 
2. Choosing Wisely Canada. Geriatrics: Five Things Physicians and Patients Should Question. Available at: https://choosingwiselycanada.org/geriatrics/ 
3. Canadian Task Force on Preventive Health Care. Prevention of Falls in Older Adults.
4. Osteoporosis Canada. 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada.
5. Medical Council of Canada. MCCQE Part I Objectives: Falls.
6. Stiell, I.G., et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001.