Differential diagnosis between ‘unexplained’ fall and syncopal fall

Abstract

Falls may be accidental (because of slipping, tripping or environmental hazards) or 'unexplained', when there is no apparent cause. Syncope is a transient loss of consciousness (LOC) and, if it occurs when the person is in the upright position, may lead to a fall. The differential diagnosis between 'unexplained' fall and syncopal fall can be difficult, if not impossible, because many patients have retrograde amnesia after syncope, that is they do not remember their prodromal symptoms. Based on the results of many randomized studies, the international guidelines on falls suggest multifactorial assessment and multifactorial treatment. Unfortunately, however, the vast majority of studies have been carried out on a mixed population of patients who have suffered accidental and 'unexplained' falls. As 'unexplained' falls account for a minority of cases, we really do not know the efficacy of multifactorial treatment in patients with this type of fall. Very recent data seem to prove that many older patients with 'unexplained' falls are actually affected by reflex syncope with retrograde amnesia, as they experience LOC during tilt testing or carotid sinus massage. Although these data make an important contribution to our knowledge of the mechanism of 'unexplained' falls, the therapeutic problems remain largely unsolved.

The different clinical presentations of vasovagal syncope

“…If syncope occurs when the patient is in the upright position, he/she will fall and, therefore, the clinical findings of syncope and falls could be very similar 18 19. In this regard, retrograde amnesia has been demonstrated in patients with syncope induced in the laboratory; about 25% of patients have been found not to remember their prodromal symptoms and TLoC during tilt-induced or carotid sinus massage (CSM)-induced syncope 20 21.…”

“…When the tilt test is positive in these patients, VVS could be diagnosed in the absence of any competing diagnosis 19. The treatment of VVS with a clinical presentation as a fall remains undefined, since published data are not available.…”

Does baseline depression increase the risk of unexplained and accidental falls in a cohort of community‐dwelling older people? Data from The Irish Longitudinal Study on Ageing (TILDA)

“…Furthermore, there has been limited research to date aimed at exploring the specific falls type associated with depression in an older population. Accidental or mechanical falls are terms used to describe falls due to slipping or tripping while unexplained or non‐accidental falls (AFs) cannot be explained by simple trips or slips, and can be caused by unrecognised syncope, seizures, and associated with loss of consciousness . Assessment of older fallers is complicated by the fact that older patients regularly have amnesia for loss of consciousness and falls due to syncope can therefore be incorrectly classified as accidental.…”

“…Accidental or mechanical falls are terms used to describe falls due to slipping or tripping 20 while unexplained or non-accidental falls (AFs) cannot be explained by simple trips or slips, and can be caused by unrecognised syncope, seizures, and associated with loss of consciousness. 21 Assessment of older fallers is complicated by the fact that older patients regularly have amnesia for loss of consciousness 22 and falls due to syncope can therefore be incorrectly classified as accidental. Given the very different underlying causes of different falls types, it is important therefore to distinguish between the two when attempting to examine associations or identify causes of falls.…”

Falls, non-accidental falls and syncope in community-dwelling adults aged 50 years and older: Implications for cardiovascular assessment

“…In addition to shared cardiovascular associations there is a higher reported prevalence of depression in patients with both NAF and syncope[13, 14]. Despite the overlap, falls, NAF and syncope are generally reported separately, therefore studies which distinguish between them and examine them in more depth are required [15]. …”