As life expectancy increases and the geriatric population expands dramatically, falls have become a more substantial health risk. According to the US Center for Disease Control, falls are already the leading cause of injury-related death among Americans aged 65 years and older.1 The consequences of a fall include death and immediate incapacitating injuries such as hip fractures, and also a decline in functional status, nursing home placement and a higher usage of medical resources.2

The WHO has focused on eliminating the preventable causes of falls as one of the highest priorities in healthcare prevention for the 21st century.3 At the same time, efforts to reduce the cost of medical care by eliminating non-diagnostic medical testing and an increasing emphasis on implementing evidence-based medicine argue for more discriminate testing when evaluating falls.

The first step in reducing the number of falls is understanding the aetiology of unexplained falls. Cerebral hypoperfusion related to dysrhythmia, volume depletion or vagal tone, the mechanism for syncope, has also been described as the mechanism for near syncope. Recent data suggest not surprisingly that the likelihood of adverse outcome in both syncope and near syncope is the same.4 Up to 50% of patients presenting to the emergency department (ED) with syncope are sent home with an unknown aetiology of their syncopal event. Thirty to forty per cent of non-institutionalised adults over the age of 65 years fall each year, while an estimated 20% of these falls are currently unexplained.5 As many patients presenting with falls are either unable to recall the events surrounding their falls or are unwitnessed, one might hypothesise that the aetiology of these falls to be related to occult syncope or near syncope with cerebral hypoperfusion causing the fall.

In the current issue of Heart, Bhangu et al6 suggest that 20% of unexplained falls are due to dysrhythmia or unexplained syncope or near syncope. According to the US Census Bureau about 40 million adults were 65 years of age or older in 2010.7 Approximately, 60% of patients with a history of a fall in the previous year will have a subsequent fall.3 Assuming Bhangu and his colleagues are correct, using implantable loop recorders could explain the cause in over a million fallers annually in the USA alone, potentially preventing recurrent falls, improving health and functionality and substantially reducing medical cost in the geriatric population.

Prior studies of the use of outpatient monitoring in unexplained syncope have yielded mixed results. One study found that in patients receiving short-term dysrhythmia monitoring on ED discharge, the aetiology of the event was determined in <1%.8 Yet, as quoted by Bhangu, a study using implantable loop recorders in geriatric high-risk syncope (frequent syncope, with reduced quality of life or recurrent syncope with absence of premonitory symptoms or syncope occurring during high-risk activity such as driving) found a dysrhythmic aetiology in 20%–40% of this patient population. Bhangu has taken this one step further as the first study to wisely use event diaries along with implantable loop monitoring to help identify the aetiology of previously unexplained falls. Clearly, comprehensive use of both of these tools must be more frequently considered.

Often, treatment of injuries resulting from a fall does not include investigation of the cause of the fall. Along these lines, as the Bhangu study points out, 40% of older patients who fall have amnesia regarding loss of consciousness, and 60% of non-institutionalised geriatric patients do not have witnesses to their fall. The finding that up to 20% of patients with unexplained falls in reality have dysrhythmic aetiologies, suggests that perhaps a large group of this cohort of fallers fell secondary to previously unrecognised cerebral hypoperfusion or a syncopal type event.

While most ED studies use 7–30 days follow-up, Bhangu's study detected dysrhythmia within 9 months with a median of 45 days. Future studies of ED patients presenting following falls or syncope, particularly those with unknown aetiologies following their ED evaluation, might include longer term testing and follow-up.

Future directions must begin with the systematic use of event diaries along with implantable loop recorders and long-term follow-up after falls. While investigations should focus on early detection of occult dysrhythmia of falls to verify the utility of these interventions in preventing future falls in the elderly, Bhangu and his colleagues have taken a critical step in focusing our direction.