Drop attacks

Definition. A drop attack is a sudden, unexpected fall to the ground WITHOUT loss of consciousness and without warning (no prodrome), with preserved awareness throughout, occurring in the absence of dizziness or vertigo. The patient characteristically says "my legs just gave way", and there is no post-event confusion. Recovery is usually immediate, although some patients are unable to rise for a period despite full alertness. It is commonest in older women, and is a descriptive term rather than a diagnosis — a syndrome requiring a cause to be sought.

The central diagnostic problem. The most important point is that many "drop attacks" are in fact unrecognised syncope — in the elderly, syncope frequently presents as a history of falls or drop attacks with no recall of loss of consciousness, because retrograde amnesia for the blackout is common. Carotid sinus syndrome in particular is a modifiable risk factor for non-accidental falls in older adults (SAFE PACE), and is not confined to patients who describe fainting with neck movement. Therefore every unexplained drop attack in an older person must be investigated as possible syncope until proved otherwise.

Causes.

Evaluation. Obtain a meticulous history with an eyewitness account, focusing on posture and activity at onset, any prodrome, whether awareness was truly preserved, duration, ability to rise, injury pattern and drug history. Facial and knee injuries suggest a genuinely unprotected fall, which supports syncope or an atonic mechanism rather than a mechanical trip. Examine the cardiovascular system (murmurs, pulse, lying and standing blood pressure at 1 and 3 minutes), the neurological system (gait, tone, power, cerebellar signs, cervical spine, cognition) and perform a gait and balance assessment. Investigations: 12-lead ECG, full blood count, urea, electrolytes, creatinine, glucose, calcium, vitamin D and B12, thyroid function; echocardiography if a murmur is present; carotid sinus massage and head-up tilt testing; prolonged ambulatory monitoring or an implantable loop recorder for infrequent attacks; and MRI brain and cervical spine if there are neurological features. Assess bone health and fracture risk in all.

Management. Treat the identified cause — pacing for a documented cardioinhibitory carotid sinus syndrome (which reduces falls) or for high-grade heart block, valve intervention for aortic stenosis, antiepileptic therapy for atonic seizures, shunting for normal pressure hydrocephalus, and surgery for cervical myelopathy. Where no cause is found — as is common — manage as an unexplained fall using a multifactorial falls intervention: medication review with withdrawal of sedatives, antihypertensives and anticholinergics; strength and balance training; vitamin D and calcium; treatment of visual impairment; footwear and home hazard assessment; and osteoporosis treatment to reduce fracture risk. Teach the patient and carer how to get up from the floor and how to summon help, and consider a personal alarm or pendant, since a long lie causes rhabdomyolysis, pressure injury, hypothermia and loss of confidence. Address the resulting fear of falling, which itself causes activity restriction and further deconditioning.

The 2022 World Guidelines for Falls Prevention and Management in Older Adults (a joint initiative of the geriatric societies, published in Age and Ageing and carried into current practice) formally abolish the artificial separation between "falls" and "syncope" clinics by recommending a single stratified pathway: every older person is assessed as low, intermediate or high risk, and anyone with an unexplained fall, a fall with injury, or recurrent falls is placed in the high-risk group requiring a full multifactorial assessment that explicitly includes cardiovascular evaluation for syncope, orthostatic hypotension and carotid sinus syndrome. The guideline also stresses de-prescribing of fall-risk-increasing drugs (FRIDs), exercise incorporating balance and strength training as the single most effective intervention, and concurrent assessment of bone health and fracture risk — which together is the correct modern framework for the patient presenting with drop attacks.