Station 10 · Falls

Persona and manner

• Courteous, precise, understated; minimises; keen not to be 'a nuisance'. Terrified of losing independence — his late wife went into a care home after a fall and 'never came out'.
• He will admit the second fall only if asked directly, then downplay it.

Opening line — say this verbatim

• "Good morning. I'm just after my sleeping tablets — they've run out and I sleep dreadfully without them. I gather my daughter's been on the phone; she does fuss."

Volunteer freely if given the space

• Sleeps 'badly' — goes to bed at nine, up at two, three and five to pass water; the tablet 'knocks me out for a few hours'.
• The hip is 'still sore' from 'the tumble' three weeks ago.

Only if asked

• Second fall: Sunday night, getting out of bed to go to the toilet, 'the room swam' and his legs 'went'; lay on the floor twenty minutes before getting up using the bed. No injury. Did not tell anyone; the daughter noticed the bruise on his arm.
• Dizzy on standing 'most mornings' and after meals; worse since the summer. No chest pain; no palpitations; no blackouts (he 'may have gone a bit grey' — he is not sure whether he lost consciousness).
• Amitriptyline 'for the pins and needles in my feet' — 'I don't think it does much'. Zopiclone every night for 18 months. Takes doxazosin and tamsulosin both at night 'as told'.
• Weight down: 'I don't cook properly since Margaret died'; eats toast and soup; drinks one whisky nightly, 'sometimes two'.
• Eyesight: cataracts 'on the list'. Uses a stick outside, not inside. Bungalow; loose rug in the hall; no grab rails; bathroom light on a pull cord across the room.
• Mood: lonely; 'not depressed, just quiet'; sleeps to pass time. No thoughts of harming himself.
• Daughter lives 40 minutes away, visits weekly, wants him to have 'one of those alarm buttons' — he refuses because 'that's the beginning of the end'.

Ideas, concerns and expectations

• Idea: 'old age, and not sleeping'.
• Concern: being 'put in a home'; losing the car; his daughter 'taking over'.
• Expectation: zopiclone re-issued; no fuss.

Cues to deliver, timed

• Minute 1: 'she does fuss.'
• Minute 3: 'the room swam' — only if asked how the fall happened.
• Minute 7: 'that's how it started with Margaret' — when any support or referral is mentioned.

How to respond to the doctor's plan

• If the doctor takes a proper falls history, recognises postural hypotension caused by two alpha-blockers, a thiazide, amitriptyline and zopiclone, explains this honestly as the fixable cause, proposes a medication review (stop doxazosin — tamsulosin alone for prostate; consider stopping the thiazide; withdraw amitriptyline; taper zopiclone with sleep hygiene), checks lying and standing BP, arranges bloods, an ECG, a bone health assessment (FRAX/DXA, vitamin D), refers to the falls service and physiotherapy for strength and balance, addresses nutrition and alcohol, and frames all of it as the way to stay at home — and involves the daughter with his consent: he is quiet, then 'so the tablets are making me fall?' and 'if it keeps me in my own house, I'll do it.' He agrees to the alarm 'on trial'.
• If the doctor re-issues zopiclone: 'thank you, doctor' — he goes; the examiner does not.
• If the doctor says 'we need to think about whether you can manage alone': he closes down and asks to leave.

Examination findings if requested

• BP lying 142/80, standing at one minute 108/64 (symptomatic); pulse 76 regular; no murmur; gait: slow, wide-based, uses furniture; Timed Up and Go 18 seconds; bruise left forearm; cognition: alert, oriented, 4AT normal; feet: reduced vibration sense.

Do not

• Volunteer the second fall or the dizziness until asked directly.
• Refuse help if it is framed as staying at home; refuse it if framed as needing care.