Differential diagnosis between 'unexplained' fall and syncopal fall: a difficult or impossible task

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.