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Drop attacks of the elderly
  1. James W Lance1,
  2. Sophie E Waller2
  1. 1 Emeritus Professor of Neurology, Prince of Wales Hospital, University of New South Wales, Sydney, New South Wales, Australia
  2. 2 Division of Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
  1. Correspondence to Professor James W Lance, University of New South Wales, Sydney NSW 2025, New South Wales, Australia; jimlance{at}

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Falls are frequent in the elderly, often leading to significant injury, transfer to residential care or death. Well-recognised risk factors include medications (particularly polypharmacy and the use of psychotropic agents), cognitive impairment, pre-existing gait disturbance, age-related muscular wasting (sarcopenia), dizziness and syncope (box 1). However, the cause of many falls, described by WB Matthews1 as ‘The Undiagnosable Blackout’, remains unexplained. When the fall is sudden and not associated with a perceptible loss of consciousness, it has been described as a drop attack.2

Box 1

Aetiology of drop attacks


  • Ménière’s disease — otolithic crisis

  • Superior canal dehiscence syndrome


  • Atherosclerotic vertebrobasilar insufficiency

Craniocervical junction pathology

  • Chiari I malformation

  • Posterior fossa tumour

  • Osteophytes resulting in brainstem compression


  • Epileptic

    • Atonic seizures

    • Myoclonic epilepsy

    • Focal motor seizures

  • Post-hypoxic myoclonus

  • Orthostatic myoclonus


  • Limb weakness

  • Knee instability


  • Cataplexy

  • Colloid cyst of the third ventricle

  • Syncope with unrecognised loss of consciousness

  • Cryptogenic

  • Functional

To our knowledge, this term was introduced by Sheldon2 in 1960, in describing elderly patients who fell, often with preservation of consciousness, but who were unable to rise for minutes, or sometimes hours. Greenwood and Hopkins3 later commented that some, although remaining conscious, appeared unable to generate sufficient antigravity muscle tension in time to prevent falling. A correlation between postural instability and the tendency to trip with age, found by Overstall et al,4 did not explain these patients’ inability to avoid a fall.

Sheldon2 had commented that older people frequently reported inability, after tripping, to preserve their balance—saying ‘once you’re going, you’ve got to go’. This remark reveals a pre-existing age-related problem with balance. He noted ‘they appear to fall under the unrestrained pull of gravity and the speed of descent is such that injuries are common…there is little doubt that the loss of power is associated with a loss of muscle tone – a flaccid state’. …

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  • Contributors JWL is the primary author, and contributed to the introduction, clinical observations, and all references to EMG recordings. SEW is the secondary author, and also contributed to the introduction and clinical observations, as well as the treatment review of myoclonus and the conclusion.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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