2 - Managing Falls Flashcards
What are some of the common causes of falls in older people?
Syncopal or Non-Syncopal (INTRINSIC OR EXTRINSIC)
- Trips on hazards
- Diabetes
- OA
- Stroke
- UTI
- Aortic stenosis
- Vasovagal episode
- Ruptured AAA
- Post micturition syncope
- Postural hypertension
- Hip OA
- Dehydration
- GBS
What questions do you need to ask in a history of a present complaint if someone presents with a fall?
Who? - Did anyone see so can take collateral history
When? - Night/Vision, did they get up out of a chair or go to the toilet
Where? - Home, shops, any trip hazards or flashing lights from TV
What? - Before, During, After
How? - How long on the floor for rhabdomyolysis, how many times before and in last 6 months, any serious injuries
What questions do you need to answer in the WHAT section of taking a history for a fall?
COLLATERAL HISTORY IMPORTANT
Before:
- Any symptoms before like lightheadedness?
- Chest pain?
- Trip?
During:
- Loss of consciousness?
- Incontinence, tongue biting, shaking, pale?
- Any injuries
After:
- Did they regain consciousness quickly?
- Could they get up without help?
- Any confusion or neurological symptoms?
What are the most common causes for loss of consciousness?
Syncope
Seizures
What is syncope and what are the symptoms of pre-syncope?
Transient loss of consciousness characterised by fast onset and spontaneous recovery due to reduced perfusion pressure in the brain. It is self limiting
- Light headedness
- Sweating
- Pallor
- Blurred vision
Why is it important to think about a seizure in an elderly patient if they have had loss of consciousness during a fall?
- Lots of new epilepsy diagnoses present at older age
- Seizures can be really subtle, e.g a twitch, so ask collateral if any abnormal movements
What are the three main categories of the causes of syncope?
- Reflex syncope
- Orthostatic hypertension
- Cardiac/Cardiopulmonary Disease
What is reflex syncope and some examples of this?
Brief loss of consciousness due to a neurologically induced drop in blood pressure as there is a drop in sympathetic innervation so heart rate goes down and so does cardiac output and blood pressure
- Vasovagal: prolonged standing, stress etc
- Situational: coughing, straining
- Carotid Sinus massage: tight collar
What is the definition of orthostatic hypotension?
Decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position
What is the pathophysiology behind orthostatic hypotension (postural) syncope? (baroreceptor reflex important)
- Standing up causes 500/800ml of blood to pool in legs
- Decrease in EDV and therefore CO and therefore BP
- Baroreceptors detect this and raise CO by increasing HR and contractility
- If baroreceptor reflex fails there is not an increase in CO so syncope as loss of perfusion pressure
What are some causes of baroreceptor reflex failure?
- Lose sensivity with age and hypertension
- Dehydration (so elderly need to drink regularly)
- Medications like antihypertensives
What are some causes of cardiac syncope?
DO ECG ON ANYONE PRESENTING WITH FALL
Why does aortic stenosis lead to syncope and why does it need to be detected and treated quickly?
- Narrowing of the aortic valve so heart has to work harder so if exercising can fail to adequately perfuse brain
- Mean survival is 2-5 years if untreated
What are some red flags in a patient’s history that would indicate their syncope is cardiac related?
- Exertional syncope
- Family history of cardiac disease or sudden cardiac death
- Preceding chest pain or palpatations
- PMH of heart disease, e.g ASD as a kid
- Abnormal ECG
What is the most common cause of a non-syncopal fall?
- Trips and slips
- Can be multifactoral e.g OA and diabetic nephropathy and tripping on hazard
- LOC following head trauma is still non-syncopal fall