[8] Falls Flashcards
What is syncope?
The medical term for fainting or passing out
What causes syncope?
A temporary drop in the amount of blood that flows to the brain
What is syncope characterised by?
- Fast onset
- Short duration
- Spontaneous recovery
What symptoms might be present before the loss of consciousness with syncope?
- Light-headedness
- Sweating
- Pale skin
- Blurred vision
- Nausea or vomiting
- Feeling warm
What are the important systems involved in balance?
- Vision
- Proprioception, or joint position sense
- Vestibular system
- Brain
- Effector mechanisms
How is vision involved in balance?
Required for spatial orientation
Give 4 things that affect vision?
- Cataracts
- Age-related macular degeneration
- Diabetic retinopathy
- Bifocal lenses
How is proprioception involved in balance?
Helps with orientation when eyes are shut or vision is impaired
Give 3 things that affect proprioception
- Sensory neuropathy
- Joint replacements
- Ageing
How is vestibular system involved in balance?
Helps with orientation in 3D
How does the vestibular system help with orientation in 3D?
By use of 3 semi-circular canals at 90 degrees to each other
What does the vestibular system respond to?
Responds rapidly to head movements
Give 3 things that affect the vestibular system
- Previous middle ear infections
- Meniere’s disease
- Ototoxic drugs
How does the brain help with balance?
Helps to integrated and co-ordinate the sensory input, and tells the body what to do in order to counteract any challenge to upright posture
Give 3 things that affect the brain
- Cerebrovascular disease
- Dementia
- Low blood pressure
What effector mechanism in particular affects balance?
Quadriceps muscle
How are effector mechanisms involved in balance?
They are the main mechanism the body uses to re-balance
Give 3 things that affect effector mechanisms
- Proximal myopathy
- Any neurological disease
- Disuse atrophy
Give 2 causes of proximal myopathy
- Steroid exposure
- Vitamin D deficiency
What is it important to check in a person who has fallen?
Postural cardiovascular system reflexes
Why is it important to check the postural cardiovascular system reflexes in someone who has fallen?
Because in someone who is vulnerable, a reduction in brain perfusion on standing can give rise to disequilibrium and so a fall
What investigations to check postural cardiovascular reflexes should all patients have following a fall?
- ECG
- Postural BP
What further investigation to check postural cardiovascular reflexes might some patients require?
Detailed assessment using tilt table
What is the baroreflex?
A homeostatic mechanism that helps to maintain BP at nearly constant levels
How does the baroreflex work?
It provides a rapid negative feedback loop, in which an elevated BP reflexively causes the HR to decrease and therefore the BP to decrease
What are baroreceptors found?
In the aortic arch and carotid sinus
What is the importance of baroreceptors being found in the carotid sinus?
Carotid sinus massage will cause a slowing of the pulse and a dramatic fall in BP
What is the main risk factor for falling?
History of falling, particularly in last 12 months
What are the other risk factors for falls?
- Age <80
- Female gender
- Low weight
- Dependancy in ADL
- Medical problems
- Medication and polypharmacy
- Inappropriate footwear
- Environmental factors
What medical problems increase the risk of falls?
- Orthostatic hypotension
- Diabetes mellitus
- Confusion and cognitive impairment
- Disturbance in vision
- Gait disorders
- Urinary incontinence
- Depression
- Muscle weakness
In addition to the risk factors for falls, what other risk factors should be looked at in falls?
Risk factors for fracture of proximal femur
What are the risk factors for fractures of proximal femur?
- Weak bones
- Poor self protection
What can cause weak bones?
- Osteoporosis
- Osteomalacia
- Paget’s disease of bone
- Mets to bone
What can cause poor self-protection?
- Lack of protective SC fat
- Neurological problems preventing reflex breaking or cushioning of fall
- Falls associated with LoC
- Motor and sensory problems
What can the causes of falls be divided into?
- Environmental factors
- Poor power and balance
- Neurological problems
- Alcohol
- Syncope
- Seizures
- Drop attacks
- Visual disturbance
- Medication
Give 3 environmental factors that can cause falls
- Loose rugs/mats
- Electricity leads
- Poor lighting
Give 5 neurological problems that can cause falls
- Strokes
- Parkinson’s disease
- Neuropathy, e.g. caused by diabetes
- Proximal myopathy
- Cognitive impairment
How can alcohol cause falls?
- Acute intoxication
- Consequences of chronic alcoholism
What consequences of chronic alcoholism can cause falls?
- Polyneuropathy
- Wernicke’s encephalopathy
- Korsakoff’s psychosis
What are drop attacks?
When the cause of fall is unknown, the event is unexpected, and there is no loss of consciousness
What are the categories of drugs that contribute to falls?
- Drugs of sedation
- Drugs causing hypotension
- Drugs causing reduced visual acuity/blurred vision
- Drugs causing muscle weakness
- Drugs causing ataxia
Why are drugs of sedation an important contributor to falls?
Because elderly patients are susceptible to CNS side effects of drugs, including excessive sedation, increased body sway, and slowing of reaction time
Give 6 drugs of sedation
- Benzodiazepines
- TCAs
- Anti-psychotics
- Barbiturates
- Sedating anti-histamines
- Analgesic opiates
Give 2 examples of benzodiazepines
- Diazepam
- Lorazepam
Give 2 examples of TCAs
- Amitriptyline
- Trazodone
Give 2 examples of anti-psychotics
- Promazine
- Haloperidol
Give an example of barbiturates
- Barbiturates
Give 2 examples of sedating anti-histamines
- Chlorphenamine
- Hydroxyzine
Give 2 examples of analgesic opiates
- Codeine
- Morphine
Why are drugs causing hypotension an important contributor to falls?
Orthostatic blood pressure control is already impaired in the elderly, and they are more likely to suffer drug-induced postural hypotension, which can lead to light-headedness and falls
Give 11 drugs causing hypotension
- Diuretics
- Beta-blockers
- ACE inhibitors
- Alpha blockers
- Calcium channel blockers
- Vasodilators
- Urinary anti-muscarinics
- Phenothiazines
- TCAs
- Anti-Parkinsonian drugs
- ACh inhibitors
Give 2 examples of diuretics
- Furosemide
- Bendoflumethiazide
Give 2 examples of beta-blockers
- Atenolol
- Propanolol
Give an example of ACE inhibitors
Valsartan
Give 2 examples of alpha blockers
- Doxazoasin
- Prazosin
Give 3 examples of alpha blockers
- Nifedipine
- Amlodipine
- Verapamil
Give 2 examples of vasodilators
- Hydralazine
- Nitrates
Give 2 examples of urinary anti-muscarinics
- Oxybutunin
- Tolterodine
Give 2 examples of phenothiazine
- Promazine
- Chlorpromazine
Give an example of an anti-Parkinsonian drug
LevoDOPA
Give 2 examples of ACh inhibitors
- Donepezil
- Rivastigmine
Give 2 examples of drugs causing reduced visual acuity/blurred vision
- Pilocarpine eyedrops
- Anti-cholinergics
Give an example of an anti-cholinergic
Procyclidine
Give 2 examples of drugs causing muscle weakness
- Baclofen
- Dantrolene
Give 2 examples of drugs causing ataxia
- Carbamazepine
- Phenytoin
What is the role of polypharmacy in falls?
A study has shown there is a 14% increase in falls with each additional medication beyond a 4-medication regime
What should the examination include in falls?
- Functional
- Cardiovascular
- Neurological and locomotor
- Mental state
- Eyes
What should be included in a functional examination in falls?
Timed up and go test
What happens in a timed up and go test?
You should ask the patient to stand from chair, walk, turn around, walk back, and sit back down
What should be included in the cardiovascular examination in falls?
- Pulse
- Lying and standing BP
- Auscultation of heart
What postural drop is significant?
More than 20mmHg systolic
What should you look for in the neurological examination in falls?
Signs of;
- Stroke
- Peripheral neuropathy
- Parkinson’s disease
- Vestibular disease
- Myelopathy
- Cerebellar degeneration
- Cognitive impairment
What might be helpful when assessing the mental state of a patient with falls?
MMSE
What should the examination of the eyes include if there is suggestion of poor eyesight?
Should at least include reading of the Snellen chart
What routine investigations should be done in a falls patient?
- FBC
- Vitamin D
- B12 and folate
- U&Es
- ECG
- Glucose
- Calcium and phosphate
- TFTs
What will further investigations in falls patients be directed by?
Suspected cause
What further investigations may be done in falls patients?
- 24 hour ECG
- Echocardiogram
- Head-up tilt table testing
What are the potential consequences of falls?
- Trauma
- Long lie
- Psychological
- Social
What trauma might result from falls?
- Soft tissue injury
- Fragility fractures
- Joint dislocation
- Subdural haemorrhage
What might result from long lie after falls?
- Hypothermia
- Pressure related injury
- Dehydration and AKI
What are the potential psychological consequences of falls?
Ongoing concern about falling and limitation of performance of daily activities
What problems are the psychological consequences of falls associated with?
- Activity limitation
- Participation restriction
- Low quality of life
- Anxiety and depression
What are the social consequences of falls?
- Social isolation
- Carer strain
- Institutionalism
Why might falls lead to social isolation?
Due to avoidance of activities, often associated with fear of falling
What is the link between falls and institutionalism?
The likelihood of older people requiring admission to care home increase with number and severity of falls recorded
What is essential in the assessment and management of falls?
An integrated approach
Who should be offered a multi-factorial falls risk assessment?
Older people who;
- Present for medical attention because of a fall
- Report recurrent falls in the past year
- Demonstrate abnormalities in gait/balance
Who should perform the multi-factorial falls risk assessment?
A HCP with appropriate skills and experience, normally in the setting of a specialist falls service
What might a multi-factorial falls risk assessment involve?
Assessment of;
- Falls history
- Gait, balance, and mobility, and muscle weakness
- Older persons perceived functional ability and fear relating to falling
- Visual impairment
- Cognitive impairment and neurological examination
- Urinary incontinence
- Home hazards
- Cardiovascular examination and medications review
What is included in the general approach to minimising falls?
- Strength and balance training
- Environmental assessment
- Medical review
What does strength and balance training following a fall involve?
A physiotherapist making an assessment of an individual and then prescribing a tailored course of therapy aimed at improving strength and balance
What might therapy to improve strength and balance after a fall involve?
Variety of activities, including CVS training, strength training, and balance training
How long does therapy to improve strength and balance after a fall take?
Usually lasts many weeks, with at least 50 hours required
Who leads the environmental assessment after a fall?
Occupational therapist
What is involved in the environmental assessment after a fall?
Assessment of individual and their environment to identify ay potential hazards, by visiting the individual in their home
What might the outcome of the environmental assessment after a fall be?
- Suggests improvements to environment
- Provide assistive equipment
What assistive equipment might be provided after a fall?
- Bath aids, e.g. bath boards and seats, electrical bath lifts
- Toilet lifts or commodes
- Aids to help with dressing
- Grab rails
What is the medical review aimed at assessing?
- Diagnose medical reason for falls
- Optimise management of conditions contributing to falls
- Bone health assessment
- Medication review
What interventions into falls have NICE recommended as being effective?
- Strength and balance training
- Home hazard intervention and follow up
- Medication review
- Cardiac pacing where indicated
What is primary prevention for falls aimed at?
Preventing falls in people who have not fallen
What might primary prevention for falls include
- Increasing exercise and physical activity
- Reviewing medication
- Changing adverse environmental factors
- Improving management of medical conditions
