Elderly - falls and immobility Flashcards
What are the main causes of falls?
MSK causes Drugs Neurological Sensory CVS Generally unwell Incontinence
What MSK causes lead to falls?
Arthritis of weight bearing joints
Sarocopenia
Deformities of feet
What are neurological causes of falls?
Stroke - old or new Parkinsonism Dementia Delirium Ataxia
What are sensory causes of falls?
Visual impairment
Inattention
What are CVS causes of falls?
Postural hypotension
Arrythmia
Heart failure
Aortic stenosis
Why does incontinence lead to falls?
Rushing to the toilet
What drugs cause falls?
Anti-hypertensives Sedatives Alcohol Beta blockers Anticholinergics Opioids
Why do drugs cause falls?
Decrease blood pressure Decrease heart rate Decrease awareness Increase urine output Increase sedation Increase hallucinations Increase dizziness Increase QTc interval
How are patients likely to be after a fall in the falls clinic?
Likely to be well with a difficult and multifactorial fall
How are patients likely to be in A&E after a fall?
More likely to be acutely unwell
How are inpatients who have fallen in hospital likely to be?
Very likely to be acutely unwell, significant injury possible
What roles does the nurse have in the falls clinic?
Eye test
ECG
Lying and standing BP
Incontinence questionaire
What is the role of the physiotherapist in the fall clinic?
Full assessment of gait and balance
What is the role of the doctor in the falls clinic?
Thorough history and examination
Consider bone health and osteoporosis screening
What details should be found in the history of a fall?
If they remember the fall - syncope or cognition
Clear history of the trip
Palpitations preceding fall?
On turning? - postural instability
Any ‘near misses?’ - unsteady on standing
Syncope on exertion?
What should be asked about in systematic enquiry?
Memory
Urinary symptoms - might not tell you if you dont ask
Has walking changed recently?
What should be found in drug history other than the common causes?
Antihistamines
What neurological signs should be examined?
Cranial nerves except olfactory
Check for neglect
Cerebellar signs
Bradykinesia, rigidity
What non-neurological signs should be examined?
Pulse BP Heart sounds Kyphosis Abdominal examination
What should be examined in the legs?
Feet - footwear and toenails Sensation, vibration sense, proprioception Co-ordination Romberg's test Gait
What pathology would cause ataxic gait?
Cerebellar damage
What pathology would cause arthralgic gait?
Arthritis
What pathology would cause hemiplegic gait?
Stroke
What pathology would cause gait with shuffling small steps?
Parkinsonism
What pathology would cause high stepping gait?
Peripheral neuropathy
What are typical features of falls patients in A&E?
Tired Injured In pain Unable to stand due to injury - gait is difficult to assess Systemically unwell Will need MDT assessment later
What should be found in the history in A&E?
ABCDE assessment How did they fall - trip? Any other falls Assess cognition Incontinence? Syncope? Features of seizure? Drunk? Talk to relatives
What should be done in examination in A&E?
Neuro exam
Look at legs and try to assess gait
Full set of obs
What investigations should be done in A&E?
ECG
Bloods - B12, Folate, CK, TFTs
Check for delirium using 4AT
Consider CT head
What needs to be considered about a patient going home after a fall?
Can they go to the toilet on their own?
Can they get themselves food and drink between carer visits
Can they walk in A&E?
Could they summon help if they fell?
What immediate assessments are done for serious injuries?
Head injury and extradural haematoma Seizure C-spine injury Abdo injury Flail chest Pelvic injury Limb fracture
What would indicate immediate CT head?
GCS<13 Still confused after 2 hours Focal neurology Signs of skull fracture Seizure Vomiting Anti-coagulation
When should a joint be X-rayed?
If pain on moving joint
No deformity but pain on weight bearing
What can cause falls in inpatients?
Postural hypotension New medication Low blood glucose Getting more ill Delirium De-conditioning
What could lead to a patient lying for a long time after a fall?
Call bell out of reach
What do the nurses do after an inpatient falls?
Repeat risk assessment
Datix
Call family
Try and prevent further fall
