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Specialties > Elderly - Immobility and Falls > Flashcards

Elderly - Immobility and Falls Flashcards

1
Q

What is the definition of a fall?

A

š“Inadvertently coming to rest on the ground or other lower level without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force”

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2
Q

How common are falls?

A
  • 30% of community dwellers > 65 years
  • 40% of community dwellers > 80 years
  • 50% of those in hospital/care facilities fall
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3
Q

What is the serious implications of falls?

A
  • 1 fall-related death every 5 hours in UK
  • 1% of falls result in hip fracture, 1/4 elderly will die due to hip fracture
  • Accidental injuries cause more deaths in older adults than sepsis!
  • Mortality in the elderly who fall is 10x that of under 65s
  • Falls in the over 65s cost NHS £4.6 million a day
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4
Q

Is there a link between falls and increasing age?

A
  • OBVIOUSLY
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5
Q

What are common outcomes from falls?

A
  • Injury (50% - soft tissue, fracture, subdural)
  • Rhabdomyolysis (increase CK)
  • Loss of confidence
  • Inability to cope
  • Dependency / ¯ QOL
  • Carer stress
  • Institutionalisation
  • Terminal decline
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6
Q

Is it a diagnosis or a symptom?

A

It is a symptom

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7
Q

What are some common RF for falls?

A
  • Muscle weakness
  • History of falls
  • Gait deficit
  • Balance deficit
  • Use assistive device
  • Visual deficit
  • Arthritis
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8
Q

What is the triad of factors why patients fall?

A
  • Extrinsic factors
  • Intrinsic factors
  • Situational factors
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9
Q

What are the intrinsic factors?

A
  • Gait and Balance problems
    • Postural instability
    • Vertigo
  • Syncope
    • Cardiac
    • Vagal
    • Other
  • Chronic disease
    • Neurological
    • Musculoskeletal
  • Visual problems
  • Acute illness
  • Cognitive disorder
  • Vitamin D deficiency
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10
Q

What are the situational factors?

A
  • Medications
  • Alcohol
  • Urgency of micturition
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11
Q

Which medications have increased fall risk?

A
  • Antidepressants – TCAs > SSRIs
  • Antipsychotics
  • Anticholinergics/antimuscarinics
  • Benzodiazepines
  • Anti-hypertensives
  • Diuretics
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12
Q

What are some extrinsic factors of falls?

A
  • Inappropriate footwear
  • Environmental hazards
    • Uneven paving
    • Carpets
    • Walking aids
    • Stairs
  • Poor lighting
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13
Q

Postural instability: first, what allows us to have this stability?

A
  • Having enough cerebral perfusion: this can be altered by pathology and medications
  • Need vasomotor tone: this is reduced as we age
  • Static and dynamic balance: dynamic means being able to react to change
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14
Q

How do we control balance?

A
  • See, sense and feel where we are in the environement
  • Need to be processed in CNS: cerebrum, cerebellum, basal ganglia, brain stem
  • This then controls the muscle activity
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15
Q

How do we assess gait and balance?

A
  • Sitting to standing ability
  • Static standing balance: control of sway
  • Close thier eyes: Romberg test
  • Dynamic standing balance: functional reach, heel toe walking
  • Assess gait
  • Simple thing to do is timed up and go: get up from chair, walk 3m, then turn around and sit down: more than 12 secs to complete TUG is at increased risk of falling
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16
Q

Vertigo: what are some pathologies that can cause vertigo?

A
  • Labyrinthitis
  • Acute ear infection
  • Benign paroxysmal positional vertigo
  • Meniere’s
  • Cerebellar/brainstem pathology
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17
Q

How do we assess if it is inner ear problem?

A

Dix-hallpike manoevre

18
Q

What are the main four causes of syncope?

A
  1. Neurally mediated
  2. Orthostatic (postural) hypotension
  3. Cardiac arrhythmias
  4. Structural cardiac or cardiopulmonary disease
19
Q

What are the types of neurological deficit syncopes?

A
  • Vasovagal syncope (common faint)
  • Carotid sinus hypersensitivity
  • “situational syncope”
    • acute haemorrhage
    • cough, sneeze
    • micturition
20
Q

What are the different causes of orthostatic hypotension (postural hypotension)?

A
  • Autonomic failure
    • primary autonomic failure syndromes (e.g. pure autonomic failure, multiple system atrophy, Parkinson’s disease with autonomic failure)
    • secondary autonomic failure syndromes (e.g., diabetic neuropathy, amyloid neuropathy)
    • Drug (and alcohol)-induced orthostatic syncope
  • Volume depletion
    • Haemorrhage, diarrhoea, addisons
21
Q

Which cardiac arrythmias can cause syncope?

A
  • Sinus node dysfunction
  • AT conduction system disease
  • Paroxysmal supraventricular and ventricular tachycardias
  • Inherited syndromes (e.g., long QT syndrome, Brugada syndrome)
22
Q

Which structural cardiac/cardiopulmonary pathologies can cause syncope?

A
  • Cardiac valvular disease
  • Acute MI
  • Obstructive cardiomyopathy
  • Atrial myxoma
  • Acute aortic dissection
  • Pericardial disease/tamponade
  • Pulmonary embolus/pulmonary hypertension
23
Q

What is subclavian steal syndrome?

A

Need answered

24
Q

How do we manage a transient loss of consciousness?

A
  • History from patient
  • Collateral History
  • Examination
  • 12 lead ECG
  • Assess for red flags
  • Consider further tests
25
Q

What needs gathered from history of syncope?

A
  • Prodromal symptoms
  • ?Loss of consciousness
  • What are the last and first things they recall
  • Previous episodes
  • Injuries?
  • PMH
  • Family history – including of sudden death
  • Medications
26
Q

What needs gathered from the collateral history of syncope?

A
  • Circumstances of the event
  • Posture immediately before loss of consciousness
  • Appearance
  • Presence or absence of movement during the event (?limb-jerking)
  • Tongue-biting
  • Duration of the event (onset to regaining consciousness)
  • Presence or absence of confusion during the recovery period
  • Weakness down 1 side during the recovery period.
27
Q

bugger

A

this

28
Q

How does a falls patient need examined of syncope?

A
  • Vital signs including lying and standing blood pressure
  • Focussed neurological and cardiovascular examination
  • Look for any injuries
29
Q

When assessing syncope what needs to be looked out for on 12 lead ECG?

A
  • Innapropriate, persistant bradycardia
  • Long QT (corrected QT > 450 ms) and short QT (corrected QT < 350 ms) intervals
  • Abnormal T wave inversion
  • There are various others on the lecture
30
Q

What are the red flags when assessing syncope?

A
  • An ECG abnormality (those in bold)
  • Heart failure (history or physical signs)
  • Onset with exertion
  • Family history of sudden cardiac death (<40) years and/or an inherited cardiac condition
  • New or unexplained breathlessness
  • A heart murmur.
31
Q

What factors would suggest a seizure?

A

1 or more of:

  • A bitten tongue
  • Head-turning to 1 side during episode
  • No memory of abnormal behaviour that was witnessed before, during or after episode by someone else
  • Unusual posturing
  • Prolonged, simultaneous limb-jerking
  • Confusion after the event
32
Q

What factors might suggest it is not a seizure?

A
  • Prodromal symptoms that on other occasions have been abolished by sitting or lying down
  • Sweating before the episode
  • Precipitated by prolonged standing
  • Pallor during the episode.
33
Q

What are some factors of acute illness that may cause a fall?

A
  • Limited cerebral functional reserve
  • Hypoxia ® impaired central processing of information, or correction of imbalance
  • Usually secondary to acute illness
    • Infection: chest, urinary tract
    • Dehydration
  • Usually reversible
  • Often associated with delirium
34
Q

What are some factors of dementia that are likely to increase fall risk?

A
  • Impaired judgement
  • Abnormal gait
  • Affects visuo-special perception
  • Affects ability to recognise and avoid hazards
35
Q

Which website do we use to assess osteoperosis fracture risk?

A

FRAX website

36
Q

What is sarcopenia?

A

Degenerative loss of skeletal muscle mass (0.5–1% loss per year after the age of 50), quality, and strength associated with aging.

A component of the frailty syndrome.

37
Q

What is the mnemonic for sarcopenia?

A
  • Diabetes/Insulin resistance
  • Elderly
  • Chronic Disease
  • Lack of use
  • Inflammation
  • Nutritional Deficiency
  • Endocrine dysfunction
38
Q

What are the physical complications of immobility?

A
  • Muscle wasting
  • Muscle contractures
  • Pressure sores
  • Deep venous thrombosis
  • Constipation / incontinence
  • Hypothermia
  • Hypostatic pneumonia
  • Osteoporosis
39
Q

Psychological implications of immobility? Social implications?

A

Psychological:

  • Depression
  • Loss of confidence

Social:

  • Isolation
  • Institutionalization
40
Q

What are the learning outcomes for this lousy lecture?

A
  • Understand why falls are an important clinical presentation in the elderly
  • Learn to carry out a structured clinical assessment of falls aiming to identify modifiable risk factors.
  • Explain the importance of a multidisciplinary approach to assessment and management of falls.
  • Discuss clinical guidelines regarding assessment and management of falls
  • Understand the important overlap between falls and immobility
  • Outline the main conditions causing immobility and assessment of immobile patients

Specialties (23 decks)

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