Elderly - Immobility and Falls Flashcards
What is the definition of a fall?
“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”
How common are falls?
- 30% of community dwellers > 65 years
- 40% of community dwellers > 80 years
- 50% of those in hospital/care facilities fall
What is the serious implications of falls?
- 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
Is there a link between falls and increasing age?
- OBVIOUSLY
What are common outcomes from falls?
- Injury (50% - soft tissue, fracture, subdural)
- Rhabdomyolysis (increase CK)
- Loss of confidence
- Inability to cope
- Dependency / ¯ QOL
- Carer stress
- Institutionalisation
- Terminal decline
Is it a diagnosis or a symptom?
It is a symptom
What are some common RF for falls?
- Muscle weakness
- History of falls
- Gait deficit
- Balance deficit
- Use assistive device
- Visual deficit
- Arthritis
What is the triad of factors why patients fall?
- Extrinsic factors
- Intrinsic factors
- Situational factors
What are the intrinsic factors?
- Gait and Balance problems
- Postural instability
- Vertigo
- Syncope
- Cardiac
- Vagal
- Other
- Chronic disease
- Neurological
- Musculoskeletal
- Visual problems
- Acute illness
- Cognitive disorder
- Vitamin D deficiency
What are the situational factors?
- Medications
- Alcohol
- Urgency of micturition
Which medications have increased fall risk?
- Antidepressants – TCAs > SSRIs
- Antipsychotics
- Anticholinergics/antimuscarinics
- Benzodiazepines
- Anti-hypertensives
- Diuretics
What are some extrinsic factors of falls?
- Inappropriate footwear
- Environmental hazards
- Uneven paving
- Carpets
- Walking aids
- Stairs
- Poor lighting
Postural instability: first, what allows us to have this stability?
- 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
How do we control balance?
- 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
How do we assess gait and balance?
- 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
Vertigo: what are some pathologies that can cause vertigo?
- Labyrinthitis
- Acute ear infection
- Benign paroxysmal positional vertigo
- Meniere’s
- Cerebellar/brainstem pathology
How do we assess if it is inner ear problem?
Dix-hallpike manoevre
What are the main four causes of syncope?
- Neurally mediated
- Orthostatic (postural) hypotension
- Cardiac arrhythmias
- Structural cardiac or cardiopulmonary disease
What are the types of neurological deficit syncopes?
- Vasovagal syncope (common faint)
- Carotid sinus hypersensitivity
- “situational syncope”
- acute haemorrhage
- cough, sneeze
- micturition
What are the different causes of orthostatic hypotension (postural hypotension)?
-
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
Which cardiac arrythmias can cause syncope?
- Sinus node dysfunction
- AT conduction system disease
- Paroxysmal supraventricular and ventricular tachycardias
- Inherited syndromes (e.g., long QT syndrome, Brugada syndrome)
Which structural cardiac/cardiopulmonary pathologies can cause syncope?
- Cardiac valvular disease
- Acute MI
- Obstructive cardiomyopathy
- Atrial myxoma
- Acute aortic dissection
- Pericardial disease/tamponade
- Pulmonary embolus/pulmonary hypertension
What is subclavian steal syndrome?
Need answered
How do we manage a transient loss of consciousness?
- History from patient
- Collateral History
- Examination
- 12 lead ECG
- Assess for red flags
- Consider further tests
What needs gathered from history of syncope?
- 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
What needs gathered from the collateral history of syncope?
- 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.
bugger
this
How does a falls patient need examined of syncope?
- Vital signs including lying and standing blood pressure
- Focussed neurological and cardiovascular examination
- Look for any injuries
When assessing syncope what needs to be looked out for on 12 lead ECG?
- 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
What are the red flags when assessing syncope?
- 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.
What factors would suggest a seizure?
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
What factors might suggest it is not a seizure?
- 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.
What are some factors of acute illness that may cause a fall?
- 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
What are some factors of dementia that are likely to increase fall risk?
- Impaired judgement
- Abnormal gait
- Affects visuo-special perception
- Affects ability to recognise and avoid hazards
Which website do we use to assess osteoperosis fracture risk?
FRAX website
What is sarcopenia?
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.
What is the mnemonic for sarcopenia?
- Diabetes/Insulin resistance
- Elderly
- Chronic Disease
- Lack of use
- Inflammation
- Nutritional Deficiency
- Endocrine dysfunction
What are the physical complications of immobility?
- Muscle wasting
- Muscle contractures
- Pressure sores
- Deep venous thrombosis
- Constipation / incontinence
- Hypothermia
- Hypostatic pneumonia
- Osteoporosis
Psychological implications of immobility? Social implications?
Psychological:
- Depression
- Loss of confidence
Social:
- Isolation
- Institutionalization
What are the learning outcomes for this lousy lecture?
- 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
