Elderly - Immobility and Falls

Question 1

What is the definition of a fall?

Answer 1

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”

Question 2

How common are falls?

Answer 2

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

Question 3

What is the serious implications of falls?

Answer 3

• 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

Question 4

Is there a link between falls and increasing age?

Answer 4

• OBVIOUSLY

Question 5

What are common outcomes from falls?

Answer 5

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

Question 6

Is it a diagnosis or a symptom?

Answer 6

It is a symptom

Question 7

What are some common RF for falls?

Answer 7

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

Question 8

What is the triad of factors why patients fall?

Answer 8

• Extrinsic factors
• Intrinsic factors
• Situational factors

Question 9

What are the intrinsic factors?

Answer 9

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

Question 10

What are the situational factors?

Answer 10

• Medications
• Alcohol
• Urgency of micturition

Question 11

Which medications have increased fall risk?

Answer 11

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

Question 12

What are some extrinsic factors of falls?

Answer 12

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

Question 13

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

Answer 13

• 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

Question 14

How do we control balance?

Answer 14

• 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

Question 15

How do we assess gait and balance?

Answer 15

• 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

Question 16

Vertigo: what are some pathologies that can cause vertigo?

Answer 16

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

Question 17

How do we assess if it is inner ear problem?

Answer 17

Dix-hallpike manoevre

Question 18

What are the main four causes of syncope?

Answer 18

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

Question 19

What are the types of neurological deficit syncopes?

Answer 19

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

Question 20

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

Answer 20

• 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

Question 21

Which cardiac arrythmias can cause syncope?

Answer 21

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

Question 22

Which structural cardiac/cardiopulmonary pathologies can cause syncope?

Answer 22

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

Question 23

What is subclavian steal syndrome?

Answer 23

Need answered

Question 24

How do we manage a transient loss of consciousness?

Answer 24

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

Question 25

What needs gathered from history of syncope?

Answer 25

* 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

Question 26

What needs gathered from the collateral history of syncope?

Answer 26

* 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.

Question 27

bugger

Answer 27

this

Question 28

How does a falls patient need examined of syncope?

Answer 28

* Vital signs including lying and standing blood pressure * Focussed neurological and cardiovascular examination * Look for any injuries

Question 29

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

Answer 29

* 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

Question 30

What are the red flags when assessing syncope?

Answer 30

* 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.

Question 31

What factors would suggest a seizure?

Answer 31

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

Question 32

What factors might suggest it is not a seizure?

Answer 32

* 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.

Question 33

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

Answer 33

* 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

Question 34

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

Answer 34

* Impaired judgement * Abnormal gait * Affects visuo-special perception * Affects ability to recognise and avoid hazards

Question 35

Which website do we use to assess osteoperosis fracture risk?

Answer 35

FRAX website

Question 36

What is sarcopenia?

Answer 36

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.

Question 37

What is the mnemonic for sarcopenia?

Answer 37

* **D**iabetes/Insulin resistance * **E**lderly * **C**hronic Disease * **L**ack of use * **I**nflammation * **N**utritional Deficiency * **E**ndocrine dysfunction

Question 38

What are the physical complications of immobility?

Answer 38

* Muscle wasting * Muscle contractures * Pressure sores * Deep venous thrombosis * Constipation / incontinence * Hypothermia * Hypostatic pneumonia * Osteoporosis

Question 39

Psychological implications of immobility? Social implications?

Answer 39

Psychological: * Depression * Loss of confidence Social: * Isolation * Institutionalization

Question 40

What are the learning outcomes for this lousy lecture?

Answer 40

* 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