Elderly - Immobility & Falls Flashcards
Basic rules for looking after older people:
- There will be more than ___ thing wrong
- Most illness will present __________
- One presenting complaint can lead to a ________ of diagnosis
- (much more interesting than single organ-ology clinics)
- Be an annoying toddler, keep asking ‘why?’
Usually present with one of the _________ syndromes
one
atypically
multitude
geriatric
what are the causes of falls?
what are the musculoskeletal causes of a fall?
Arthritis of weight bearing joints
Sarocopenia (syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength and it is strictly correlated with physical disability, poor quality of life and death)
Deformities of feet
what are the drugs causes of a fall?
Anti hypertensives
Sedatives, alcohol
And lots of others
what are the neurological causes of a fall?
Stroke, old or new
Parkinsonism
Dementia
Delirium, Ataxia (Seizure, TIA)
Other neurological conditions
what are the sensory causes of a fall?
Visual impairment
Inattention
(Hearing)
what are the cardiovascular causes of a fall?
Postural hypotension
Arrythmia
Heart failure (can make people to weak to stand up)
Aortic Stenosis
how doe sincontinence cause a fall?
Rushing to the toilet
how do drugs cause a fall? what do they decrease and what do they increase?
what are some culprit drugs that may cause a fall?
- Antihypertensive (easy to stop)
- Beta blocker
- Sedatives
- Anticholingerics
- Opioids
- Alcohol
Where are you seeing a perosn who has had a fall? and what are they likely to be presenting like?
- Falls clinic - Likely to be well patients, difficult and multifactorial falls
- A+E - More likely to be acutely unwell. May not be possible to do it all
- Assessing a hospital inpatient who has fallen - Very likely to be acutely unwell. Significant injury possible
The falls clinic is a full MDT - who is involved and what is their role?
- Nurse - Eye test, ECG, Lying and standing BP, incontinence questionarrie. MMSE
- Physiotherapist - Full assessment of gait and balance
- Doctor - Through history and examination, consider bone health and osteoporosis screening. (45 minutes +)
- MDT discussion - Treatment plan made
History in falls is the same as any other medical history - what would be involved?
- PC/HPC Detail of the fall. What were you doing. Who with? What happened? What happened next. How did you get up off the floor
- Collapse with no memory ?syncope or cognition
- Clear history of trip – think sensory (eyes, nerves)
- Palpitations preceding fall and no trip - think cardiac
- On turning – think postural instability
- Any ‘near misses’- unsteady on standing
- Syncope on exertion think aortic stenosis
systemic enquiry - Very important – in addition to usual things:
what informaiton should you get?
- Memory – Ideally ask a relative too
- Urinary symptoms (they won’t tell you if you don’t ask)
- Has walking changed recently
Drugs:
- Yes, I want to know everything. Especially over the counter antihistamines…
- Especially alcohol
what would you do on examination?
top to toe:
- Get patient on couch
- Head and arms:
- Cranial nerves, apart from smell. Check glasses
- Check neglect,
- Cerebellar signs
- Bradykineasia, ridigidity – signs of PD (parkinsons)
- Pulse, (BP) Heart sounds. Signs of heart failure and respiratory disease
- Kyphosis
- Abdominal examination (+PR if prostate)
see patient walking
what examination of the legs is required?
- Look at feet (footware, toenails).
- Check sensation, vibration sense, and proprioception – remember usually glove and stocking not dermatomal
- Co-ordination
Put shoes and socks back on. (You may need a shoehorn) Stand patient up:
- Romberg’s
- Assess gait
Match the gait to the pathology:
ataxic
Cerebellar damage
Ataxic is a wide gate, Cerebellar damage is caused by alcohol followed by stroke
Match the gait to the pathology:
Arthralgia
arthritis
trying not to put weight on one leg
Match the gait to the pathology:
Hemiplegic
stroke
stiff leg and not putting weight through it
Match the gait to the pathology:
Small steps, shuffling
(Vascular) parkinsonism
Shuffling gate is very common
Match the gait to the pathology:
high stepping
Peripheral neuropathy
scenario 1:
- It’s 2am in accident and emergency. You are the FY2. You have been asked to see Mabel. She is a 93 year old woman who has been waiting since 4pm.
- She was brought to A+E by ambulance after she was found at home by her carers having fallen.
- What do you do?
The patient in A+E who has fallen - what do they present like?
- Non-injured fallers are often left at home by paramedics and referred to community falls pathways- including falls clinic
- Patients in A+E are usually:
- Tired
- Injured
- In pain
- Unable to stand due to injury (so can’t assess gait)
- Systemically unwell
- Will need MDT assessment later
A falls assessment in A+E - History - what informaiton would you gather?
- First do ABDCE assessment and assess and treat any injury
- How did they fall? Did they trip over? What did they trip over?
- Long lie – check CK for rhabdomyolysis. Pneumonia and skin injury common as well
- Any other falls
- Any cognitive impairment (may be dementia or deliruim)
- Any incontinence
- Any syncope
- Any features of seizure (rare but happens)
- Are they drunk
- Look at ambulance sheet – about where they were, where they fell, what assessment at scene, they will normally of done a blood glucose
- Talk to relative (even if they seem to have capacity)
