Falls Flashcards
Should term mechanical fall be used
No
- all falls have a mechanical element to them
Fall history
What were they doing? How did the fall happen? How did they feel before the fall? Was there and dizziness or a lightheaded feeling? Did they lose consciousness? Did they have any cardiac symptoms? Are they weak anywhere? Has this happened before? Have they had any near misses before? What medication do they take? Think sedatives, cardiac medications, anticholinergics, hypoglycaemics, opiates that can contribute to falls. How do they normally mobilise?
Features of falls examination
Functional assessment of mobility - how do they mobilise - mobility aids - gait CVS exam - ECG - lying and standing BP - immediate, 3 and 5 minutes Neuro exam MSK exam - assess all joints
Fall assessment tools
- Time up and go test – time person getting up from chair without using arms, walking 3 metres, turn around, return to chair and sit down
• If usually use walking aid use it in the test
• Score of 12-15 seconds or more has been show to indicate high risk of falls - Turn 180° test
• Ask person to stand up and step around until they facing opposite direction
• If person takes more than four steps further assessment should be considered - Multifactorial assessment
• Identification of falls history
• Assessment of gait, balance and mobility, and muscle weakness
• Assessment of osteoporosis risk
• Assessment of older person’s perceived functional ability and fear relating to falling
• Assessment of visual impairment
• Assessment of urinary incontinence
• Assessment of home hazards
• CVS examination and medication review
Risk factors for osteoporosis
Reduced bone mineral density
- endocrine disease including DM, hyperthyroidism, hyperparathyroidism
- GI disorders that cause malabsorption
- Crohn's disease
- UC
- coeliac disease
- pancreatitis
- CKD
- chronic liver disease
- COPD
- menopause
- immobility
- BMI less than 18.5 kg/m2
Do not reduce BMD
- age
- oral corticosteroids
- smoking
- alcohol
- previous fragility fracture
- RA
- parental history of hip fracture
- SSRIs
- PPIs
- anticonvulsant drugs - carbamazepineAssessment of osteoporosis
Duel-energy X-ray absorptiometry (DEXA) - measures bone mineral density - high risk if -2.5 or less Assess for vitamin D deficiency and calcium intake - calcium intake of at least 1000mg/day
Drug mx for osteoporosis
Bisphosphonate
- alendronate 10mg OD/70mg once weekly
- risedronate 5mg OD/ 35mg once weekly
- give to postmenopausal women and men over 50 years who have DXA scan of -2.5 or less
If calcium intake adequate (700mg/day)
- 10 micrograms (400 international units) of vitamin D
- 1000mg calcium daily
Consider HRT to women who have premature menopause
Lifestyle advice for osteoporosis
Take regular exercise - improve muscle strength
- walking especially outdoors, strength training
Eat balanced diet
Stop smoking
Drink alcohol within recommended limits
Advice for taking bisphosphonates
Must only be taken on empty stomach - absorption affected by food, drink and other drugs
- risedronate taken before breakfast
- alendronate taken 30 mins before first food
Tablet must be swallowed whole with pint of plain water
Must be taken upright and must not lie down for at least 30 mins
For daily missed preparations advise person to skip missed dose and continue next day
For weekly preparations take missed dose on day that is remembered and continue to take tablet on normal day
Side effects of bisphosphonates
GI - nausea - dyspepsia - mild gastritis - abdo pain Bone, joint and muscle pain Oesophageal reactions (uncommon) - oesophagitis - oesophageal ulcers - oesophageal strictures - oesophageal erosions Osteonecrosis of external auditory canal (very rare)
Drug interactions of bisphosphonates
Calcium supplements of antacids - decreased absorption Food and drink - coffee and orange juice reduce bioavailability NSAIDs - increased risk of GI irritation
Contraindications of bisphosphonates
Hypocalcaemia Severe CKD - alendronate if eGFR < 35 - risedronate if eGFR < 30 Those unable to stand/sit upright for at least 30 mins Abnormalities of oesophagus Pregnant or breastfeeding women
Calculate osteoporosis fracture score
Estimate absolute risk when assessing risk of fracture
Complete risk score first before considering DXA
- FRAX
- QFracture
10 year fracture risk of 10% considered threshold for arranging of DXA
Side effects of antidepressants
Drowsiness
Blurred vision
Dizziness
Postural hypotension
Suggested action for antidepressants if a falls risk
Review indication
Stop if possible - may need to slow withdraw
Consider changing from TCA to SSRI
Side effects of antipsychotics
Postural hypotension Confusion Drowsiness Extrapyramidal symptoms Blurred vision
Suggested action for antipsychotics if a falls risk
Review indication
In long term use do not stop without specialist input
Avoid in delirium management
Side effects of antiemetics
Postural hypotension
Confusion
Drowsiness
Extrapyramidal symptoms
Suggested action for antiemetics if a falls risk
Review indication
Domperidone is suitable alternatives if extrapyramidal symptoms occur
Side effects of sedatives and hypnotics
Drowsiness - lasting into next day
Light-headedness
Confusion
Memory loss
Suggested action for sedatives/hypnotics if a falls risk
Stop if possible - may need slow withdrawal with long term use
Side effects of Parkinson’s drugs
Sudden daytime sleepiness Dizziness Insomnia Confusion Hallucinations Hypotension Arrhythmias Blurred vision Paraesthesia
Suggested action for Parkinson’s drugs if a falls risk
May not be possible to change
Seek specialist review
Assess for postural hypotension
Side effects of anticholinergic drugs
Dizziness Blurred vision Urinary retention Drowsiness Hallucinations
Suggested action for drugs with anticholinergic side effects if a falls risk
Review indication
Reduce dose or stop if possible
Side effects of muscle relaxants
Drowsiness
Dizziness
Hypotension
Suggested action for muscle relaxants if a falls risk
Withdraw slowly
Side effects of CVS drugs
Low blood pressure Postural hypotension Dizziness Tiredness Sleepiness confusion
Suggested action for CVS drugs if a falls risk
Assess for postural hypotension Review indication Review dose May not be possible to stop Consider alternatives to alpha-blockers
Side effects of opioids
Drowsiness Confusion Hallucinations Postural hypotension Dizziness Vertigo
Suggested action for opioids if a falls risk
Review dose - start low and go slow
Use pain ladder to avoid excess use
Side effects for anticonvulsants
Drowsiness
Blurred vision
Ataxia
Peripheral neuropathy
Suggested action for anticonvulsants if a falls risk
Consider indication - some for mood or pain
May need specialist review before changing
Consider vitamin D supplements if long-term
Who should a multifactorial risk assessment be performed on
Had 2 or more falls in the last 12 months
Has presented for medical attention following a fall
Has difficulty with walking or balance
