Falls Flashcards
Why are the causes of falls?
Motor problems- gait or balance impairement, muscle weakness
Sensory impairement- peripheral neuropathy, vestibular dysfunction, vision impairment
Cognitive or mood ipairment- dementia, depression, delirium
Orthostatic hypotension
Polypharmacy or certain medicines (particularly psychotropic medicinesand opioids)
Impairment of activities on daily living
Environmental hazards- loose rugs, poor lighting, clutter
Age or comorbid illnesses
Footwear
Circulation
What might your GP recommend?
having a sight test if you’re having problems with your vision, even if you already wear glasses
having an ECG and checking your blood pressure while lying and standing
requesting a home hazard assessment, where a healthcare professional visits your home to identify potential hazards and give advice
doing exercises to improve your strength and balance (read about exercise for older adults)
What is a fall prevention programme?
Addressing the risk factors, advocating exercise (strength and balance training), reviewing medicines, assessing vision and home safety, with interventions as deemed as necessary.
What are the differentials for urgent differentials for a stroke.
Any history of sudden change in alertness of level of consciousness- cerebrovascylar (TIA, stroke, seizure), cardiovasculad (hypotension, bradycardia, tachycardia), medicatiom adverse egfects (especially newly prescribed) or imfection
New head trauma- concurrent use of anticoagulation or antiplatelet thefapy raises concern for a subdural haematoma
Pain suggesting a potential fracture- persistent pain, Inability to bear weight, any obvious anatomical abnormality should prompt a quick evaluation for a fracture, along with appropriate orthopaedic consultation. Consideration should be given to treating osteoporosis in parients with fractures associated with low impact falls
What is the approach to falls?
The approach to evaluating falls, and the risk of falls, remains under debate. One approach has been to identify factors intrinsic or extrinsic to individual patients.
Intrinsic factors may include:
Gait, balance, or musculoskeletal dysfunction
Foot problems (e.g., foot drop, calluses/bony abnormalities associated with neuropathy)
Cognitive, sensory or other neurological impairment
Age
Cardiovascular disease or other acute or chronic illnesses.
Extrinsic factors may include:
Environmental hazards Medicines and their side effects and interactions Substance abuse Restraints Use of a walking stick or frame Being housebound or living alone A prior history of falls. Events that precipitate the fall are then identified, for example, loss of footing, dizziness or syncope. However, many falls may be multi-factorial in origin. For example, a combination of environmental factors such as slippery floors and rugs, along with a proprioceptive problem, may place a patient at risk for loss of balance.
What associated symptoms concurrent with a fall should be assessed?
Any change in level or loss of consciousness
Cardiovascular symptoms- chest pain, palpitations, dizziness, vertigo or lightheadedness
Symptoms related to a change in position
Pain or neurological symptoms (headache, weakness, tingling, numbness or acute changes in mental status), which may indicate an underlying acute condition such as stroke
Medicines should be reviewed
What does the physical examination of someone with a fall involve?
The focus is on….
- factors contributing to a fall
- identification of any fall related injury (fracture/subdural haematoma from head trauma)
- fall risk factors which can be reduced/modified/corrected to prevent future falls
- cardiovascular examination
(Check rate and rythm)
Identify and characterise murmurs - musculoskeletal examination
Identify presence of contractures, joint crepitations
Identify reduction in range of motion (joint injuries, contractures from prolonged immobility), pain in range of motion (osteoarthritis)
Assess strength - neurolpgical examination
Assess mental status (mini mental state exam, MoCA montreal cognitive assesment)
Identify parkinsonism
Co ordination and cerebellar dysfunction
Rombergs
Dix Hallpike manouever
Vision exam
Gait exam
What bedside/ imaging investigations can you do for a person with a stroke?
X rays of bones should be performed if a patient has persistent pain or is unable to bear weight following a fall
CT/MRI should be done in a patient with a head injury
MRI spine if spinal disease is suspected
ECG should be performed in patients with syncope
Echocardiogram should be performed if there is a hx of heart disease or ECG data suggestive of structural heart disease
An electroencephalogram if seizure is suspected
Testing of vision, hearing, vestibular function should be carried out if indicated
Electromyography (peripheral neuropathy)
Dual energy X ray absorptiometry
What bloods should you do if someone has a fall?
FBC
Serum b12
Blood glucose (including glycated haemoglobin HbA1C) to assess level of control in diabetic pts, electrolytes, TSH are useful in evaluation of peripheral neuropathy or a change in mental status
What does normal gait involve?
The neurological system- basal ganglia and cortical basal ganglia loop
MSK system (must have appropiate tone and strength(
Effective processing of the senses- sight, sound, sensation (fine touch and propioception)
As individuals get older they are more likely to experience medical problems affecting these symptoms
What are the risk factors for falls in the elderly?
Lower limb muscle weakness Vision problems Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson's disease etc) Polypharmacy (4+ medications) Incontinence >65 Have a fear of falling Depression Postural hypotension Arthritis in lower limbs Psychoactive drugs Cognitive impairment
What is syncope?
Sudden, completely reversible loss of consciousness secondary to an acute reduction of cerebral perfusion which may last from several seconds up to minutes
The most frequent form is form is vasovagal syncope which is triggered by emotional stress or prolonged standing
What is cardiac syncope and what are the causes?
The hearts inability to meet an increased oxygen demand for example during exertion, it leads to reduced cerebral perfusion
Causes…
- sick sinus syndrome
- ventricular tachycardia
- atrioventricular block
- supraventricular arrythmias
What are the causes of syncopes?
Cardiac syncope
Reflex syncope
Orthostatic syncope (postural hypotension)
What are the clinical features of syncope?
Prodome= presyncope this differs depending on the type
Vasovagal syncope= impairement of senses (nausea, pallor, warmth, diaphoresis, lightheadedness, hyperventilation
Orthostatic- lightheadedness, nausea, dizziness
Cardiac- no prodome, they often suddenly fall
How do you treat syncope?
Treat the underlying condition
Arrythmogenic syncopes require a pacemaker, or treatment with antiarrythmic drugs
Patients with carotid sinus syndrome should be advised to avoid tight collars and remain hydrated
Patients with vasovagal syncopes can perform physiological counterstrategies (crossing the legs, tensing muscles, lying down, elevating legs) And avoiding triggers
Patients with orthostatic syncopes should have a sufficient intake of sodium and fluids, wear compression stockings, have there medications adjusted (like diuretics) and give fludrocortisone if they are unable to manage with non pharmalogical interventions
How do you diagnose postural hypotension?
Lying and standing blood pressure
This is best measured in the morning, with a manual blood pressure
Make the patient lie as flat as possible for 6 minutes, BP lying within 1 minute of standing and at 3 minutes
What is diagnostic of posturql hypotension
Drop of more than 20/10 with symptoms
Drop to <90 systolic
What are the symptoms of postural hypotension?
Dizziness, syncope, presyncope, occipital headache
What are presyncopal symptoms?
Feeling lightheaded, grey, something awful going to happen
What can dizziness mean to people?
Very different to each individual It can mean… - vertigo - presyncopal symptoms - unsteadiness - anxiety (heart racing, nausea etc..)
What are easy things you can do when an elderly patient presents with a fall?
Assesment of vision- reversible problems are common (refractive errors- needing glasses, cataracts, bifocals)
Assesment of baseline cognitive state
Postural BP readings
Medication review
What should you ask in a fall history?
What were they doing? How did the fall happen? How did they feel before the fall? Was there dizziness or lightheaded feeling? Did they lose conciousness? Did they have any cardiac symptoms? Are they weak anywhere? Has this happened before? Have they had any near misses before? What medications do they take- any sedatives, cardiac meds, anticholinergics, hypoglycaemics, opiates How do they normally mobilise?
What should examination of a fall focus on?
A functional assessment of their mobility- how do they mobilise,what with and what is their gait like?
Cardiovascular exam- ECG, lying snd standing blood pressue (immediate, 3, 5 minutes)
Neurological exam
MSK exam- assess their joints
List three fall risk assesment tools
Turn 180 degrees test
Timed up and go
Multifactorial risk assesment
What does the timed up and go test involve and how long does it take?
Time the person getting up from a chair without using their arms, walking 3 metres, turning around and returning to the chair and sitting down
A score of 15-25 seconds has been shown to indicate a high risk of falls in older people
What does the turn 180 degrees test involve?
Asking the person to stand up and step around until they are facing the opposite direction, if the person takes more than 4 steps then further assessment should be considered.
What are the interventions commonly offered by specialist falls services?
Strength and balance training — most likely to benefit older community-dwelling people with a history of recurrent falls or balance and gait deficit.
Home hazard assessment and intervention — should be offered to older people who have received treatment in hospital following a fall.
Vision assessment and referral.
Medication review — psychotropic drugs are reviewed, with specialist input if appropriate, and discontinued if possible.
