Falls

Question 1

1. How do we define a fall in geriatrics?
2. What are the main implications of falls for patients?
3. Why are elderly people more likely to fall?

Answer 1

1. An UNEXPECTED event in which the participant comes to rest on the ground, floor or lower level.
2. Likely injury, fractures, hospitalisation, nursing home admission, Falls lead to functional decline, social isolation, loss of confidence, morbidity and mortality.
3. Reduced reaction time, poorer vision, poorer cardiorespiratory health, loos of muscle mass and function, sensation and proprioception decreased.

Question 2

1. Identify some extrinsic factors contributing to falls.

2. What types of drugs increase the risk of falls?

Answer 2

1. Medications, tripping hazards, inappropriate lighting, inappropriate footwear and use of walking aids.
2. Psychotropic drugs, antihypertensives,

Question 3

1. What type of hypotension is a common cause of falls?

2. How might orthostatic hypotension be managed?

Answer 3

1. Orthostatic hypotension
2. Stop culprit drugs – diuretics, anti-hypertensives, SNRIs, Dopamine agonists, pregabalin…
   Encourage patient to avoid sudden changes in movements.
   ‘Water loading’
   Increase salt in diet
   Compression stockings
   Keep legs elevated when sitting/sleeping.
   Calf muscle exercises when standing for prolonged periods

Question 4

1. What questions may you include when investigating a fall?

Answer 4

1. Where did the fall occur?
   Events preceding/during/after fall?
   Any loss of consciousness?
   Any injury – in particular any head injury?
   Were they able to get up? [Community alarm?]
   How long did they lie?
   Any previous falls? What was different about today? Did they have usual aid?
   Fear of falling?
   Systemic review - ?concurrent illness

Question 5

1. What would you look for in an examination following a fall?
2. What investigations might you carry out?

Answer 5

1. Vital signs, signs of injury, cardio for BP and murmurs, neuro exam for signs of stroke/peripheral neuropathy/gait. Snellen chart to check visual acuity.
2. ECG, postural BPs, blood sugar, CT brain, echocardiogram.

Question 6

1. When is an urgent CT scan recommended?

Answer 6

1. Drop in GCS <13
Drop in GCS <15, 2 hours after injury
Open or depressed skull fracture suspected
Signs of skull base fracture (panda eyes/haemotympanum/CSF leak from nose or ears/Battle’s sign
Post-traumatic seizure
New focal neurology
2 or more episodes of vomiting
2.

Question 7

1. What is the purpose of the carotid sinus?

2. What is CSS? Define it.

Answer 7

1. Carotid sinus is an area of dilatation in the ICA which contains a number of baroreceptors.
   In order to maintain homeostasis, as a response to increased pressure within the vessel wall the resultant effect is peripheral vasodilation and reduction in heart rate.
2. Carotid Sinus Syndrome, CSS is a condition of abnormal activation of this structure which leads to symptoms secondary to cerebral hypoperfusion

Question 8

1. How is CSS investigated?
2. What does a positive finding look like?
3. If there is a negative finding what should be done?

Answer 8

1. Carotid receptor massage
2. Cardio-inhibitory CSS – pause in HR >3 seconds.
   Vasodepressor CSS – drop in systolic BP of 50mmHg
   Mixed CSS – simultaneous combination of both.
3. Tilt-table CSM with patient upright because more sensitive.