Falls Flashcards
Define a fall
A fall is defined as an event which causes a person to, unintentionally, rest on the ground or lower level, and is not a result of a major intrinsic event (such as a stroke) or overwhelming hazard.
(GOV UK website)
Discuss what should be included in a falls history
Hx Presenting Complaint
- When did they fall?
- Where did they fall?
- Did anyone see them fall?
- Before:
- What were they doing?
- How did they feel before the fall?
- Any dizziness/light-headedness
- Any cardiac symptoms e.g. chest pain, palpitations
- Any weakness
- During:
- How did they fall?
- How did they land?
- Did they hurt themselves
- Did they lose consciousness? If so, for how long?
- Any tongue biting, incontinence?
- After:
- What happened after fall?
- How long were they on the floor?
- Could they get up on their own or did someone help you?
- Was there any confusion? If so for how long?
- Any weakness, speech difficulty, visual changes after the event?
- Could you resume normal activities?
PMH
- Any previous falls or near misses
- Any other current, previous or potential (i.e. currently being investigated for) medical problems
- Medications
- Allergies
FH
- Any medical conditions in family i.e. Cardiac history, strokes, epilepsy, neurological conditions
Social
- Who live with? How are they?
- Where live? Stairs?
- How do they usually mobilise?
- How do they manage?
- Any equipment/modifications at home
- ADLs
- Alcohol
- Smoking
- Recreational drugs
What medications are you particularly interested in when taking a falls history?
- Sedatives e.g. benzodiazepines
- Opiates
- Cardiac medications e.g. antihypertensives, beta blockers
- Anticholinergics
- Diabetic medications with hypoglycaemia risk
Briefly outline the different types of fall
- Syncopal vs non-syncopal
- Simple vs multifactorial
What do we mean by a simple fall?
What do we mean by a multifactorial fall?
- Simple fall: due to a chronic impairment of cognition, vision, balance, or mobility. (NICE CKS)
- Multifactorial: due to multiple factors
Should the term ‘mechanical fall’ be used?
No; all falls by definition have a mechanical element to them hence it doesn’t tell us anything about the cause of the fall
Define syncope
Transient loss of consciousness characterised by fast onset and spontaneous recovery. Caused by reduced perfusion pressure to brain. Usually self-limiting; being horizontal will increase/restore perfusion to brain
What is meant by pre-syncope?
Symptoms preceding a syncope e.g.:
- Light headedness
- Sweating
- Pallor
- Blurred vision
Outline the 3 broad categories of syncope and any sub-categories within each
-
Reflex/neurally mediated syncope
- Vasovagal
- Situational
- Carotid sinus massage
-
Orthostatic hypotension
- Drug induced
- ANS failure
-
Cardiac/cardiopulmonary disease
- Arrhythmias
- Structural
Describe the mechanism behind reflex/neurally mediated syncopes
A ‘stress’ of some form causes a sudden, transient change in autonomic efferent activity; inhibition of sympathetic system and increased output from parasympathetic system. Results in bradycardia and peripheral vasodilation leading to reduced cerebral perfusion pressure (below compensatory limits of cerebral autoregulation).
Subcategories of reflex/neurogenic syncope:
- Vasovagal: normally triggered by reduction in venous return due to prolonged standing, excessive heat or a large meal. Decreased venous return to ventricles causing them to vigorously contract in attempt to maintain cardiac output. Ventricular mechanoreceptors are then triggered causing vasodilation and bradycardia.
- Carotid sinus massage: increase pressure in carotid sinus hence baroreceptors interpret this as high BP so attempt to lower BP
- Situational: identifiable trigger leads to vasovagal reaction e.g. micturition, defaecation, coughing
State some potential causes of situational syncope
- Micturition
- Defaecation
- Coughing
- Sneezing
- Swallowing
- Weight lifting
Cardiopulmonary syncope’s can be due to two main reasons; state these and explain how they can lead to syncope
- Arrhythmias: leading to inadequate cardiac output e.g. AF, bradycardia
- Structural heart disease: inadequate cardiac output- often during exertion, e.g. aortic stenosis, hypertrophic obstructive cardiomyopathy
Discuss the pathophysiology of postural hypotension
When we stand, blood shifts from the chest to below the diaphragm. This fluid shift reduces venous return, which reduces the filling of the ventricles in the heart. This decrease in preload thereby reduces cardiac output. This causes a reduction in blood pressure.
The gravity-induced reduction in blood pressure is detected by baroreceptors in the aortic arch and carotid sinus. These baroreceptors trigger baroreflexes, including vasoconstriction and compensatory tachycardia in an attempt to restore blood pressure. There is an increase in sympathetic outflow and a decrease in vagal nerve activity; thereby reducing parasympathetic stimulation to the heart. The baroreceptors also send signals to the arterioles and venules in the circulatory system to increase total peripheral resistance. These measures overall work to increase and thus normalise blood pressure.
Postural hypotension occurs when these mechanisms to regulate blood pressure are impaired. The body is unable to maintain the same blood pressure on sitting up or standing.
Postural hypotension can occur due to one or more of the following:
- Failure of baroreflexes (autonomic failure)
- Volume depletion
- End-organ dysfunction
Causes of postural hypotension can be neurogenic or non-neurogenic; discuss the meaning of each
- Neurogenic: insufficient release of NA from sympathetic vasomotor neurones → limits vasoconstriction → body unable to normalise BP upon standing. Most often seen in disorders that cause autonomic dysfunction
- Non-neurogenic: hypotension arises from either hypovolaemia, cardiac failure or venous pooling
State some:
- Neurogenic
- Non-neurogenic
… causes of postural hypotension
Neurogenic
- T2DM
- Parkinson’s disease
- Small cell lung cancer
- Monoclonal gammopathies
Non-neurogenic
- Cardiac impairment e.g. aortic stenosis, MI
- Reduced intravascular volume e.g. dehydration, adrenal insufficiency
- Medicatons:
- Diuretics
- Alpha blockers
- Antihypertensives
- Insulin
- Levodopa
- TCAs
*Insulin, levodopa & TCAs can cause vasodilation and postural hypotension in predisposed patients
State some reasons why older people are more susceptible to postural hypotension
- More prone to hypovolaemia
- Increase in natriuretic peptides
- Reduction in renin, angiotensin & aldosterone
- Diminished first resposne
- Cardiovascular changes
- Decreased baroreceptor sensitivity
- Impaired alpha-1 adrenergic vasoconstriction
- More likely to be on medications that are associated with postural hypotension
- More likely to experience greater severity of symptoms from postural hypotension due to deconditioning from lack of exercise
State some exacerbating factors for postural hypotension
- Rising too quickly
- Prolonged motionless standing
- Dehydration
- Physical exertion
- Alcohol intake
- Fever (vasodilation)
- Time of day (early morning after nocturnal diuresis)
Syncope summary
State some factors that may predispose patients to falls
- Hx of falls
- Cognitive impairment
- Visual impairment
- Conditions affecting mobility or balance
- Muscle weakness (could be post-stroke)
- Parkinson’s
- Osteoarthritis
- Peripheral neuropathy (e.g. diabetes)
- Incontinence
- Cardiovascular
- Orthostatic hypotension
- Arrhythmias
- Valvular heart disease
- ACS
- Psychosocial
- Cognitive impairment
- Depression
- Alcohol misuse
- Medications/polypharmacy
- Sedatives e.g. benzodiazepines
- Opiates
- Anticholinergics
- Antihypertensives
- Hypoglycaemic medications
- Environmental
- Loose rugs/mats
- Poor lighting
- Wet surfaces
- Clutter/overcrowding
What examinations should you perform on someone who has fallen; for each outline why you would do it
- AMT-10/MMSE: assess for confusion
- Functional assessment of their mobility: how they mobilise, gait, aids
- Cardiovascular examination: including ECG, lying & standing BP immediate/3 mins/5 mins for cardiac abnormalities which may have caused cardiac syncope
- Neurological examination: assess for any weakness, balance abnormalities, vision, stiffness etc… could be cause of fall or could be consequence of fall
- MSK examination: assess joints for stiffness, assess for any tenderness, any deformities etc… could have been causative factor or consequence
What should a multi-factorial falls risk assessment include?
- History of falls.
- Gait, balance and mobility, and muscle weakness.
- Osteoporosis risk.
- Perceived impaired functional ability and fear relating to falling.
- Visual impairment.
- Cognitive, neurological, and cardiovascular problems.
- Urinary incontinence.
- Home hazards.
- Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example, drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants).
You must assess the risk of _____ in patients who fall
Osteoporosis
Assess using FRAX tool, then consider DEXA scan and decide if treatment needed. If pt >75yrs comes into hospital and fractures a long bone with minimal trauma they are often started on treatment for osteoporosis automatically without FRAX or DEXA.
Describe the timed up and go test
- Time the person getting up from a chair without using their arms, walking 3 metres, turning around, returning to the chair, and sitting down. If the person usually uses a walking aid, this can be used during the test.
- If take 12-15 seconds or more indicates high risk falls
Describe the turn 180 test
Ask the person to stand up and step around until they are facing the opposite direction. If the person takes more than four steps, further assessment should be considered
State 3 fall risk assessment tools
- FRAT (Falls risk assessment tool)
- STEADI (Stopping Elderly Accidents, Deaths and Injuries)
- Timed up & go test
- Turn 180 test
???ASK
What investigations might you consider/do for someone who has fallen? For each explain why you would do it
*Structure as bedside, bloods, imaging/other
Bedside
- ECG (and consider 24hr cardiac monitoring): ?arrhythmias
- Lying & standing BP immediate, 3 mins & 5 mins: ?orthostatic hypotension
- Urine dipstick &/or culture: assess for UTI
- Plasma glucose: assess hypoglycaemia
Bloods
- FBC: ?anaemia, ?infection
- CRP: infection
- U&Es: ?electrolyte imbalances leading to cognitive impairment, ?renal function
- Creatine kinase: ?rhabdomyolysis if long lie
- LFTs: baseline
- TFTs: thyroid issues can cause cognitive impairment
- Coagulation: ?bleeding risk
Imaging/other
- Echocardiogram: ?structural heart disease
- CT head: ?injury or ?cause of confusion
- Other x-rays: ?fractures
- DEXA scan: ?osteoporosis risk
What BP results indicate postural hypotension?
Postural hypotension, also known as orthostatic hypotension, is defined as a sustained reduction in systolic BP of at least 20mmHg, or diastolic BP of 10mmHg, that occurs within three minutes of standing
Discuss the management of falls
Management is via MDT and is focused on identifying and treating risk factors. Many falls are multifactorial hence may need to continue investigating for causes even once found one. Aspects of management include:
Describe some falls prevention strategies
Management is via MDT and is focused on identifying and treating risk factors. Many falls are multifactorial hence may need to continue investigating for causes even once found one. Aspects of management include:
-
Treating underlying condition if present e.g:
- Pacemaker
- Valve replacement
- Parkinson’s medications
- Antibiotics
- Managing incontinence
- etc…
- Medication review
-
Specialist MDT input:
- Physiotherapy: exercises, mobility aids, increase confidence
- Occupational therapy: adaptations at home, inspecting home and addressing environmental hazards
- Ophthalmology/optometry: correct visual impairment
Management of postural hypotension is centred around reducing venous pooling, increasing blood volume and increasing vasoconstriction; discuss the non-pharmacological & pharmacological aspects of treating postural hypotension
- Education
- Avoidance of exacerbating factors
- Not rising too quickly
- Not standing for too long
- Dehydration
- Hot environments
- Measures to reduce venous pooling:
- Compression stockings to reduce venous pooling
- Counter manoeuvres (e.g. toe raising, leg elevation, leg crossing)
- Measures to expand blood volume
- Drinking plenty
- Increasing salt intake
Pharmacological
- Fludrocortisone: synthetic mineralocorticoid that increases plasma volume
- Midodrine: short acting vasopressor useful in neurogenic postural hypotension
- Pyridostigmine: acetylcholinesterase inhibitor (has a vasoconstrictive only while standing. Thought to increase peripheral resistance)
With all aspects of management must also minimise supine hypertension
State some potential complications of falls
- Loss of confidence
- Loss of independence
- Social isolation
- Injury
- Cuts/grazes
- Bruises
- Fractures
- Head trauma e.g. subdural haemorrhage
- AKI due to rhabdomyolysis due to long lie
Discuss the role of the wider MDT in the assessment & management of falls
- Physiotherapy: exercises, mobility aids, increase confidence
- Occupational therapy: adaptations at home, inspecting home and addressing environmental hazards
- Ophthalmology/optometry: correct visual impairment
- Carers/HCAs: assist with transfers etc…
What BP results indicate postural hypotension?
Postural hypotension, also known as orthostatic hypotension, is defined as a sustained reduction in systolic BP of at least 20mmHg, or diastolic BP of 10mmHg, that occurs within three minutes of standing
