Falls Flashcards
What do falls cost the NHS per year?
£2.3 billion
Causes of falls can be divided into extrinsic, intrinsic and combination.
What are some examples of extrinsic causes of falls?
Environmental hazards:
- Trip hazards e.g. carpets, wires etc
- Poor fitting footwear
- Walking aids/lack of – walking sticks, frames, three wheeled walker
What are some examples of intrinsic causes of falls?
Patient factors:
- Joint pain/muscle weakness
- Postural hypotension
- Balance problems
- Peripheral neuropathy
- Dehydration
- Infection & delirium
- Collapse - neurological/cardiac
What conditions can cause postural hypotension?
- Parkinson’s disease itself
- Levodopa used to treat Parkinson’s
What medication is used to raise blood pressure in people with postural hypotension?
Fludrocortisone
What conditions can cause balance problems?
- Parkinson’s disease
- Deconditioning (muscle wasting)
- Inner ear problems e.g. BPPV, Meniere’s disease, acoustic neuroma
What conditions can cause peripheral neuropathy?
- Diabetes
- B12 deficiency
- Hypothyroid
- Alcohol
Give some cardiac causes of a collapse
aortic stenosis, arrythmias
Give some neurological causes of a collapse
Seizure
What are some examples of combination causes of falls?
- Polypharmacy
- Incontinence/rushing to toilet
- Poor eye sight/inappropriate glasses
Give some medications that can increase the risk of falls
- Antihypertensives e.g. ACEi, ARBs, CCBs, beta blockers
- Diuretics e.g. loops, K+ sparing, thiazide, thiazide-like
- Anti-anginals e.g. GTN spray
- Hypoglycaemic medications e.g. insulin, gliclazide
- Z drugs
What are Z drugs?
A class of psychoactive drugs that are very benzodiazepine-like in nature e.g. zopiclone
Give some examples of nephrotoxic medications (DIAMOND)
DIAMOND
- Diuretics
- IV contrast
- ACEi & antibiotics
- Metformin
- Opiates
- NSAIDs
- Digoxin
What are some medications that should be reviewed in the elderly presenting with a fall?
- Blood thinners → warfarin, DOAC, LWMH
- Antihypertensives
- Opioids
- Nephrotoxic medications
Why should opioids be reviewed in the elderly?
- increased side effects in the elderly
- constipation can make delirious
- morphine can accumulate and make drowsy
When taking a falls history, what 2 questions can you initially ask?
- Why do you think you fell?
- Have you fallen before? If so, how many I the past 6 months?
When taking a falls history, you can separate questions into the 5 W’s. What are these?
- When
- Where
- What
- Why
- How
What questions can be asked in the when section?
- What time of day did you fall?
- What were you doing at the time?
What questions can be asked in the where section?
In the house or outside?
The what section can be split into ‘before’ ‘during’ and ‘after’. What questions can be asked in the ‘before’ section?
- What were you doing at the time?
- Who found you?
- Did you have any warning you were going to fall (e.g. dizziness, leg pain, weakness, aura)?
- RED FLAGS → palpitations, SOB, chest pain
What questions can be asked in the ‘during’ section?
- Was there any incontinence or tongue biting?
- Was there any loss of consciousness?
- Were they pale/flushed?
- Did they injure themselves?
- What part of the body had first contact with the ground?
What questions can be asked in the ‘after’ section?
- What happened after the fall?
- How long were they on the ground for?
- Were they able to get themselves up? How long did it take them?
- Were they able to resume normal activities afterward?
- Was there any confusion after? Any head injury?
- Any pain?
- Any weakness or speech difficulty after?
Falls assessment:
What bedside investigations would you request in a patient presenting with a fall?
- Vital signs
- Lying and standing BP
- Blood glucose
- 12-lead ECG
- Urinalysis
How do you take a lying and standing BP?
- 1) Ask patient to lie down for 5 mins
- 2) Take BP 1
- 3) Ask patient to stand
- 4) Take BP 2 within 1st minute
- 5) Take BP 3 after 3 minutes
What bloods would you request in a patient presenting with a fall?
- FBC
- U&Es
- LFTs
- CRP
- CK
- Consider bone profile – calcium, phosphate, vitamin D
What would indicate the need for a head CT in a patient presenting with a fall?
- GCS 13 on arrival or <15 2 hours after
- Suspected skull fracture
- Sign of basal skull fracture – panda eyes, battles sign, haemotympanum, CSF fluid leak
- Post traumatic seizure
- Focal neurological deficit
- 2 or more vomits
- Patient on anticoagulants with head trauma
What do ‘panda eyes’ and the ‘battles sign’ indicate?
Basal skull fracture
What imaging would you request in a patient presenting with a fall?
- CXR
- AXR
- Head CT if indicated
- Joint imaging
What special tests would you request in a patient presenting with a fall?
- Urine culture (if symptomatic)
- 24 hour tape
- Echocardiogram
Examples of management of underlying causes of falls:
Give some complications of falls
- Osteoporosis
- Fractures:
- Neck of femur fracture (morality rate 33% over next year)
- Pubic rami fracture
- Head injury:
- Subdural haematoma
- Extradural haematoma
- Fear of falling
- Post fall immobilisation:
- Rhabdomyolysis
- DVT
- Pneumonia
- Pressure sores
- Delirium
- Pain
Describe some head CT features of a subdural haematoma
- Midline shift
- White is fresh blood – shaped like a banana/crescent
Describe some head CT features of an extradural haematoma
Blood shaped like a lemon
Do falls in the elderly typically cause extradural or subdural haematomas?
Subdural
Define syncope
A sudden, transient loss of consciousness due to reduced cerebral perfusion leaving to unresponsiveness and a loss of postural control.
Define presyncope
A feeling of lightheadedness that would lead to syncope if not correct.
Give some causes of syncope
- Hypotension
- Vaso-vagal’ – vagal stimulation
- Carotid sinus syndrome
- Pump problem – MI or ischaemia, arrythmia
- Outflow obstruction – AS
- PE
What is the main differential for syncope?
Seizure
Define orthostatic hypotension
A drop in BP >20 systolic or >10 diastolic (from lying to standing)
What situations can trigger orthostatic hypotension?
- Post prandial (after a big meal)
- Post exercise
- Night
- Warm environments
- Cough
- Defecation
- Micturition
What medications can cause postural hypotension?
- diuretics
- alpha & beta blockers
- antidepressants
- antipsychotic
- levodopa
- alcohol
Give some causes of postural hypotension
- Medications
- Volume depletion (e.g. D&V, dehydration)
- Sepsis
- Autonomic failure – Diabetes mellitus/Parkinson’s
- Adrenal insufficiency (e.g. Addison’s disease)
- Prolonged bed rest
Management of postural hypotension?
- Treatment of underlying cause
- Increase volume
- Modify behaviour e.g. get out of bed slowly in stages
- Compression stocking
- Caffeine
- Fludrocortisone
What is carotid sinus syndrome?
Hypersensitivity to carotid baroreceptor which causes either a) drop in BP or b) decrease in HR
- Drop in BP is a vasodepressor (drop in BP >50mmHg)
- Drop in HR is a cardioinhibitory (sinus sinus pause >3 seconds)
Give some triggers for carotid sinus syndrome
- Neck turning
- Tight collars
- Straining
- Post-prandial
- Prolonged standing
Give some risk factors for carotid sinus syndromw
- Age
- Atheroma in carotid arteries
- Beta blockers
- Digoxin
Diagnostic test for carotid sinus syndrome?
Tilt table
What questions can be asked in the why section?
Why do you think you fell? (e.g. may have tripped over a rug or started a new medication)
What questions can be asked in the how section?
How many times have you fallen over in the last 6 months?
Describe a brief systems enquiry you can ask in a falls history
Some relevant PMH in a falls history
What are some important aspects of a SH to ask about in a falls history?
- Alcohol
- Support at home
- Mobility - walking aids, home adaptations
What is the Dix hall pike manoeuvre used to diagnose?
BPPV
Give some cardiac causes of falls
- Arrhythmias
- Orthostatic hypotension
- Bradycardia
- Valvular heart disease
Give some neurological causes of falls
- Stroke
- Peripheral neuropathy
Give some urinary causes of falls
- Incontinence
- Urinary tract infection
Give some endocrine causes of falls
Hypoglycaemia
Give some MSK causes of falls
- Arthritis
- Disuse atrophy
Give some ENT causes of falls
- Benign paroxysmal positional vertigo
- Ear wax