Falls Flashcards
1
Q
What do falls cost the NHS per year?
A
£2.3 billion
2
Q
Causes of falls can be divided into extrinsic, intrinsic and combination.
What are some examples of extrinsic causes of falls?
A
Environmental hazards:
- Trip hazards e.g. carpets, wires etc
- Poor fitting footwear
- Walking aids/lack of – walking sticks, frames, three wheeled walker
3
Q
What are some examples of intrinsic causes of falls?
A
Patient factors:
- Joint pain/muscle weakness
- Postural hypotension
- Balance problems
- Peripheral neuropathy
- Dehydration
- Infection & delirium
- Collapse - neurological/cardiac
4
Q
What conditions can cause postural hypotension?
A
- Parkinson’s disease itself
- Levodopa used to treat Parkinson’s
5
Q
What medication is used to raise blood pressure in people with postural hypotension?
A
Fludrocortisone
6
Q
What conditions can cause balance problems?
A
- Parkinson’s disease
- Deconditioning (muscle wasting)
- Inner ear problems e.g. BPPV, Meniere’s disease, acoustic neuroma
7
Q
What conditions can cause peripheral neuropathy?
A
- Diabetes
- B12 deficiency
- Hypothyroid
- Alcohol
8
Q
Give some cardiac causes of a collapse
A
aortic stenosis, arrythmias
9
Q
Give some neurological causes of a collapse
A
Seizure
10
Q
What are some examples of combination causes of falls?
A
- Polypharmacy
- Incontinence/rushing to toilet
- Poor eye sight/inappropriate glasses
11
Q
Give some medications that can increase the risk of falls
A
- 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
12
Q
What are Z drugs?
A
A class of psychoactive drugs that are very benzodiazepine-like in nature e.g. zopiclone
13
Q
Give some examples of nephrotoxic medications (DIAMOND)
A
DIAMOND
- Diuretics
- IV contrast
- ACEi & antibiotics
- Metformin
- Opiates
- NSAIDs
- Digoxin
14
Q
What are some medications that should be reviewed in the elderly presenting with a fall?
A
- Blood thinners → warfarin, DOAC, LWMH
- Antihypertensives
- Opioids
- Nephrotoxic medications
15
Q
Why should opioids be reviewed in the elderly?
A
- increased side effects in the elderly
- constipation can make delirious
- morphine can accumulate and make drowsy
16
Q
When taking a falls history, what 2 questions can you initially ask?
A
- Why do you think you fell?
- Have you fallen before? If so, how many I the past 6 months?
17
Q
When taking a falls history, you can separate questions into the 5 W’s. What are these?
A
- When
- Where
- What
- Why
- How
18
Q
What questions can be asked in the when section?
A
- What time of day did you fall?
- What were you doing at the time?
19
Q
What questions can be asked in the where section?
A
In the house or outside?
20
Q
The what section can be split into ‘before’ ‘during’ and ‘after’. What questions can be asked in the ‘before’ section?
A
- 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
21
Q
What questions can be asked in the ‘during’ section?
A
- 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?
22
Q
What questions can be asked in the ‘after’ section?
A
- 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?
23
Q
Falls assessment:
A
24
Q
What bedside investigations would you request in a patient presenting with a fall?
A
- Vital signs
- Lying and standing BP
- Blood glucose
- 12-lead ECG
- Urinalysis
25
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**
26
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
27
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
28
What do ‘panda eyes’ and the ‘battles sign' indicate?
Basal skull fracture
29
What imaging would you request in a patient presenting with a fall?
* CXR
* AXR
* Head CT if indicated
* Joint imaging
30
What special tests would you request in a patient presenting with a fall?
* Urine culture (if symptomatic)
* 24 hour tape
* Echocardiogram
31
Examples of management of underlying causes of falls:
32
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
33
Describe some head CT features of a **subdural haematoma**
* Midline shift
* White is fresh blood – shaped like a banana/crescent
34
Describe some head CT features of an **extradural haematoma**
Blood shaped like a lemon
35
Do falls in the elderly typically cause extradural or subdural haematomas?
Subdural
36
Define syncope
A sudden, **transient** loss of consciousness due to **reduced cerebral perfusion** leaving to unresponsiveness and a loss of postural control.
37
Define presyncope
A feeling of lightheadedness that would lead to syncope if not correct.
38
Give some causes of syncope
* Hypotension
* Vaso-vagal’ – vagal stimulation
* Carotid sinus syndrome
* Pump problem – MI or ischaemia, arrythmia
* Outflow obstruction – AS
* PE
39
What is the main differential for syncope?
Seizure
40
Define orthostatic hypotension
A drop in BP \>20 systolic or \>10 diastolic (from lying to standing)
41
What situations can trigger orthostatic hypotension?
* Post prandial (after a big meal)
* Post exercise
* Night
* Warm environments
* Cough
* Defecation
* Micturition
42
What **medications** can cause postural hypotension?
* diuretics
* alpha & beta blockers
* antidepressants
* antipsychotic
* levodopa
* alcohol
43
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**
44
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**
45
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)
46
Give some triggers for carotid sinus syndrome
* Neck turning
* Tight collars
* Straining
* Post-prandial
* Prolonged standing
47
Give some risk factors for carotid sinus syndromw
* Age
* Atheroma in carotid arteries
* Beta blockers
* Digoxin
48
Diagnostic test for carotid sinus syndrome?
Tilt table
49
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)
50
What questions can be asked in the **how** section?
How many times have you fallen over in the last 6 months?
51
Describe a brief systems enquiry you can ask in a falls history
52
Some relevant PMH in a falls history
53
What are some important aspects of a SH to ask about in a falls history?
* Alcohol
* Support at home
* Mobility - walking aids, home adaptations
54
What is the Dix hall pike manoeuvre used to diagnose?
BPPV
55
Give some **cardiac** causes of falls
* Arrhythmias
* Orthostatic hypotension
* Bradycardia
* Valvular heart disease
56
Give some **neurological** causes of falls
* Stroke
* Peripheral neuropathy
57
Give some **urinary** causes of falls
* Incontinence
* Urinary tract infection
58
Give some **endocrine** causes of falls
Hypoglycaemia
59
Give some MSK causes of falls
* Arthritis
* Disuse atrophy
60
Give some ENT causes of falls
* Benign paroxysmal positional vertigo
* Ear wax
