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Yr 3 - Elderly Medicine > Falls > Flashcards

Falls Flashcards

1
Q

What do falls cost the NHS per year?

A

£2.3 billion

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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
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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
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4
Q

What conditions can cause postural hypotension?

A
  • Parkinson’s disease itself
  • Levodopa used to treat Parkinson’s
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5
Q

What medication is used to raise blood pressure in people with postural hypotension?

A

Fludrocortisone

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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
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7
Q

What conditions can cause peripheral neuropathy?

A
  • Diabetes
  • B12 deficiency
  • Hypothyroid
  • Alcohol
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8
Q

Give some cardiac causes of a collapse

A

aortic stenosis, arrythmias

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9
Q

Give some neurological causes of a collapse

A

Seizure

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10
Q

What are some examples of combination causes of falls?

A
  • Polypharmacy
  • Incontinence/rushing to toilet
  • Poor eye sight/inappropriate glasses
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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
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12
Q

What are Z drugs?

A

A class of psychoactive drugs that are very benzodiazepine-like in nature e.g. zopiclone

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13
Q

Give some examples of nephrotoxic medications (DIAMOND)

A

DIAMOND

  • Diuretics
  • IV contrast
  • ACEi & antibiotics
  • Metformin
  • Opiates
  • NSAIDs
  • Digoxin
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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
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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
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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?
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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
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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?
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19
Q

What questions can be asked in the where section?

A

In the house or outside?

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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
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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?
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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?
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23
Q

Falls assessment:

A
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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
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25
Q

How do you take a lying and standing BP?

A
  • 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
Q

What bloods would you request in a patient presenting with a fall?

A
  • FBC
  • U&Es
  • LFTs
  • CRP
  • CK
  • Consider bone profile – calcium, phosphate, vitamin D
27
Q

What would indicate the need for a head CT in a patient presenting with a fall?

A
  • 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
Q

What do ‘panda eyes’ and the ‘battles sign’ indicate?

A

Basal skull fracture

29
Q

What imaging would you request in a patient presenting with a fall?

A
  • CXR
  • AXR
  • Head CT if indicated
  • Joint imaging
30
Q

What special tests would you request in a patient presenting with a fall?

A
  • Urine culture (if symptomatic)
  • 24 hour tape
  • Echocardiogram
31
Q

Examples of management of underlying causes of falls:

32
Q

Give some complications of falls

A
  • 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
Q

Describe some head CT features of a subdural haematoma

A
  • Midline shift
  • White is fresh blood – shaped like a banana/crescent
34
Q

Describe some head CT features of an extradural haematoma

A

Blood shaped like a lemon

35
Q

Do falls in the elderly typically cause extradural or subdural haematomas?

36
Q

Define syncope

A

A sudden, transient loss of consciousness due to reduced cerebral perfusion leaving to unresponsiveness and a loss of postural control.

37
Q

Define presyncope

A

A feeling of lightheadedness that would lead to syncope if not correct.

38
Q

Give some causes of syncope

A
  • Hypotension
  • Vaso-vagal’ – vagal stimulation
  • Carotid sinus syndrome
  • Pump problem – MI or ischaemia, arrythmia
  • Outflow obstruction – AS
  • PE
39
Q

What is the main differential for syncope?

40
Q

Define orthostatic hypotension

A

A drop in BP >20 systolic or >10 diastolic (from lying to standing)

41
Q

What situations can trigger orthostatic hypotension?

A
  • Post prandial (after a big meal)
  • Post exercise
  • Night
  • Warm environments
  • Cough
  • Defecation
  • Micturition
42
Q

What medications can cause postural hypotension?

A
  • diuretics
  • alpha & beta blockers
  • antidepressants
  • antipsychotic
  • levodopa
  • alcohol
43
Q

Give some causes of postural hypotension

A
  • 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
Q

Management of postural hypotension?

A
  • Treatment of underlying cause
  • Increase volume
  • Modify behaviour e.g. get out of bed slowly in stages
  • Compression stocking
  • Caffeine
  • Fludrocortisone
45
Q

What is carotid sinus syndrome?

A

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
Q

Give some triggers for carotid sinus syndrome

A
  • Neck turning
  • Tight collars
  • Straining
  • Post-prandial
  • Prolonged standing
47
Q

Give some risk factors for carotid sinus syndromw

A
  • Age
  • Atheroma in carotid arteries
  • Beta blockers
  • Digoxin
48
Q

Diagnostic test for carotid sinus syndrome?

A

Tilt table

49
Q

What questions can be asked in the why section?

A

Why do you think you fell? (e.g. may have tripped over a rug or started a new medication)

50
Q

What questions can be asked in the how section?

A

How many times have you fallen over in the last 6 months?

51
Q

Describe a brief systems enquiry you can ask in a falls history

52
Q

Some relevant PMH in a falls history

53
Q

What are some important aspects of a SH to ask about in a falls history?

A
  • Alcohol
  • Support at home
  • Mobility - walking aids, home adaptations
54
Q

What is the Dix hall pike manoeuvre used to diagnose?

55
Q

Give some cardiac causes of falls

A
  • Arrhythmias
  • Orthostatic hypotension
  • Bradycardia
  • Valvular heart disease
56
Q

Give some neurological causes of falls

A
  • Stroke
  • Peripheral neuropathy
57
Q

Give some urinary causes of falls

A
  • Incontinence
  • Urinary tract infection
58
Q

Give some endocrine causes of falls

A

Hypoglycaemia

59
Q

Give some MSK causes of falls

A
  • Arthritis
  • Disuse atrophy
60
Q

Give some ENT causes of falls

A
  • Benign paroxysmal positional vertigo
  • Ear wax

Yr 3 - Elderly Medicine (3 decks)

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