Falls Flashcards
What questions would you ask regarding when did you fall ?
- What time of day ?
- What were they doing at the time ? (Looking upwards - vertebrobasilar insufficiency, getting up from the bed - postural hypotension)
What questions would you ask regarding where did you fall ?
- In the house or outside?
What questions would you ask regarding what happened before/ during/ after the fall ?
- Before: any warning, was there any dizziness/ chest pain/ palpitations
- During: was there any incontinence or tongue biting ? Was there any loss of consciousness? Was the patient pale/flushed? Did the patient injure themselves? What part of the body had the first contact with the floor?
- After: what happened after the fall ? Was the patient able to get themselves up off the floor? How long did it take them ? Was the patients able to resume normal activity afterwards? Was there any confusion after the event ? Was there any weakness or speech difficulty after the event ?
What questions should be asked regarding why?
- Why did you think you may have fallen
What questions should be asked regarding how?
- how many times have you fallen over the last 6 months
What questions would you ask for a general systems review?
- Fatigue
- Weight loss
What questions would you ask for a CVS systems review?
- Chest pain
- Palpitations
What questions would you ask for a Respiratory systems review?
- SOB
- Cough
What questions would you ask for a Neurological systems review?
- Loss of consciousness
- Seizures
- Motor/ sensory disturbances
What question would you ask for a GI systems review?
- Abdominal pain
- Diarrhoea
- Constipation
What questions would you ask for a Urology systems review?
- Incontinence
- Urgency
- Dysuria
What questions would you ask for a MSK systems review?
- Joint pain
- Muscle weakness
What is significant in the Past Medical History for Falls?
- Visual/ Hearing impairment
- Diabetes
- Anaemia
- CVS disease
- Arrhythmias
- COPD
- Parkinson’s disease
- Peripheral neuropathy
- Stroke
- Dementia
- Recurrent UTI
- Incontinence
- Diverticulitis
- Chronic diarrhoea
- Alcoholic liver disease
- Arthritis
- Chronic pain
- Fractures
What is important to establish from the social history for falls?
- Alcohol intake
- support at home = friends/ family and carers
- mobility - use of mobility aids
What should you assess during clinical examination of a falls patient?
- Is the Patient orientated/ alert? Can the patient perform the timed up and go test? (getting up walking 3 meters and returning?
- Pulse/ BP? Bruits- carotids? Murmurs?
- Increased work of breathing? Coarse crackles (pneumonia)? Dullness on percussion (pleural effusion)
- Cranial nerve examination
- Power weakness (stroke)? Tone changes (stroke)? Reflexes (reduced = diabetic neuropathy, increased = UMN lesions)? Sensation reduced (UMN/LMN lesions)? Co-ordination impaired (Chronic alcohol misuse or cerebellar degeneration)?
- Abdominal tenderness? Organomegaly?
- Injuries associated with falls?
- Ear wax? tympanic membranes intact?
What Investigations would you do for Falls?
- Bedside: BP/HR/RR/Spo2/Temp
- Lying and Standing BP (orthostatic hypotension)
- Urine dipstick: infection, rhabdomyolysis
- ECG: Bradycardia, Arrhythmias
- Cognitive Screening: AMT - Cognitive Impairment
- Blood Glucose: Hypoglycaemia
- Bloods: FBC
- U+E: Dehydration, electrolyte abnormalities, rhabdomyolysis
- LFTs: Chronic Alcohol Use
- Bone Profile: Calcium abnormalities in malignancy, over-supplementation of Calcium
- Imaging: CXR, CT head (stroke, bleeds), ECHO (valvular heart disease - Aortic stenosis)
- Specialist - Tilt Table Test (Orthostatic hypotension), Dix-Hallpike test (BPPV), Cardiac Monitioring (48 hour tape)
What Investigations would you do for Falls?
- Bedside: BP/HR/RR/Spo2/Temp
- Lying and Standing BP (orthostatic hypotension)
- Urine dipstick: infection, rhabdomyolysis
- ECG: Bradycardia, Arrhythmias
- Cognitive Screening: AMT - Cognitive Impairment
- Blood Glucose: Hypoglycaemia
- Bloods: FBC
- U+E: Dehydration, electrolyte abnormalities, rhabdomyolysis
- LFTs: Chronic Alcohol Use
- Bone Profile: Calcium abnormalities in malignancy, over-supplementation of Calcium
- Imaging: CXR, CT head (stroke, bleeds), ECHO (valvular heart disease - Aortic stenosis)
- Specialist - Tilt Table Test (Orthostatic hypotension), Dix-Hallpike test (BPPV), Cardiac Monitioring (48 hour tape)
What are some of the Differential Diagnosis for falls?
- General: Mechanical (poor footwear/ visual impairments, Polypharmacy)
- CVS: Arrhythmias, orthostatic hypotension, bradycardia, valvular heart disease
- Neurological: Stroke, Peripheral Neuropathy
- Genitourinary: Incontinence, UTI
- Endocrine: Hypoglycaemia
- MSK: Arthritis, Disuse Atrophy
- ENT: BPPV, Ear wax
What is the Management for Gait Issues with falls?
- Physiotherapy
What is the managment for Visual Problems with Falls?
- Eye tests
- Ensures glasses are worn
What is the managment for Hearing Difficulties with Falls?
- Remove Earwax
- Hearing Assessment
What is the managment for Medication Reviews with Falls?
- Cut down any unnecessary medications
What is the managment for Alcohol intake regarding Falls?
- Alcohol cessation advice
- Alcohol service referral
What is the managment for Cognitive Impairment for Falls?
- Psychiatric team
What is the managment for Postural Hypotension for Falls?
- Review Medication
- Improve Hydration
What is the managment for Continence in Falls?
- Treat/ rule out infections
- Continence assessment
What is the managment for Footwear in Falls?
- Ensure good fitting footwear
What is the managment for Environmental Hazards in Falls?
- Turn on Lights
- Take up Rugs
What is the managment options for Falls?
- Gait
- Visual Problems
- Hearing Difficulties
- Medications Review
- Alcohol Intake
- Cognitive Impairment
- Postural Hypotension
- Continence
- Footwear
- Environmental Hazards
What are the three Fall Risk Assessment Tools?
- FRAT (falls risk assessment tool)
- Timed Up and Go test ( Time the person getting up from a chair without using their arms walking 3 metres, turning around, returning to their chair and sitting down)
- Time 180 test ( Ask the person to stand up and step around until they are facing the opposite direction)
What are the three Fall Risk Assessment Tools?
- FRAT (falls risk assessment tool)
- Timed Up and Go test ( Time the person getting up from a chair without using their arms walking 3 metres, turning around, returning to their chair and sitting down)
- Time 180 test ( Ask the person to stand up and step around until they are facing the opposite direction)
What is Osteoporosis?
- Osteoporosis is a condition where there is a reduction in the density of the bones
What are the risk factors of Osteoporosis?
- Older Age
- Female
- Reduced Mobility and Activity
- Low BMI
- RA
- Alcohol and Smoking
- Long term corticosteroids
- Other Medications: SSRI, PPIs, Anti-epileptics and Anti-oestrogens
- Post-menopausal women
- Oestrogen is protective against osteoporosis
What is the FRAX tool?
- Frax tool gives a prediction of the risk fo fragility fracture over the next 10 years.
- Looks at age, BMI, co-morbidities, smoking, alcohol and family history
- It gives results as a percentage 10-year probability of a: Major osteoporotic fracture and hip fracture
What is Bone Mineral Density?
- BMD is measured using a DEXA scan ( Dual-energy xray absorptiometry)
- Gives you a T score
- This forms the basis for the WHO classification of the level of osteoporosis
What is the WHO classification Score?
- More than -1 = Normal
- -1 to -2.5 = Osteopenia
- Less than -2.5 = Osteoporosis
- Less than -2.5 plus a fracture = severe osteoporosis
How would you go about assessing for osteoporosis?
Perform a Frax assessment on:
1. Women aged >65
2. Men aged >75
3. Younger Patients with risk factors such as previous fragility fractures, history of falls, low BMI, long term steroids, endocrine disorders and RA
After Frax assessment perform a BMD:
- low risk = reassure
- intermediate risk = offer DEXA scan and recalculate the risk with the results
- high risk = offer treatment
Frax outcome with BMD:
1. Treat
2. Lifestyle advice and Reassure
What is the Managment for Osteoporosis?
- Activity and Exercise
- Maintain a Healthy weight
- Adequate calcium + Vit D intake ( Calchichew- D3 = 1000mg of calcium and 800 units of Vit D)
- Avoiding Falls
- Stop Smoking
- Reduce Alcohol Consumption
What are some examples of Bisphosphonates?
- Alendronate 70mg
- Risedronate 35mg
- Zoledronic Acid 5mg
What are some of the side effects of Bisphosphonates?
- Reflux and oesophageal erosions - taken on empty stomach sitting upright for 30 minutes before moving or eating
- Atypical fractures
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
What are some other medical options if bisphosphonates are contraindicated?
- Denosumab = monoclonal antibody which works by blocking the activity of the osteoclasts
- Strontium Ranelate = stimulate osteoblasts and blocks osteoclasts, but increases the risk of DVT, PE and MI
- Raloxifene = used as secondary prevention only. It is a SERM that stimulates oetrogen receptors on the bone but blocks them in the breast and uterus
- HRT = considered in women who go through menopause early
What is the Follow Up for Patients who have Osteoporosis?
- Low risk patients only given lifestyle advice should be followed up within 5 years
- Patients on Bisphosphonates should have a repeat FRAX and DEXA scan after 3-5 years and a treatment holiday should be considered if there BMD has improved
