FALLS Flashcards
Prevalence of falls in the elderly population?
30% of those aged 65 and over have a fall at least once each year
50% in people aged 80 and over
Risk factors for falls?
History of falls
Conditions affecting mobility or balance - arthritis, diabetes, stroke, syncope, parkinsons etc
Conditions e.g. muscle weakness, visual impairment, alcohol misuse, poor balance
Fear of falling
Depression
Polypharmacy or drugs causing postural hypotension
Environmental hazards - loose rugs, mats, poor lighting, uneven surfaces, wet surfaces, loose fittings, poor footwear
Risk of having a second fall within 1 year of the first fall?
66%
Physiological changes of ageing that increase risk of falls?
Degradation of vestibular system
Proprioception
Eyesight
Sarcopenia
Decay of postural reflexes
Loss of autonomic reflexes
3 ways of categorizing falls?
Simple ‘one off’ falls
Recurrent falls
Syncope/presyncope
History of falls?
Was it witnessed
Before - what were they doing e.g. exercise, getting up, turning head, up from toilet? Do they remember falling or hitting the floor? Was there any warning signs e.g. chest pain or weakness? Have they felt well in days prior? Was there an obvious cause? Rule out possible seizure e.g. Aura
During - LOC? Seizure activity e.g. incontinence, tongue biting, muscle jerking? Head injury? Balance issues? Did they injure themselves?
After - how long were they on the floor? How did they get up? Post-ictal state? Amnesia?
PMHx - previous falls and other comorbidities
DHx - cause? Always ask about anticoags, steroids
Social
ICE
Assessment of a pt after a fall?
Examination of eyesight, lying and standing bp, 12 lead ECG
Obs, BG, urine dip
Bloods - FBC, U&Es, LFTs, bone profile
X-ray e.g. if concern of fracture
Physio - mobility and balance assessment, need for walking aids, Timed Up and Go test
OT - check home environment for any required adaptations, check need for equipment and assess ability to perform ADLs
What is 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.
During the test, observe the person’s postural stability, gait, stride length, and sway
A score of 12-15 seconds or more has been shown to indicate high risk of falls in older people
What is the Turn 180 test?
Ask the person to stand up and step around until they are facing the opposite direction
If they take more than 4 steps, further assessment should be considered
What is deconditioning syndrome?
condition of physiological, psychological and functional decline that occurs as a result of complex physical changes’, which happens with prolonged bed rest and the associated loss of muscle strength
Campaigns to raise awareness about deconditioning?
national Deconditioning Awareness and Prevention Campaign: Sit up, Get Dressed, Kepp Moving
Recondition the nation
Medications that can cause postural hypotension?
Nitrates
Diuretics
Anticholinergics
Antidepressants
Beta blockers
L-dopa
ACEi
Which patients should be given a multidisciplinary assessment by a qualified clinician regarding falls?
Pt over 65 with:
- >2 falls in the last 12 months
- A fall that requires medical treatment
- Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
What is syncope?
a transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery
What is reflex syncope?
Vasovagal, situational or carotid sinus syncope
An inappropriate loss of sympathetic tone which either causes a vaso-depressor effect (blood vessels dilate) or cardio-inhibitory effect (low hr)
What is orthostatic syncope?
Syncope resulting from a postural decrease in bp either from low peripheral resistance (e.g. vasodilators drugs, or structural damage to ANS) or from low cardiac output and inadequate venous returns (e.g. hypovolaemia, chronic venous insufficiency or diuretics)
Causes of orthostatic syncope?
primary autonomic failure: Parkinson’s disease, Lewy body dementia
secondary autonomic failure: e.g. Diabetic neuropathy, amyloidosis, uraemia
drug-induced: diuretics, alcohol, vasodilators
volume depletion: haemorrhage, diarrhoea
What can cause cardiac syncope?
Cardiac problem causing a reduced cardiac output = low blood flow to the brain:
- Arrhythmias
- Valvular heart disease
- MI
- HOCM
- massive PE
What is postural hypotension defined as?
a fall of systolic blood pressure > 20 mmHg on standing.
What can cause postural hypotension?
hypovolaemia
autonomic dysfunction: diabetes, Parkinson’s
drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives
alcohol
Which drugs can cause orthostatic hypotension?
diuretics
antihypertensives e.g. alpha blockers, CCB, ACEi
L-dopa
phenothiazines
antidepressants e.g. TCAs
sedatives
Nitrates
Anticholinergics
Opioids
Sedatives
Benzodiazepines
Pathophysiology of syncope?
Reduced cerebral blood flow - 6-8 seconds is enough
What is FLOF?
Means found lying on the floor
How do you do a lying and standing bp?
Lie down for 5 mins and take bp
Stand and immediately take again
Repeat at 1, 2 and 3 minutes
Diagnosis if systolic BP drops by 20mmHg or diastolic drops by 10mmHg and they MUST have symptoms
Red flags for reflex syncope?
Usually a long history of recurrent episodes
Usually occurs on prolonged standing
Prodrome or dizziness, flushing
Sometimes with head rotation if carotid sinus sensitivity
May have a specific trigger
No Hx of cardiac disease
Red flags for orthostatic hypotension?
Occurs after standing up, prolonged standing, after exertion, post-prandial
Red flags for cardiac syncope?
Occurs during exertion or when lying down
Palpitations
No warning about syncope at all
FHx of SHD or having SHD
Abnormal ECG
Some Extra investigations that can be done to determine the cause of syncope…
Carotid sinus massage
In hospital telemetry - if high risk of arrhythmia
Outpatient holter monitor - rubbish unless having 1-2 arrhythmias a day
Implantable loop recorder
Echocardiography if evidence of SHD
Neuroimaging
DVLA guidance after syncope?
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
What is a mechanical fall?
This is when an external force causes the patient to fall and there is no underlying pathology of concern e.g. a slip
What is vertigo?
The false sensation that the body or environment is moving
Presentation of benign paroxysmal positional vertigo?
Brief 10-20 second episodes of mild-intense dizziness usually triggered by changes in head position
Presentation of vestibular neuronitis?
Recurrent attacks of vertigo that last hours-days following a recent viral infection
NO hearing loss
Presentation of viral labyrinthitis?
Recent viral infection
Sudden onset vertigo with n&v
May affect hearing
Presentation of Ménière’s disease?
Vertigo
Hearing loss and tinnitus
Sensation of fullness or pressure in1 or both ears
Presentation of vertebrobasilar ischaemia?
Dizziness
Vertigo
Headaches
N&v
Diplopia
Ataxia
Weakness bilaterally - may cause drop attacks
Altered consciousness
Presentation of acoustic neuroma?
Unilateral hearing loss
Tinnitus
Vertigo
If large it may also cause persistent headaches, double or blurry vision, numbness/pain/weakness on 1 side of the face, ataxia on 1 side of the body, voice changes or dysphagia
What are falls prevention services?
Services that’s provide assessment, advice and exercises for older people at risk of falling
Aims to prevent falls and unnecessary admission to hospital by rebuilding strength balance and confidence
A team made up of PT, OT, nurse and rehabilitation technicians
Causes of falls?
Trauma
Vasovagal syncope
Cardiac syncope
Orthostatic hypotension
Infections
Alcohol/drug use
Mechanical falls
CNS disorders e.g. cerebellar dysfunction, stroke, CN palsies, parkinsons etc
Seizures
Balance issues and instability - gait disorders?
Haemorrhages and anaemia
Polypharmacy
Metabolic e.g. hypoglycaemia, electrolytes
Complications of falls?
Fractures
Haemorrhages
Broken skin
Head injuries
DVT/PE
Long lie - rhabdomyolysis, hypothermia
Investigtaions following a fall
Bedside - ECG, L/S bp, BM. If you suspect infection MSU, sputum culture, viral swabs, stool culture.
Bloods - FBC, CRP, ESR, U&E, CK, bone profile, vit D, HbA1c, haematinics. Consider ABG/VBG
Radiology - CR, MSK XR, CThead, echo, MRI spine
Mortality rate following a hip fracture?
30 days - 10%
1 year - 1/3rd
(Note though that <50% of these deaths are attributable to the fracture)
What is the most common cause of dizziness and loss of balance in the elderly?
Vestibular problems e.g.BPPV
Remember aortic stenosis as a good differential for a fall in the elderly as very common due to age degeneration of the valve leaflets!!
