Falls

Question 1

What is the definition of a fall?

Answer 1

An unexpected event in which the participant comes to rest on the ground, floor or lower level.

Question 2

Prevalence of falls increases with age. True/false?

Answer 2

True

30% of over 65s
42% of over 75s
50% of over 80s fall at least once a year.

Question 3

What complications can result due to a fall?

Answer 3

Lead to functional decline, social isolation, loss of confidence, morbidity and mortality.

Question 4

Why are older people more likely to experience falls?

Answer 4

Vision: smaller pupils, lens thickening = less light in to eye

Sarcopenia: loss of muscle mass and function

Decreased cardiorespiratory fitness

Decreased peripheral sensation and proprioception leading to increased postural sway

Central processing and cognition: decreased reaction time

Question 5

Intrinsic factors leading to falls?

Answer 5

Age-related changes in gait, postural reflexes, muscle strength etc

Medical conditions

Cognition

Impaired vision and hearing

Question 6

Intrinsic factors leading to falls (medical conditions)?

Answer 6

Diabetes mellitus → diabetic neuropathy →altered proprioception + poor vision

Arthritis, Parkinson’s, Stroke → altered gait pattern

Incontinence → increased need to rush, mobilising at night etc

Acute illness (almost anything)

Question 7

Extrinsic factors leading to falls?

Answer 7

Medications such as diuretics, anti-hypertensives, sedatives, anti-cholinergics, hypoglycaemic agents.

Environmental – rugs, furniture, stairs etc

Inadequate lighting – falls at night

Inappropriate footwear

Inappropriate use of walking aids

Question 8

What is the annual incidence of falls in people with cognitive impairment?

Answer 8

70-85%

Question 9

What can decrease risk/rate of falls?

Answer 9

Early cataract surgery

Bifocal and varifocal glasses are associated with increased falls risk.

Question 10

How many medications must the patient be on to be considered a falls risk?

Answer 10

4 or more

However the more medications the patient is on, the greater the risk

Question 11

What drug groups can increase the risk of falls?

Answer 11

Psychotropic drugs

Taking such a medicine roughly doubles the risk of falling.

Remember some antidepressants and antipsychotics also cause orthostatic hypotension (e.g. venlafaxine, duloxetine, risperidone, haloperidol)

Phenytoin may cause permanent cerebellar damage and unsteadiness in long term use at therapeutic dose. Excess blood levels cause unsteadiness and ataxia.

Question 12

What blood pressure in people of older age increases fall risk?

Answer 12

In older people a systolic BP of 120mmHg or below is associated with an increased risk of falls.

Question 13

What % of people over 80 have gait disturbances?

Answer 13

Around 62% - whether from neurological or non-neurological causes such as osteoarthritis

Question 14

For older people with gait disturbances, what is to be examined in the lower limb?

Answer 14

Always examine the lower limbs for:

Joint swelling or muscle atrophy
Shortening/Foot drop from previous injury
Peripheral neuropathy
Abnormalities of the feet or inappropriate footwear.

Romberg’s test – positive in both proprioceptive and vestibular disorders.

Question 15

What is the most common neurological cause of ataxia in the elderly, resulting in impairments in distal proprioception and strength.

Answer 15

Peripheral neuropathy

Question 16

What features can indicate functionally significant peripheral neuropathy?

Answer 16

loss of heel reflexes

decreased vibratory sense that improves proximally

impaired position sense at the great toe

inability to maintain unipedal stance for 10 seconds in three attempts.

Question 17

How is orthostatic hypotension confirmed and tested?

Answer 17

Diagnosis based largely on typical history of postural symptoms.

Confirmed by lying/standing blood pressure testing:
- Measuring blood pressure and pulse rate when lying down and standing up
- Doing blood tests to check thyroid and sugar levels
- Doing an electrocardiogram (ECG) to check heart rhythm

Question 18

What are the causes of orthostatic hypotension?

Answer 18

Baroreflex dysfunction – loss of baroceptor sensitivity and vasoconstriction associated with ageing (and vascular disease).

Triggered by medications or other circumstances (e.g., volume depletion, physical deconditioning due to prolonged bed rest).

Many diseases that cause peripheral neuropathy (most notably diabetes mellitus and amyloidosis) can produce autonomic neuropathy and neurogenic orthostatic hypotension.

Patients with Parkinson’s disease and Lewy body dementia frequently suffer neurogenic orthostatic hypotension of varying severity.

Question 19

What is the management of orthostatic hypotension?

Answer 19

Stop culprit drugs – diuretics, anti-hypertensives, dopamine agonists, pregabalin, review anti-depressants

Encourage patient to avoid sudden changes in movements.

‘Water loading’

Increase salt in diet

Compression stockings

Keep legs elevated when sitting/sleeping.

Calf muscle exercises when standing for prolonged periods

Question 20

For orthostatic hypotension, what is the medical management if conservative management proves ineffective?

Answer 20

Only when conservative measurements have failed then consider medication – fludrocortisone, midodrine

Question 21

When orthostatic hypotension is not detected during the posture test and the patient gives a history suggestive of orthostatic hypotension. What test can be used?

Answer 21

Tilt-table test

Records blood pressure, heart rhythm and heart rate on a beat-by-beat basis as the table is tilted to different angles. The table always stays head-up.