Falls Flashcards
what are some questions to think about when taking a falls history in the presenting complaint ?
who has seen you fall ?
when did you fall ( time of day, what were you doing ) ?
where did you fall ?
what happened before/during the fall ( incontinence, tongue biting, loss of consciousness, injury )?
what happened after the fall ( weakness or speech issues, confusion, recovery period ) ?
why do you think you fell ( trip ) ?
how often do you fall / have you ever fallen before ?
what are some conditions associated with falls ?
visual or hearing impairment
DM
anaemia
CVD
arrhythmias
COPD
parkinson’s disease
stroke
dementia
recurrent UTI
arthritis
fractures
what are some examples of medications that increase the risk of falls ?
beta blockers - bradycardia
diabetic medications - hypoglycaemia
anti-hypertensives - hypotension
benzodiazepines - sedation
antibiotics - intercurrent infection
in a clinical exam what should be assessed in a falls patient ?
pulse
BP - hypotension
bruits and murmurs
coarse crackles - lungs
CNS exam and PNS exam
abdo tenderness
organomegaly
MSK - check for injuries
what are the investigations to perform when a patient presents with a fall ?
bedside - vitals, lying and standing BP, ECG, urine dip, blood glucose
bloods - FBC, U&E’s, LFT’s, bone profile
imaging - CXR, CT head
specialist - dix hallpike, cardiac monitoring
what are some differentials for a fall ?
mechanical - visual disturbance and poor footwear
poly-pharmacy
arrhythmia
bradycardia
stroke
peripheral neuropathy
UTI
hypoglycaemia
arthritis
BPPV
what are some management options when a patient presents with a fall ?
physiotherapy
eye test and ensure correct glasses use
hearing assessment
medication review
alcohol cessation
ensure appropriate footwear
what are the components that contribute to a normal gait ?
neurological system - basal ganglia
MSK - appropriate tone and strength
effective processing of sight, sound and sensation ( fine touch and proprioception )
what are some risk factors for falling ?
previous falls
lower limb weakness
vision problems
balance / gait disturbance
polypharmacy ( +4 )
incontinence
over 65
depression
postural hypotension
what are some medications that cause postural hypotension ?
nitrates
diuretics
anticholinergic
antidepressants
beta blockers
L-Dopa
ACEi
what are some vestibular causes of dizziness ?
BPPV
neuritis and labyrinthitis
meniere’s disease
migraines
what are some non-vestibular causes of dizziness ?
syncope
drug side effects
anxiety
allergies
what are the 5 components that must be fulfilled for syncope ?
transient loss of consciousness
loss of voluntary muscle tone
rapid onset
full recovery
transient global cerebral hypo-perfusion
what are some causes of syncope ?
reflex syncopal syndromes - vasovagal, carotid sinus syndrome
orthostatic hypotension
cardiac syncope
what are some causes of cardiac syncope ?
arrhythmias - brady and tachy
valvular disease
cardiomyopathy
vascular - PE, MI, aortic dissection
what are the suggestive features of cardiac syncope ?
new onset chest pain or SOB
palpitations
collapse during exercise
PMH of arrythmias, LVSD, IHD
family history
what are some features that would indicate a seizure in a falls patient ?
vagueness / absence
abnormal movements
tonic clonic jerks
myoclonus
loss of consciousness
tongue biting
incontinence
post-ictal period
grunting / snoring
what are some features that would indicate BPPV in a falls patient ?
dizzness or light-headedness associated with :
- postural changes
- rolling in bed
- lying down/getting up
-diplopia
- nausea and vomiting
- episodic
what is the definition of orthostatic hypotension ?
systolic BP fall of over 20 mmHg
or
diastolic BP fall of over 10mmHg
in first 3 mins of standing
what are some causes of orthostatic hypotension ?
hypovolaemia - dehydration, haemorrhage
drugs - anti-hypertensives, anti-anginals
alcohol
proloned bed rest
autonomic failure
idiopathic
what are some preventative measures for orthostatic hypotension ?
recognise and avoid predisposing factors
- warmth and alcohol
-drugs
elastic support stockings
increase intra-vascular volume
stop anti-hypertensives
what is the abnormal response to standing in vaso-vagal syncope ?
decrease in BP
-
feeling faint
-
decrease in HR ( decrease in peripheral vascular resistance )
-
decrease in BP
-
faint and fall
what are the indications for tilt table testing ?
to confirm suspected diagnosis of vasovagal syndrome
recurrent unexplained syncope
elderly with unexplained falls
what is the management of vasovagal syndrome ?
education
reassurance
physical counter pressure manoeuvres
drug / polypharmacy alteration
