Falls

Question 1

what are some questions to think about when taking a falls history in the presenting complaint ?

Answer 1

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 ?

Question 2

what are some conditions associated with falls ?

Answer 2

visual or hearing impairment
DM
anaemia
CVD
arrhythmias
COPD
parkinson’s disease
stroke
dementia
recurrent UTI
arthritis
fractures

Question 3

what are some examples of medications that increase the risk of falls ?

Answer 3

beta blockers - bradycardia
diabetic medications - hypoglycaemia
anti-hypertensives - hypotension
benzodiazepines - sedation
antibiotics - intercurrent infection

Question 4

in a clinical exam what should be assessed in a falls patient ?

Answer 4

pulse
BP - hypotension
bruits and murmurs
coarse crackles - lungs
CNS exam and PNS exam
abdo tenderness
organomegaly
MSK - check for injuries

Question 5

what are the investigations to perform when a patient presents with a fall ?

Answer 5

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

Question 6

what are some differentials for a fall ?

Answer 6

mechanical - visual disturbance and poor footwear
poly-pharmacy
arrhythmia
bradycardia
stroke
peripheral neuropathy
UTI
hypoglycaemia
arthritis
BPPV

Question 7

what are some management options when a patient presents with a fall ?

Answer 7

physiotherapy
eye test and ensure correct glasses use
hearing assessment
medication review
alcohol cessation
ensure appropriate footwear

Question 8

what are the components that contribute to a normal gait ?

Answer 8

neurological system - basal ganglia
MSK - appropriate tone and strength
effective processing of sight, sound and sensation ( fine touch and proprioception )

Question 9

what are some risk factors for falling ?

Answer 9

previous falls
lower limb weakness
vision problems
balance / gait disturbance
polypharmacy ( +4 )
incontinence
over 65
depression
postural hypotension

Question 10

what are some medications that cause postural hypotension ?

Answer 10

nitrates
diuretics
anticholinergic
antidepressants
beta blockers
L-Dopa
ACEi

Question 11

what are some vestibular causes of dizziness ?

Answer 11

BPPV
neuritis and labyrinthitis
meniere’s disease
migraines

Question 12

what are some non-vestibular causes of dizziness ?

Answer 12

syncope
drug side effects
anxiety
allergies

Question 13

what are the 5 components that must be fulfilled for syncope ?

Answer 13

transient loss of consciousness
loss of voluntary muscle tone
rapid onset
full recovery
transient global cerebral hypo-perfusion

Question 14

what are some causes of syncope ?

Answer 14

reflex syncopal syndromes - vasovagal, carotid sinus syndrome
orthostatic hypotension
cardiac syncope

Question 15

what are some causes of cardiac syncope ?

Answer 15

arrhythmias - brady and tachy
valvular disease
cardiomyopathy
vascular - PE, MI, aortic dissection

Question 16

what are the suggestive features of cardiac syncope ?

Answer 16

new onset chest pain or SOB
palpitations
collapse during exercise
PMH of arrythmias, LVSD, IHD
family history

Question 17

what are some features that would indicate a seizure in a falls patient ?

Answer 17

vagueness / absence
abnormal movements
tonic clonic jerks
myoclonus
loss of consciousness
tongue biting
incontinence
post-ictal period
grunting / snoring

Question 18

what are some features that would indicate BPPV in a falls patient ?

Answer 18

dizzness or light-headedness associated with :
- postural changes
- rolling in bed
- lying down/getting up
-diplopia
- nausea and vomiting
- episodic

Question 19

what is the definition of orthostatic hypotension ?

Answer 19

systolic BP fall of over 20 mmHg

or

diastolic BP fall of over 10mmHg
in first 3 mins of standing

Question 20

what are some causes of orthostatic hypotension ?

Answer 20

hypovolaemia - dehydration, haemorrhage
drugs - anti-hypertensives, anti-anginals
alcohol
proloned bed rest
autonomic failure
idiopathic

Question 21

what are some preventative measures for orthostatic hypotension ?

Answer 21

recognise and avoid predisposing factors
- warmth and alcohol
-drugs
elastic support stockings
increase intra-vascular volume
stop anti-hypertensives

Question 22

what is the abnormal response to standing in vaso-vagal syncope ?

Answer 22

decrease in BP
-
feeling faint
-
decrease in HR ( decrease in peripheral vascular resistance )
-
decrease in BP
-
faint and fall

Question 23

what are the indications for tilt table testing ?

Answer 23

to confirm suspected diagnosis of vasovagal syndrome
recurrent unexplained syncope
elderly with unexplained falls

Question 24

what is the management of vasovagal syndrome ?

Answer 24

education
reassurance
physical counter pressure manoeuvres
drug / polypharmacy alteration

Question 25

what is the definition of a fall ?

Answer 25

inadvertently coming to rest on the ground or other lower level with or without loss of consciousness and other than as a consequence of overwhelming external force, sudden onset paralysis, epileptic seizure or excess alcohol intake

Question 26

what are some intrinsic factors that contribute to falls ?

Answer 26

cardiac
sensory - hearing or vision
MSK - weakness, arthritis
neuromuscular - gait / balance

Question 27

what are some extrinsic factors that contribute to falls ?

Answer 27

drugs
obstacles
stairs
clothing
inappropriate walking aids
lighting

Question 28

what are some therapy services for a patient with falls ?

Answer 28

physiotherapy - gait, walking aid assessment, muscle power, dizziness, balance
OT

Question 29

what is the falls prevention programme ?

Answer 29

therapy and education to alter lifestyle to reduce risk of falls