Falls Flashcards
Define fall
Coming to rest on a lower level, with or without LOC, not due to external force or medical problem
What questions should you ask someone who has had a fall?
- How did the fall happen?
- What were they doing at the time?
- How did they feel before the fall?
- Was there and dizziness or a lightheaded feeling?
- Did they lose consciousness?
- Did they have any cardiac symptoms?
- Are they weak anywhere?
- Has this happened before?
- How do they normally mobilise?
- What medication do they take? Think sedatives, cardiac medications, anticholinergics, hypoglycaemics, opiates that can contribute to falls
Common causes of falls?
Muscle weakness/sarcopenia
Poor balance/instability
Hypotension
Vision loss
Key investigations for underlying cause of a fall?
CGA - general frailty and functional ability
FBC - anaemia/bleeds
Lying and standing bp- orthostatic hypotension
ECG - arrhythmias
AXR- faecal impaction
CT head- subarachnoid haemorrhage
Multidisciplinary interventions for discharge post fall?
Pharmacist- review TTO
Physios - improve strength and mobility
Occupational therapists- AODL
GP follow up
Commonly prescribed drugs that increase falls risk?
Antihypertensives
Alpha blockers
Diuretics
Benzodiazepines
Define postural hypotension
Drop in systolic BP > 20 mmHg or diastolic BP > 10 mmHg within 3 mins of standing
How do you test someone for postural hypotension?
- Lie for 5 minutes
- Stand and take BP at 1 min, 3 min and 5 mins
What can cause postural hypotension?
Idiopathic
Hypovolaemia: dehydration, haemorrhage
Drugs: antihypertensives, anti-anginals, antidepressants, alcohol
Prolonged bed rest
Autonomic failure:
primary (eg MSA, PD)
secondary (DM)
How is postural hypotension managed?
- Hydration
- Review polypharmacy
- Reduce adverse outcomes from falls (e.g. fall alarm, soft flooring)
- Behavioural changes (e.g. rising from sitting slowly, calf pumping before standing)
- Compression stocking
- Fludrocortisone (poor evidence base) or Midodrine
How can you explain postural hypotension to a patient?
your heart is a pump
when you are standing, you have to pump against gravity to get the blood to your brain
so if you aren’t able to pump hard enough against gravity your brain is the first thing to go which causes these sxs (blurred vision, black spots, headache, nausea, feeling hot)
when you lie down your heart and brain are on the same level so the blood can get there more easily and you recover
so when you notice these symptoms, the best thing you can do to help your brain is to lie down
when should you refer a patient for multidisciplinary assessment by a qualified clinician after they have had a fall?
all over 65 who:
had more than 2 falls in 1 year,
a fall that requires medical treatment,
Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
list some complications of falls
trauma,
pain,
loss of confidence,
loss of independence,
distress,
mortality
what lifestyle advice should you give to someone with osteoporosis?
regular exercise to improve muscle strength,
smoking cessation,
balanced diet,
drink alcohol within recommended limits
When is bone sparing treatment recommended for those with osteoporosis?
T-score -2.5 or lower
What is a fragility fracture?
fracture from a fall from standing height
What calculation tool is used to assess the risk of frailty fractures?
FRAX
What should you check before prescribing bisphosphonates?
Calcium levels,
Vitamin D levels,
Renal function
Give some vestibular causes of dizziness
BPPV
Neuritis / Labyrinthitis
Meniere’s
Vertiginous Migraine
Persistent Postural Perceptive Dizziness
SOLs
Give some non-vestibular causes of dizziness
Light-headedness
Pre-syncope / (Syncope)
Postural intolerance
Drug S/Es
Anxiety
SOLs
What is a transient loss of conciousness?
Short Duration
Abnormal Motor Control
Loss of responsiveness
Amnesia
Usually 90 seconds or less
What is syncope?
Transient global cerebral hypo-perfusion which causes TLOC and loss of voluntary muscle tone
Rapid onset, spontaneous & prompt recovery
Full recovery
What causes should you be thinking about when someone presents with dizziness / collapse?
- Significant inter current illness?
- Epilepsy?
- a Fall?
- a Vestibular problem?
- Cardiac Syncope?
- Reflex Syncope?
- Orthostatic Hypotension?
- Functional Neurological Disorder?
What are the 3 main reflex syncopal syndromes?
Situational syncope (e.g. when seeing blood)
Vasovagal syncope (common faint)
Carotid sinus syndrome
What are the red flags for a cardiac cause of syncope?
New onset chest pain or SOB
Sudden onset palpitations immediately prior
Collapse during exercise/ when seated
What should you think about asking when considering if a patient has a cardiac cause of syncope?
do they have cardiac hx?
do they have structural heart disease?
do they have a fam hx of sudden cardiac death (esp before 50)?
do they have an abnormal ECG?
How can you differentiate between vasovagal syncope and postural hypotension based on clinical features?
presence / absence of autonomic activation
in vasovagal syncope autonomic sxs are often present - rising heat, blurred vision, muffled hearing, feeling sick
in postural hypotension, autonomic sxs are not present
What questions might you ask someone about the cirumstances surrounding vasovagal syncope?
Prolonged standing
Dehydration
Hot weather
How can you investigate suspected vasovagal syncope?
- Tilt table
- ECG
- Beat to beat BP monitor
How can you manage simple vasovagal syncope?
Recognition & avoidance of triggers
* Warmth
* Alcohol
* Caffeine (low levels increase bp, lots of caffeine increases urination and vasodilates)
* Prolonged stand
Can keep a diary of pre-syncopal sxs
Increase fluid intake (2-3 L), salt
Physical Counter-pressure manoeuvres (PCM)
Compression Stockings/Abdominal binders
Midodrine
Add in falls prevention programme (2x a week for 6 weeks, safe falling) and support with ADLs e.g. putting bin out
