Falls

Question 1

When asking about falls, what questions do you need to ask about:
When
- what are possible clinical significance of different scenarios of when they might be doing something? [2]

Answer 1

When did you fall?:
- What were they doing at the time?
- What time of day?

Possible implications:
* Looking upwards (vertebrobasilar insufficiency)
* Getting up from bed (postural hypotension)

Question 2

When asking about falls, what questions do you need to ask about:
Where [1]

Answer 2

Where did you fall?
- In the house, or outside?

Question 3

When asking about falls, what questions do you need to ask about:
What [+]

Answer 3

What happened before/during and after the fall?

Before
* Was there any warning?
* Was there any dizziness/chest pain or palpitations?

During
* Was there any incontinence or tongue biting? (indicating seizure activity)
* Was there any loss of consciousness?
* Was the patient pale/flushed? (may indicate vasovagal attack)
* Did the patient injure themselves?
* What part of the body had the first contact with the floor?

After
* What happened after the fall?
* Was the patient able to get themselves up off the floor?
* How long did it take them?
* Was the patient able to resume normal activities afterwards?
* Was there any confusion after the event? (head injury)
* Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)

Question 4

When asking about falls, what questions do you need to ask about:
Why [+]

Answer 4

Why do you think you fell?
- May have tripped over a rug or started a new medication

Question 5

When asking about falls, what questions do you need to ask about:
How [1]

Answer 5

How many times have you fallen over the last 6 months?

Question 6

Name 5 key drug classes that may increase chance of falls? [5]

Answer 6

Beta-blockers (bradycardia)
Diabetic medications (hypoglycaemia)
Antihypertensives (hypotension)
Benzodiazepines (sedation)
Antibiotics (intercurrent infection)

Question 7

During a clinical examination, what findings for the systems below might indicate a fall?
- CV [4]
- Resp [3]

Answer 7

Cardiovascular
* Pulse: may have irregularities such as AF or bradycardia
* Blood pressure – hypotension
* Bruits over carotid arteries (e.g. aortic stenosis, carotid stenosis)
* Murmurs: aortic stenosis/regurgitation, mitral stenosis

Respiratory
* Inspection: increased work of breathing
* Auscultation: coarse crackles (e.g. pneumonia)
* Percussion: dullness (e.g. pleural effusion)

Question 8

During a clinical examination, what findings for the systems below might indicate a fall?
- Neurological [4]
- Resp [3]

Answer 8

Neurological
* Cranial nerve examination: stroke or visual impairment
* Power: weakness (e.g. stroke, disuse atrophy)
* Tone: increased in stroke
* Reflexes: absent (e.g. diabetic neuropathy), hyperreflexia (e.g. upper motor neuron pathology)
* Sensation: may be reduced secondary to upper or lower motor neuron pathology
* Co-ordination: may be impaired (e.g. chronic alcohol misuse leading to cerebellar degeneration)

Question 9

What are overall causes of falls from:
- CV [4]
- Neurological [2]
- GUM [2]

Answer 9

Cardiovascular
* Arrhythmias
* Orthostatic hypotension
* Bradycardia
* Valvular heart disease
* Vasovagal - emotional distress or prolonged standing leading to sudden fall without preceding symptoms.

Neurological:
- Stroke
- PD
- Peripheral neuropathy

Genitourinary
* Incontinence
* Urinary tract infection

Question 10

What are overall possible causes of falls from:
- Endocrine [1]
- MSK [2]
- ENT [2]

Answer 10

Endocrine:
- hypoglycaemia

MSK:
* Arthritis
* Disuse atrophy

ENT:
* Benign paroxysmal positional vertigo
* Ear wax

Question 12

Which electolyte dysfunction might cause a fall? [1]

Answer 12

Hypocalcaemia: Low serum calcium can cause muscle cramps and tetany leading to instability and falls.

Question 13

Which medications specifically cause postural hypotension [+]

Answer 13

• Nitrates
• Diuretics
• Anticholinergic medications
• Antidepressants
• Beta-blockers
• L-Dopa
• Angiotensin-converting enzyme inhibitors - (ACE) inhibitors

Question 14

Describe what would indicate postural hypotensin [1]

Answer 14

A drop in systolic blood pressure of at least 20 mmHg or a drop in diastolic blood pressure of at least 10 mmHg within three minutes of standing is considered diagnostic.

Question 15

What is the pharmacological interventions can provide for orthostatic hypotension? [3]

Answer 15

Fludrocortisone
- Monitor serum potassium levels and BP regularly due to the risk of hypokalaemia and supine hypertension

Sympathomimetic agents
* Midodrine - Use with caution in patients with ischaemic heart disease or cardiac arrhythmias.
* Droxidopa - This agent may be particularly useful in patients with neurogenic orthostatic hypotension.

Question 16

How do you specifically test for orthostatic hypotension? [1]

Answer 16

1 Have the patient lie down for 5 minutes. 2 Measure blood pressure and pulse rate. 3 Have the patient stand. 4 Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes.

Question 17

What are key CV causes of syncope? [3]

Answer 17

Arrhythmias:
- These are a common cause of syncope, often presenting as episodic loss of consciousness with rapid recovery.
- They can be bradyarrhythmias (e.g., sinus node dysfunction, atrioventricular block) or tachyarrhythmias (e.g., ventricular tachycardia, supraventricular tachycardia).
- Patients may describe palpitations before the syncopal episode.

Structural heart disease:
- Conditions such as aortic stenosis, hypertrophic cardiomyopathy, and mitral valve prolapse can lead to syncope, particularly during exertion.
- Patients may report chest pain, dyspnoea or fatigue prior to the event.

Vasovagal Syncope:
- Also known as neurocardiogenic or reflex syncope.
- It is characterised by a prodrome of nausea, warmth and diaphoresis.
- Triggers include prolonged standing, emotional stress or painful stimuli.

Question 18

Postural orthostatic tachycardia syndrome (POTS)

Question 19

What questions asked when falling?

Answer 19