Falls Flashcards
What are causes of falls in the elderly?
Multifactorial - medication, social factors
Mechanical falls (due to external factors)
Cognitive impairment
Unsafe environment
Medication/comorbidities
How would you assess a fall?
General observations - pain, limb deformity, mobilising
C spine assessment
ABCDE approach - GCS, pupils, obvious injuries to head/face, Battle sign, Panda eyes, CSF leakage
from nose, joint assessment, neurological assessment
Neuro observations, consider enhanced care, medication review, treat cause if known/identified
CT head - NICE Guidelines
Pathological fractures
Def, causes, sx, ix, mx
Pathological fractures are fractures that occur in diseased bone, often resulting from seemingly minor trauma that would not usually cause a fracture. Most commonly, these fractures arise from secondary tumors (metastatic), osteoporosis, Paget’s disease, and hyperparathyroidism.
Sx:
• Localized pain that may be severe and out of proportion to the injury
• An unexpected fracture after minor trauma
• Deformity at the fracture site
• Impaired function of the affected limb
Ix:
• Radiographic evaluation: To identify the fracture and any associated bony abnormalities
• Bone scans: To detect metabolic abnormalities and tumors
• Lab tests: Including serum calcium, phosphate, parathyroid hormone, and alkaline phosphatase to diagnose metabolic diseases
• Biopsy: May be necessary for the diagnosis of tumors
Mx:
• Treating the underlying disease: This may involve medications, surgery, or other therapies specific to the condition causing the fracture.
• Fracture repair: This can include immobilization, surgery, or other interventions as appropriate to the nature and location of the fracture.
Benign paroxysmal positional vertigo (BPPV)
Cause, sx, dx, mx
Cause:
Floating otoconia which get stuck on one of the semi-circular canals
Sx:
A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later.
Dx:
- Dix-Hallpike Manoeuvre
The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis). It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV.
To perform the manoeuvre:
The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
Watch the eyes closely for 30-60 seconds, looking for nystagmus
Repeat the test with the head turned 45 degrees in the other direction
In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).
Mx:
- Epley Manoeuvre
The Epley manoeuvre can be used to treat BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow.
To perform the manoeuvre:
Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
Rotate the patient’s head 90 degrees past the central position
Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
Have the patient sit up sideways with the legs off the side of the couch
Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
- Brandt-Daroff Exercises- These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.
Ménière’s disease
Def, sx, mx
Extensive expansion of membranous labyrinth (endolymphatic hydrops)
Sx:
- vertigo
- tinnitus
- fluctuating hearing loss
- aural fullness (4th core symptom)
Mx:
- low salt diet
- caffeine restriction
- betahistine
- vestibular sedatives
- vestibular rehab
- intratympanic injections
- labyrinthectomy
- vestibular neurotomy
Vasovagal syncope
Causes, sx, ix
Cause:
- exercise
- pain
- after food
Sx:
- warm/hot/sweaty
- nausea
- lightheaded
- disturbed vision
- tip of tongue biting
- less than 30 seconds loss of consciousness
- myoclonic jerks
Ix:
- BM
- ECG
- electrolytes
- BP
Vertigo
Def, causes, ix
Hallucination of movement or motion
Causes:
- Central (brain or CNS)- posterior stroke, SOL, tumour, MS, demyelinatation
- peripheral (vestibular system)- BPPV, labyrinthitis, vestibular neuritis, Ménière’s disease
- HINT-
Head impulse test- asses VOR (vestibular ocular reflex) by focus on object then sharp turn, if positive then peripheral, if negative then could be central or peripheral sometimes
Nystagmus- patient looks straight ahead, left and right, if direction changing then central, horizontal nystagmus then peripheral
Test of skew- cover one eye, if vertical correction then central, absence of vertical misalignment then peripheral
Ix:
- Rinnes
- Weber’s
- neuro exam
