Falls Flashcards
What is a fall?
An unexpected event in which the participant comes to rest on the ground, floor or lower level
What are some complications of falls?
Fracture (Esp. hip)
Functional decline
Social isolation
Loss of confidence
Morbidity and mortality
What is the most commonly reported cause of falls?
Dizziness
What are the 3 main categories of physiological factors that contribute to increased falls risk in the elderly?
Motor co-ordination
Biomechanics
Sensory inputs and organisation
Motor co-ordination changes in ageing causing falls
Decreased motor planning (Reaction times)
Decreased attention
Decreased co-ordination
Decreased peripheral sensation
Biomechanics changes in ageing causing falls
Decreased skeletal integrity
Decreased joint stability and flexibility
Decreased muscle strength (Sarcopenia)
Sensory changes in ageing causing falls
Smaller pupils and lens thickening cause decreased vision
Decreased vestibular function causing postural sway
Decreased proprioception
What are some medical conditions that can increase risk of falling?
Diabetes (Peripheral neuropathy + Retinopathy)
Arthritis, Parkinson’s, Stroke -> Altered gate
Incontinence -> Rushing, mobilising at night
What are some environmental factors that increase fall risk?
- Medications
- Rugs, furniture, stairs, inadequate lighting
- Inappropriate footwear
- Inappropriate use of walking aids
How does cataracts surgery affect falls risk?
It greatly reduces fall risk
How do new prescription glasses affect falls risk?
Increase fall risk due to quick change in sight
How does fear of falling increase falls risk?
Leads to a cautious gait with a decrease in walking speed and step length, therefore decreasing walking stability
What are some drug types that can increase fall risk?
Diuretics
Anti-hypertensives
Sedatives
Anti-cholinergics
Hypoglycaemic agents
Anti-psychotics
How do anti-psychotics affect falls risk?
Psychotropic drugs almost doubles fall risk and so should be stopped in old age if possible
What are some anti-depressants and anti-psychotics that can cause orthostatic hypotension?
Venlafaxine
Duloxetine
Risperidone
Haloperidol
What BP in older people is associated with falls risk?
< 120 mmHg systolic
What is the BP target in those over 80?
< 150/90
What is the BP target in those under 80?
< 140/90
What anti-hypertensives should be continued in old age?
ACEi and ß-Blockers
What anti-hypertensives should be stopped in old age?
Nitrates
Ca2+ channel blockers
Vasodilators
Alpha blockers
What are some causes of orthostatic hypotension?
Baroreflex dysfunction - Ageing, vascular
Medication
Environmental factors - Volume depletion, bed rest
Diabetes
Amyloidosis
Parkinson’s
Lewy-body dementia
How is orthostatic hypotension managed?
Stop culprit drugs
Encourage patients to avoid sudden changes in movement
Water loading
Increase dietary salt
Compression stockings
Keep legs elevated when sitting
Calf-muscle exercises
Medication
What are some medications used in orthostatic hypotension (Last resort)?
Fludricortisone
Midodrine
What is a risk of long term phenytoin use?
Permanent cerebellar damage and unsteadiness
What are some common causes of falls?
Medications
Orthostatic hypotension
Carotid sinus syndrome
Syncope
Stroke
Tripping
What is carotid sinus syndrome?
A condition of abnormal activation of the carotid sinus, leading to symptoms secondary to cerebral hypo perfusion
What is the carotid sinus (+ function)
The carotid sinus is an area of dilatation in the internal carotid artery which contains a number of baroreceptors
When pressure increases, the carotid sinus causes the resultant peripheral vasodilation and reduction in heart rate
What are the 4 main steps in assessing a falling patient?
Patient + collateral history
Examination
Investigation
Further tests
What are some important history points in a falling patient?
- Where?
- Events before, during and after the fall
- Loss of consciousness?
- Injuries?
- Could they get up?
- How long did they lie?
- Previous falls?
- Walking aids?
- Systemic enquiry
- Medical history
- Drug history
What are some examinations in a falling patient?
- General observation - Evidence of concurrent illness
- Injuries - Head, vertebrae, humerus, hips, pelvis
- Cardio - Murmur or arrhythmia, postural BP
- Neurological exam - Stroke, visual field, peripheral neuropathy, gait
- 4-AT/AMTS/MoCA
- If vertigo → Dix-Hallpike manoeuvre and HINTS
What are some investigations required in a falling patient?
- ECG ± Telemetry
- Blood sugar
- Postural BP - Lying → Standing 0, 1 and 3 minutes
- Timed up and go
- Echocardiogram (If required)
- Head CT (Consider)
What are some further tests in assessing a falling patient?
- Ambulatory ECG
- Carotid sinus massage
- Tilt-table
What are the main management steps for falls?
- Strength and balance training (3x per week for at least 12 weeks)
- Home hazard assessment and intervention
- Vision assessment and referral
- Medication review and modification/withdrawal
What is involved in carotid sinus massage?
- Connect to cardiac monitor and BP cuff
- Lie patient flat and start rhythm strip printout
- Apply pressure for 5 seconds to carotid sinus while a friend hits ‘mark’ to signify start of CSM
- Check blood pressure - Maximal drop at 15 seconds
- Repeat for other side when HR returns to normal
What are some contraindications for carotid sinus massage?
MI or CVA last 3 months, Hx of VT, carotid artery stenosis
What are some risks of carotid sinus massage?
0.1% risk of transient visual loss
0.01% risk of completed stroke
What are the 3 positive findings on carotid sinus massage?
- Cardio-inhibitory CSS - Pause in HR > 3 seconds
- Vasodepressory CSS - Drop in systolic BP of 50mmHg
- Mixed CSS - Simultaneous combination of both
