Falls Flashcards
What are the common causes of falls?
BPPV (Benign Paroxysmal Positional Vertigo)
Cardiac – e.g. arrhythmia
Chemical – e.g. Intoxication / alcohol / pharmacological
Neurological – e.g. seizure, stroke, peripheral neuropathy
Infection (commonly a UTI)
Vessels – e.g. Vasovagal/postural hypotension
Environmental (poor lighting / uneven surface) – rare!
What are the 5 systems involved in balance?
Vision
Proprioception
Vestibular system
Brain
Effector mechanisms
What are the common ways vision can be affected such that it affects balance?
i) age-related macular degeneration
ii) bifocal lenses
iii) cataracts
iv) diabetic retinopathy
What are the common ways proprioception can be affected such that it affects balance?
Proprioception is aided by joint position, thus;
i) sensory neuropathy
ii) joint replacements
iii) ageing
What are the common ways the vestibular system can be affected such that it affects balance?
i) previous middle ear infections
ii) menière’s disease
iii) ototoxic drugs
What are the common ways the effector mechanisms can be affected such that it affects balance?
i) proximal myopathy (e.g. steroid exposure, vitamin D deficiency)
ii) any neurological disease
iii) disuse atrophy
How does proprioception and joint position aid balance?
It helps when the eyes are shut
Which effector mechanisms are most commonly associated to falls?
Quadriceps as they are the main muscle the body uses to re-balance
What are the common ways the brain can be affected such that it affects balance?
i) cerebrovascular disease
ii) dementia (affects judgment)
iii) low blood pressure (reduces cerebral blood flow)
What is the sensitivity/specificity of postural hypotension testing in falls?
It is sensitive only. i.e. If found to have postural hypotension this is useful.
BUT if found not to this is not helpful as they may still have it
What should you be particularly vigilant about with a pt at risk of falls from postural hypotension?
hypotensive drugs
What are the testas you should do after a pt has a fall
1) CVS + RS examination
2) GALS examination
3) ECG (check for AF)
4) Lying + standing BP
5) Urine dip (UTI)
6) Neuro obs very regularly for first 5 hours
What is vasodepressor carotid sinus hypersensitivity (CSH)?
a symptomatic drop in systolic blood pressure
of 50mmHg or more
in response to carotid sinus massage
What types of carotid sinus hypersensitivity (CSH) are there?
Vasodepressor
Cardioinhibitory
Mixed
What is cardioinhibitory CSH?
Where carotid sinus massage prompts asystole
of 3 seconds or more
What is the best way to screen for falls?
Opportunistically ask patients if they have fallen in the last year
How are risk factors for falls broadly split?
Intrinsic (i.e. the body)
Extrinsic (i.e the enviroment
What are the three broad categories of intrinsic factors?
CV
neurological
Musculoskeletal
Name 5 common intrinsic risk factors for falls.
Metastatic prostate cancer
Thyrotoxicosis
Diabetes
Cognitive impairment
Muscle weakness
Are medications intrinsic or extrinsic risk factors for falls?
extrinsic
What medications are common culprits of causing falls?
Antihistamines
Beta-blockers
Benzodiazepines
Diuretics
Neuroleptics (aka antipsychotics)
Nitrates
Steroids
TCA’s
What are the three biggest risk factors for falls
Cognitive impairment
Muscle weakness
Home hazards
What is the common underlying cause of fractures in the elderly?
Osteoperosis
How do beta-blockers induce falls?
Reduce heart rate
lower blood pressure
reduce cerebral perfusion
How do nitrates induce falls?
Lower BP and
reduce cerebral perfusion
How do benzodiazepines induce falls?
Increase drowsiness
especially at night
for example when getting up to urinate
How do diuretics induce falls?
Dehydration
reduce pre-load and cardiac output
How do neuroleptics (aka antipsychotics) induce falls?
Drowsiness +
can induce Parkinsonism
How do steroids induce falls?
Can cause proximal muscle weakness
How do TCA’s induce falls?
Lower BP
can cause dizziness and
confusion
How do antihistamines induce falls?
Drowsiness
What can repeated falls be a marker of in the elderly?
Frailty
What are the adverse consequences of falls?
1) Fear of falling
2) Social Isolation
3) Injuries and fractures
4) Death
5) Depression and Anxiety
When doing a lying-standing BP how long should the patient lie down for before measuring there lying BP?
10 mins
How long after the patient has stood up should you take the standing blood pressure when doing lying-standing BP?
Straight away
1, 3 and 5 mins
What on a urine dip can show causes of falls?
White cells + nitrates –> UTI
Ketones –> Dehydration
What are the three cornerstones of falls prevention?
1) Strength and balance training (physio)
2) Medical review
3) OT assessment of home
How much physio is required to reduce falls risk?
50 hours
What are the four part of medical review of falls?
1) Diagnose the cause(s)
2) Reduce the risk factors
3) Bone health assessment
4) medication review
How is bone health assessed in elderly that have fallen
Look for evidence of previous fracture, if you cannot find consider
DEXA scan (bone density)
Ca2+ Vit D if at risk
+ bisphosphonates (e.g. clodronate) if they have actually had a fall
At what number do prescription medications start to increase the risk of falls in elderly?
4 or more
Why are elderly commonly on antihypertensives and what is the issue with this?
Put on to reduce CV risk, but
body alters with time such that
the antihypertensives end up doing more harm than good
What medications can be used to prevent falls?
Very few, except:
Fludrocortisone (mineralocorticoid i.e. like aldosterone) with unexplained low BP to reduce postural hypotension
Vit D + calcium as well as helping bone strength can help muscle strength
Why should a patient comes into ED due to a fall be discouraged from being admitted to hospital ?
No as falls risk reduction takes many weeks to come into effect
Once you have assessed a patient medically what can you do?
Refer them to a falls/ fracture prevention clinic
What difference in BP in Lying + standing BP is significant?
greater than
20 sys or
10 dys
is significant
