Falls

Question 1

What are the causes of falls?

Answer 1

Intrinsic
Continence issues: Urge, Frequency
Poor vision + drugs causing blurred vision, macular degeneration
Postural Hypotension + Antihypertensive meds
Balance + Gait: Stroke, Parkinsonism (postural instability and gait affected), Peripheral neuropathy (DM, B12), Cerebellar disease, Vestibular Disease, Arthritis
Deformity e.g. charcot marie tooth
Cardiac: Aortic stenosis, Carotid sinus hypersensitivity, arrhythmias
Cognitive Impairment
Polypharma
Sedation + Sedative Drugs
Age, Frailty: increased sway, slowed autonomic response
History of Falls
Alcohol
Acute Illness: MI, Hypoglycaemia
Reduced muscle mass/ strength

Extrinsic
uneven ground
poorly lit room
inappropriate footwear
furniture
pets
poor walking aids
bathroom

Question 2

What are the consequences of falls?

Answer 2

1. Trauma: soft tissue, fractures, SD haemorrhage, joint dislocation
2. Long Lie: hypothermia, pressure related injury- ulcers, AKI due to dehydration, infection, rhabdomyolysis- CK increased.
3. Psychological: loss of confidence, fear of falling, depression + anxiety
4. Social: reduced mobility subsequently due to loss of confidence and increased dependence, social isolation due to fear of falling
5. Institutionalization- due to increased dependence
6. Cg burden

Question 3

Describe a falls history?

Answer 3

Location of fall, description of env, walking aid being used? Loss of consciousness? Previous falls? Syncopal symptoms includ chest pain, palpit/ SOB/dizziness? Vertigo symptoms? could they get up? long lie? Collateral hx- seizure? look sick before falling?
Meds review- any sedative- benzos/antipsychotics/ opiates/TCAs/ anticonvulsants, antihypertensives/ antimuscarinics/ antiacetylcholinesterases (dementia)/ DA agonists/ TCAs, anticholinergics- blurred vision, baclofen- muscle weakness.
Systems review- vision, continence, osteoporosis- increased chance of sustain harm.

Question 4

Describe a falls examination.

Answer 4

1. General exam of bruising + fractures
2. Cardiovascular: pulse, murmurs, bruits, lying/standing BP at 0 minutes (lying down), 1 minute (stood up) and at 3 minutes (stood up). Drop in 20/10 mmHg are sig associated. signs of HF - ankle oedema, pulm crackles
3. Neurological exam
4. Gait: timed up and go
5. Cognitive assessment
6. Feet, joints, eyes

Question 5

What are the investigations performed on a patient following a fall?

Answer 5

1. Comprehensive Geriatric Assessment
2. ECG- rule out arrhythmia (24h tape- only show abnormality 2% times when regular ECG normal/ Echo sometimes required)
3. Anything required to distinguish between syncope, falls and other
4. Neuro obs 24h Beware of intracranial symptoms- may not develop immediately in Subdural
5. Others: FBC (anaemia, infection); UE (dehydration, rhabdomyolysis, diuretic use), CK- if hx of long lie, Bone Biochem (Ca, P, Vit D, PTH)/ DEXA, Echo if murmur + HF signs, Tilt table test ?

Question 6

What are the 5 domains covered by the Comprehensive Geriatric Assessment?

Answer 6

1. Functional Aspects
2. Physical Health
3. Mental Health
4. Environment
5. Social Aspects

Question 7

What is polypharmacy?

Answer 7

The concominant use of >=4 drugs

Question 8

How should falls be managed?

Answer 8

Multi-factorial falls assessment
Medical review- optimize med comorbids, diagnose new conditions, cognitive screen, bone health assessment
Medication review- need for medicine and how they might be impacting on patient’s risk of falling
Manage postural hypotension with lifestyle- good hydration and salt intake, graded standing, compression stockings, avoid warm and crowded env
Bone health assessment
Nursing assessment- continence, vision, hearing + referral if req
Physical Therapy assessment- gait, balance, strength assessment + exercises, aerobic exercise
OT- home hazards assessment + intervention, perceived functioning status and fear of falling
Consider cardiac pacing for people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls.
education for patient and carers

Question 9

What are the different causes of “dizziness”?

Answer 9

1. Light-headedness: Cardiac e.g. AS/ Orthostatic Hypotension/ Reflex syncope. Near faint, often assoc w/ pallor, relieved by lying down.
2. Vertigo: illusion of movement, all head movements worsen. Caused by issues centrally e.g. cerebellar stroke, brainstem ischaemia, or peripherally- meniere’s disease, acoustic neuroma, benign paroxysmal positional vertigo.
3. Disequilibrium: sense of imbalance partic when walking. unsteady when upright. Suggests abnormal sensory input e.g. visual, vestib, proprioceptive.
4. Mixed: common to frail elderly

Question 10

Describe syncope

Answer 10

• transient global cerebral hypoperfusion leading to loc
• rapid onset with short duration and spontaneous complete recovery
• Cardiac: Arrhythmias- brady/ tachycardic/drug induced- e.g. antipsychotics, ionotropes, antiarrythmics, antianginals, Structural heart disease- valvular, MI, Cardiomyopathy, Tamponade, Patent Foramen Ovale, Aortic Dissection, PE
• Orthostatic Hypotension: Drug induced, Primary Autonomic Failure, Secondary Autonomic Failure, Volume Depletion

Question 11

What is the epidemiology of falls?

Answer 11

One-third of people aged 65+, and up to half of those aged 80+ fall each year
Every 5 hours in the UK an older person dies as a direct result of a fall
The 1 year mortality in people with fractured neck of femur is 20-35%
50% of those who fall will fall again in the next 12 months [11]
Following hip fracture half of those previously independent become partly dependent and one third become totally dependent

Question 12

What are the RF for falls?

Answer 12

Previous fall- single most important predictor
WOman
Testosterone deficiency
visual deficit
Walking device
OA
Sedatives - benzos, antipsychotics, antidepressants
DM- hypo/ neuropathy
Cardiac- Syncope
Balance/ gait disorder
Hyperthyroid
Incontinence

Question 13

What is the normal autonomic response to standing in a healthy person?

Answer 13

peripheral vasconstriction and rise in HR mediated by Sympathetic NS.