Falls

Question 1

Implications of falls?

Answer 1

Immobilisation after a falls is associated with:
• Hypothermia
• Dehydration
• Pressure sores
• Rhabdomyolysis 
• Venous thromboembolism
• Bronchopneumonia
• Muscular de-conditioning

Fear of falling - a history of falls increases risk; leads to social isolation, loss of confidence and functional decline

Question 2

Occurrence of falls?

Answer 2

More common in women and residents of long-term care

Often hospital inpatients

Patients with cognitive impairment

Question 3

Causes of falls?

Answer 3

MULTI-FACTORIAL - there is ALWAYS more than 1 reason:
• Person (intrinsic) factors - includes physiology of ageing and pathology that is commonly assoc. with ageing
• Environment (extrinsic) factors
• Activity

Question 4

Why does physiology of ageing (intrinsic factor) increase the risk of falls?

Answer 4

Vision - smaller pupils, lens thickening

Central processing and recognition - decreased reaction time

Decreased cardiorespiratory fitness

Sarcopenia - loss of muscle mass and function

Decreased peripheral sensation and proprioception contributes to increased postural sway

Question 5

Common age-related pathologies?

Answer 5

The following all increase falls risk:
• CV disease and syncope
• Cognitive impairment
• Neurological 
• Vestibular disease
• Vision problems 
• MSK/gait

Question 6

Common description of syncope as a cause of falls?

Answer 6

“I just go down”; they often assume they must have tripped

Suspicious if there are significant facial injury or a Hx of pre-syncope before the fall

20% of unexplained falls are due to syncope

Question 7

Common conditions underlying syncope?

Answer 7

Arrhythmias

Orthostatic hypotension

Neurogenic (vasovagal) - simple faint

Carotid sinus hypersensitivity

Valvular heart disease (aortic stenosis)

Question 8

Define orthostatic hypotension?

Answer 8

After 3 minutes of standing:
• A fall in systolic BP of >20 mmHg
OR
• A fall in diastolic BP of >10 mmHg

Question 9

Risk factors for orthostatic hypotension?

Answer 9

Mediated by the ANS so there is an increased risk with:
• Diabetes
• Hypertension and anti-hypertensive drugs
• Parkinson’s disease (due to the disease itself and the drugs used to treat it, e.g:
Levodopa)
• Polypharmacy

Question 10

How does cognitive impairment

Answer 10

2x more likely to fall if cognitively impaired, as it affects:
• Judgement
• Visual-spatial perception
• Orientation

Question 11

Key neurological disorders that cause falls?

Answer 11

Cervical myelopathy patients have a high-stepping gait and Romberg’s test is +ve

Peripheral neuropathy causes altered sensation; patients have a wide-based gait

Lumbar stenosis causes pain and paraesthesia in legs

Cerebellar ataxia can occur in those with chronic alcohol withdrawal or if they have had a previous stroke; patients have a wide-based gait and cerebellar signs

Parkinson’s disease is characterised by shuffling gait, tremor, rigidity and bradykinesia; common cause of orthostatic hypotension as well

Stroke

Question 12

Describe Romberg’s test

Answer 12

Patient stands with feet together; doctor stand behind and asks them to close their eyes

Check how unsteady they are

Question 13

Symptoms of vestibular disease?

Answer 13

Vertigo and imbalance; clarify what a patient means by “dizzy”, as many do not describe true vertigo

Question 14

Common vestibular disease? Examination and treatment?

Answer 14

BPPV - confirm with Dix-Hallpike manoeuvre and treated with Epley manoeuvre

Question 15

Examples of how vision can increase the risk of falls?

Answer 15

Age-specific changes

Consider cataract surgery to decrease the risk of falls

Bifocal/varifocal lens pose a high risk, as they alter depth perception

Question 16

How common are gait disturbances as a part of falls?

Answer 16

2/3rds of falls will have this, often resulting from specific disease:
• Stroke
• Arthritis
• Parkinson’s disease

Question 17

Environmental (extrinsic) factors that increase the risk of falls?

Answer 17

• Medications
• Alcohol
• Environmental hazards, e.g: clutter, rugs, poor lighting, no hand rails, stairs (consider environment modification)
• Inappropriate clothing/footwear
• Inappropriate walking aids

Question 18

Why is medication a risk factor for falls?

Answer 18

Common contributor and, if a patient has polypharmacy consisting of ≥4, this is an INDEPENDENT FALLS RISK FACTOR

Question 19

Common drugs that increase the risk falls?

Answer 19

Two main classes are:
• Benzodiazepines (‘pams’)
• Neuroleptics (‘peridols’)

Other common contributors:
• Anti-hypertensives 
• Anti-depressants 
• Anti-cholinergics
• Class 1A anti-arrhythmic drugs

Question 20

What does a FALLS ASSESSMENT consist of?

Answer 20

History (often a collateral history is also helpful)

Examination:
• Focus on risk factors and cause of falls
• Tools for assessing gait and balance

Establish all RISK FACTORS for the patient

Target Ix

Question 21

What should a falls history include?

Answer 21

Prevention - screen for falls routinely
• Have you had 2/more falls in the last 12 months?
• Have you presented acutely with a fall?
• Problem with walking/balance?

Full history:
• What happened before and after the fall?
• Impact/consequences?
• Frequency of falls?
• Medication list?

Question 22

Examination of falls patient?

Answer 22

Gait, balance, joints

Nueological and Romberg’s test

CVS - pulse rate/rhythm, murmurs, lying and standing BP (for orthostatic hypotension)

Visual acuity (Snellen chart)

Feet and footwear

Incontinence assessment

Question 23

How to measure a lying and standing BP?

Answer 23

1st reading taken after lying for at least 5 minutes

2nd reading taken after standing in the 1st minute

3rd reading taken after standing for 3 minutes

Question 24

Assessment tools to check the risk of fools?

Answer 24

Timed Up and Go test (TUG) - patient stands from a chair and the time is switched on, walk 3 metres, turn around and walk back to sit in the chair.
>12 seconds is abnormal

Burg balance test

Tinetti score

Question 25

Fracture assessment tools?

Answer 25

FRAX or Qrisk scores

Consider a DEXA scan and treat osteoporosis

Question 26

Risks assoc. with being housebound or in care?

Answer 26

Vit D deficiency

Question 27

Interventions to reduce the risk of falls?

Answer 27

Strength and balance training (STRONGEST EVIDENCE) - must be done 3x per week for a minimum of 12 weeks

Environmental modification to reduce potential hazards

Footwear and foot care

Vision optimisation

Patient education and treatment

Medication review

Management of postural hypotension

Cardiac pacing, if indicated

Question 28

How should a medication review in a falls patient be carried out?

Answer 28

STOP some medications if >4 are being taken:
• Psychoactive medications (part. benzodiazepines and neuroleptics take priority)
NOTE: do not abruptly stop benzodiazepines; titrate the dose down
• Tramadol, codeine, etc (start at the bottom of the pain ladder, if possible)

START to consider Ca2+ and vit D supplementation and fracture risk assessment/osteoporosis treament