Falls Flashcards
How often do people over the age of 65 and those over the age of 80 fall each year?
- 30% of over 65s fall each year
- 50% of over 80s fall each year
What are some of the medical conditions which can develop as a result of a fall ?
- Hypothermia
- Dehydration
- Pressure sores
- Rhabdomyolysis
- Venous thromboembolism
- Bronchopneumonia
- Muscular de-conditioning
What are some of the impacts of falling ?
- Pain
- Distress
- Injury
- Loss of confidence
- Loss of independence
- Mortality
What can the fear of falling again result in ?
1/3rd of patients fear falling again resulting in:
Who are the at risk people of falling ?
- Women more than men
- More common in residents of long-term care –50% residents fall per year
- Unwell patients in hospital
- Patients with cognitive impairment
What are some of the common conditions which increase the risk of falls ?
- Cardiovascular disease/syncope
- Cognitive impairment
- Neurological
- Vestibular disease
- Vision problems
- Musculoskeletal/gait
What is a common cause of unexplained falls in the elderly and when should you be suspicious of it ?
Syncope - be suspicious of it in elderly patients with unexplained facial injuries
What is syncope ?
Syncope is a temporary loss of consciousness usually related to insufficient blood flow to the brain. It’s also called fainting or “passing out.”
What are some of the common causes of syncope ?
- Arrythmias
- Orthostatic hypotension
- Neurogenic (vasovagal)
- Carotid sinus hypersensitivity
- Valvular heart disease (Aortic stenosis)
Bascially think, postural hypotension, cardiac causes of vasovagal as the causes of syncope
Describe vasocagal syncope
Vasovagal syncope occurs when you faint because your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. It may also be called neurocardiogenic syncope.
This also causes temporary decreased blood flow to brain resulting in the faint, as it causes a sudden drop in BP and HR
Define orthostatic hypotension and what it is also known as
This is defined as a decrease in systolic BP of 20mmHg or a decrease in diastolic BP of 10mmHg within/after 3 mins of standing when compared with BP from the sitting or supine position
Give some examples of neurological disorders which increase the risk of falls
Cervical myelopathy:
- High-stepping gait
- Romberg’s positive
Peripheral neuropathy:
- Altered sensation
- Gait wide-based
Lumbar stenosis:
- Pain/paraesthesia legs
- Gait wide-based
Cerebellar ataxia
- Gait wide-based
- Cerebellar signs
Parkinson’s disease:
- Shuffling gait
- Tremor, rigidity, bradykinesia
- Orthostatic hypotension
Stroke disease
How does cognitive increase the risk of falls and by how much does it increase the risk ?
2x’s as likely to fall because Cognitive impairment impairs:
- Judgement
- Visual-spatial perception
- Orientation
How does vestibular disease increase the risk of falls ?
Results in vertigo and imbalance e.g. BPPV
What are the symptoms, provoking factors and duration of symptoms for BPPV ?
Also how is it treated and diagnosed ?
Symptoms - vertigo
Provoking factors - lying flat, sitting up from lying flat; turning over in bed; looking up (e.g. hanging washing) or bending down,
Duration - brief; usually five to 30 seconds
Diagnosis - Dix-Hallpik manouvre
Treatment - Epley manoeuvre
How does vision problems increase the risk of falls ?
- Decreased vision less likely to see where putting feet
- Bifocal/varifocal lens can increase risk by Altering depth perception
What will 2/3rds of people experiencing a fall have ? and give some examples of conditions which cause it
- 2/3rd of falls will have a gait disturbance
- Often results from specific diseases –Stroke, arthritis, Parkinson’s
What are some of the extrinsic factors causing falls ?
- Medication
- Alcohol
- Environmental hazards
- Inappropriate clothing/footwear
- Inappropriate walking aids
Give examples of some common medications which can increase the risk of falls
- Benzodiazepines e.g. lorazepam, diazepam
- Neuroleptics e.g. clozapine
- Antihypertensives
- Antidepressants e.g. amitriptyline
- Anticholinergics e.g. dihenhydramine
- Class 1A antiarrthymics e.g. quinidine
Note OH stands for orthostatic hypotension
What is an indepdant risk factor for falls but still talking about medications ?
Use of polypharmacy greater than or equal to 4 meds
What should be done in a falls assessment ?
History taken including:
- What happened before and after fall?
- Impact/consequence of fall
- Frequency of falls
- Accurate medication list
Exammination:
- Gait, balance, joints
- Neurological; Cortical, Extrapyramidal, Cerebellar, Vestibular, Peripheral, Romberg test
- CVS; Pulse rate/rhythm, Murmurs, Lying and standing BP
- Visual acuity (Snellen chart)
- Feet and footwear
- Incontinence assessment
What are some of the tests which can be used to assess someones gait,balance, mobility etc i.e. risk of falls
- Timed up and go test (TUG)
- Berg Balance test
- Tinetti Score
What should be done for diagnosing someone with orthostatic hypotension ?
Check lying and standing BP:
- 1st BP: taken after lying for at least five minutes.
- 2nd BP: taken after standing in the first minute
- 3rd BP: taken after standing for three minutes
What risk assessment method should be used for assessing someones risk of fractures ?
FRAX assessment
How is osteoporosis diagnosed and managed ?
Diagnosis = DEXA scan
Management:
1st line = bisphosphonates e.g. aledronic acid + calcium and vit D supplementation (ergocalicferol (vit D) + calcium)
When can you not take bisphosphonates and what is the alternative to them?
- When eGFR < 35
- Alternative is denosumab - give this to the renal patients with too poor an eGFR for oesteoporosis
When are bisphosphonates recommended to be taken and why?
Sitting up with a big drink of water - as they can upset the gullet
What is the key intervention for reducing the risk of falls ?
Strength and balance training for 3x per week for a min of 12wks:
- Otago exercise programme
- FaME: Falls Management Exercise
- Some forms of Tai Chi
What are some of the other interventions which can be done to reduce the risks of falls ?
- Environmental modifications
- Footwear and foot care
- Vision optimization
- Patient education and treatment
- Medication review
STOP:
- >4 medications = independent risk factor for falls
- Psychoactive medication priority & best evidence
–START
- Consider Calcium/Vitamin D +/- bisphosphonates for osteoporosis
- Best evidence in longterm care setting/proven vitamin D deficiency
- Fracture risk assessment/osteoporosis treatment
- Management of postural hypotension
- Cardiac pacing if indicated
