Falls Flashcards
Know how to measure postural cardiovascular reflexes
It is a sensitive test, not specific.
Baroreflex - helps to maintain BP at a near constant level. If BP elevated, HR decreases. Receptors found in:
aortic arch
carotid sinus
All patients with a fall should have an ECG and postural BP checked as standard.
Some may need more detailed assessment (TILT table)
Carotid sinus massage is commenced for 5 seconds using longitudinal massage over the point of maximal carotid pulsation. This is followed by slowing of the pulse and a dramatic fall in BP
Which disorders affect balance?
Vision:
cataracts, ARMD, diabetic retinopathy
Proprioception:
Sensory neuropathy
Joint replacements
Ageing
Vestibular system:
Previous middle ear infections
Meniere’s disease
Ototoxic drugs
Brain:
Cerebrovascular disease
Dementia - affects judgement
Low BP (cerebral flow)
Effector mechanisms:
Proximal myopathy eg. steroid exposure. Vit D deficiency.
Any neurological disease.
Disuse atrophy
Which drugs may be used to reduce the incidence of falls
Fludrocortison sometimes in people with unexplained, persistently low BP - to increase circulating volume and thus raise BP
Vit D and Calcium to improve muscle strength on people who are Vit D deplete. This is evidence based
How can drugs increase the number of falls?
If patient taking 4 or more drugs, risk is said to be increased.
Sedatives (benzos, TCAs, anti-psychotics, anti-convulsants, antihistaminse)
Drugs causing hypotension (body may readjust ti antihypertensives, diuretics, beta-blockers, alpha-blockers, ACEI, ARB, TCAs, Anti-parkinsonian)
Drugs causing reduced visual accuity/blurred vision (eye drops, anticholinergics)
Drugs causing muscle weakness (baclofen)
Drugs causing ataxia (carbamazepine, phenytoin)
What are the risks for falls
Main risk is a fall in the last 12 months.
Intrinsic: DM Parkinsons Thyrotoxicosis Cataracts Osteoarthritis Metastatic prostate cancer
Females more likely
Visual deficit
Medication (benzos, anti-depressants)
Extrinsic: Highly polished wooden floors Poorly fitting slipper Walking stick Poor lighting conditions
Cognitive impairment Muscle weakness Osteoarthritis Home hazards Testosterone deficiency
Which conditions, according to NICE, increase risk of falls
Dementia Delirium Lower urinary tract symptoms in men Stroke Urinary incontinence in neurological disease Urinary incontinence in women
Consequences of fall (social and psychological)
Fear of fall. Social isolation due to avoidance. Anxiety and depression.
Injuries and fractures.
Causes significant stress to carer.
Institutionalisation
Physical consequences of falls
Trauma: soft tissue injury, fragility fractures, joint dislocation. SDH
“Long Lie”:
Hypothermia. Pressure sores. Dehydration and AKI. Infection eg. pneumonia
COSTLY TO NHS
What to remember about falls assessment
Fall is not a diagnosis!
Essential to diagnose the cause of the fall.
All falls are mechanical. Actually refers to ENVIRONMENTAL cause when most people use this term.
What things may be included in a multifactorial Risk Assessment (NICE)
Identify falls history Assessment of: Gait, balance, mobility, muscle weakness Osteoporosis risk Perceived functional ability Fear relating to falling Visual impairment Cognitive impairment and neuro exam Urinary incontinence Home hazards Cardiovascular exam Medication review
Which questionnaire is designed to assess frailty?
PRISMA 7 questionnaire
What are the items in the Prisma 7 questionnaire
score >3 identifies as frail
Gait speed (m/s) Timed up and go test (time taken to stand up from a standard chair, walk a distance of 3 metres, turn, walk back to the chair and sit down)
Self-reported health - how would you rate your health on a scale of 1-10. Cut off <6 for frailty
GP assessment - GP assesses frailty
Polypharmacy - if >4 medications
Groningen Frailty Indicator questionnaire. 15 item frailty questionnaire (suitable for postal completion). >4 indicates possible presence of moderate-severe frailty.
What are the interventions to prevent falls
Strength and balancing training
Environmental assessment
Medical review
