Falls Flashcards
Consequences of falls
Hip # and other injuries Dependency - carer strain/ need for institutionalisation Immobility Further increased risk of falls Fear and social isolation Depression and anxiety
Risk factors for falls
a) Biggest one!
b) Intrinsic factors/ predisposing
c) Extrinsic factors/ precipitating
d) Main drug causes
a) Previously fallen (last 12 months)
b) Age, female, low BMI, comorbidities (diabetes, PD, arthritis, muscle weakness, cognitive impairment, depression, urinary incontinence, prostate Ca, vitamin D deficiency), sensory loss, polypharmacy,
c) Obstacles (rugs, etc.), poorly fitting shoes, poor lighting, polished floors, drug dose/infection/dehydration etc.
d) Benzodiazepines, antidepressants and antipsychotics, ototoxic drugs, diuretics, beta-blockers (and other antihypertensives), antihistamines (drowsiness), steroids and statins (myopathy)
Mechanisms involved in stability/ balance
- and things that may affect them
Vision - cataracts, AMD, diabetic retinopathy
Proprioception - sensory neuropathy, arthritis, age
Vestibular system - ototoxic drugs, Menieres, vertigo
Brain - CVD, dementia, low BP (postural HTN)
Effector mechanisms (quadriceps muscle) - vitamin D deficiency, statins and steroids, neurological disease
Three-pronged approach to falls prevention
- Which HCP would lead each of these?
What other intervention is effective (if indicated)
Strength and balance training (CV training, strength and conditioning, wobble boards) - PT
Environmental assessment (home hazards, etc.) - OT
Medical review (intrinsic factors) - physician
Cardiac pacing
OT home modification - examples
Bath seat/ lift
Raised toilet seat
Stair lift
Grab rails (shower, stairs)
Environmental hazards - examples
Loose cords Loose rugs Camouflage effect carpets Low sofas (difficult to rise from) Small gaps between furniture (hard to fit walking aid through)
Medical assessment:
- Identify causes (COPING)
- Optimise disease control
- Review medications
- Perform an assessment of…?
Cardiovascular causes e.g. syncope, ACS Opthalmic causes e.g. cataracts Psychiatric causes e.g. dementia Infective causes e.g. UTI causing a delirium Neurological causes e.g. stroke Gait disturbance
- Disease control (e.g. DM - glucose control)
- Also, any medications precipitating (unnecessary medications/inappropriate doses)
- Assess fracture risk (DEXA scan, FRAX score, etc.)
Investigating for causes of falls (consider COPING)
a) All patients should undergo what bedside tests?
b) If carotid sinus hypersensitivity suspected?
c) Examinations (systems)
d) Two specific tests for falls risk
e) General screening tests (BOXES)
a) BP (lying and standing: >20/10 mmHg drop), ECG
b) TILT test (carotid sinus massage to induce reduction in BP and HR)
c) CV (HR - AF, Heart block; carotid bruits - AS), MMSE, neuro (especially gait), visual
d) Timed up and go (instability/difficulty or > 12-14 seconds: pathological), Turn 180 degrees (> 4 steps: pathological)
e) Bloods (FBC, UEs, LFTs, Glucose, Calcium, TFTs, folate and B12, Vitamin D), Urinalysis, ECG, ?EEG, Imaging if syncope or injury suspected, visual assessments, cognitive screen
Drugs management of falls
a) General
b) If postural hypotension
a) Remove/reduce offending drugs, vitamin D and calcium to improve bone health
b) Add in fludrocortisone (or midodrine if severe autonomic dysfunction e.g. in PD)
An 82 year old patient presents with recurrent falls, witnessed by her daughter. On each occasion she has been witnessed to stumble or trip before falling to the ground. On one occasion she tripped over the edge of a rug, once she fell whilst getting out of the car and, on the most recent occasion, she fell out of the bath. She has not been noticed to lose consciousness. How would you manage?
3-pronged approach:
- Medical - review medications, identify cause (may be postural hypotension - take lying and standing BP)
- Environmental - home hazards assessment, and OT modifications (e.g. hand rails in bath, rid of rugs, etc.)
- Strength and balance training - CV, resistance and wobble board training, TAI CHI exercises!
What exercise training is particularly useful to reduce risk of falls?
Tai Chi - good for strength and balance
Hip fracture (proximal femur: #NOF)
a) Risk factors - NOF
b) Types
c) Symptoms
d) Signs O/E
e) Ix
f) Main management
g) Complications
a) No self-protection (low fat, poor reflexes e.g. due to neuro disease or sensory loss), Osteoporosis (and other bone disease - bone mets, osteomalacia), Fall risk
b) Intracapsular, Extracapsular (may be trochanteric or subtrochanteric)
c) Pain (outer thigh, groin or knee), unable to weight bear
d) Affected leg: shortened, ADDucted and externally rotated. Pain aggravated by rotation of hip
e) AP and lateral X-rays; also work-up (FBC and cross match, UEs, renal function, glucose), ECG, MUST, MMSE
f) Internal fixation with screws, ?VTE
g) Acute: Infection. Haemorrhage. Avascular necrosis.
Delayed union, malunion and non-union. Pneumonia.
DVT/PE. Pressure ulcers. Delirium
Long-term: immobility, dependence, infection, death
Improving physical exercise and mobility in the elderly
a) Solutions to instrinsic barriers
b) Solutions to extrinsic barriers
c) How much activity recommended per week?
a) Motivation, education, reassurance, change mindset
b) National policies, media campaigns, positivity, change environment
c) 30 mins moderate intensity 5 days per week
Risks of bisphosphonates
Atypical femoral fractures
Osteonecrosis of the jaw (ONJ)
Take first things in the morning, empty stomach, with lots of water, upright 30 minutes
Osteoporosis
a) Define
b) Fragility fracture - define. Common bones?
c) Secondary osteoporosis - causes
a) Hip BMD T-score > 2.5 SDs from the mean for young adult
b) Fragility fractures result from mechanical forces that would not ordinarily result in fracture. Vertebral, hip and forearm common
c) T1DM, OI in adults, chronic untreated hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition or malabsorption and chronic liver disease
