Falls Flashcards
When should you investigate a fall
> 2 in 6 months
Admit and evaluate for a treatable cause
How do you manage syncope / elderly person found on floor
History + collateral
Examination - postural BP, focussed neurological and CVS
Assess cognition and capacity - 4AT / MMSE
12 lead ECG
Bloods - FBC, U+E, CRP, BM, VBG
CXR / urine dip
Assess red flags
Any physical injury - X-ray
CT for anyone >65 / anti-coagulant within 8 hours
Drug review
Further tests
How do you manage falls
Treat cause CGA Strength and balance training = physio Home hazard intervention / falls alarm- OT Medication review Cardiac pacing if necessary Anddress and treat osteoporosis
What are the complications of immobility
Physical
- Muscle wasting
- Pressure sore
- DVT
- Constipation / incontinence
- Hypothermia
- Pneumonia
- Osteoporosis
Psychological
- Depression
- Loss of confidence
Social
-Isolation
What are the RF for falls (often multifactorial)
Previous Hx = most predictive Age >80 Frailty Muscle weakness / sarcopenia Impaired mobility - PMR / OA Poor nutrition Weight loss Polypharmacy Intrinsic / extrinsic / situaitional
What are intrinsic factors
Gait and balance Vertigo Syncope Chronic disease - MSK e.g. arthritis / deformity so examine - Neuropathy from B12 / DM / alcohol - Parkinson's causing tremor / weakness Acute illness Cognitive disorder Visual - Cataract / glaucoma / macular degeneration = very common VitD / B12 deficinecy - Proprioception / weakness / neuropathy?? Metabolic disturbances - Hypo or hyperglycaemia - AKI so U+E important
What are extrinsic factors
Footwear Weather ENvironmental hazard - OT Impaired ADL Social isolation Use of assistive device
What are situational factors
Medication
Alcohol
Incontience / urgency
What medication is involved with increased risk of falls
Drugs that cause postural hypo Anti-hypertensive - ACEI / BB / nitrates Anti-cholinergic Diuretics L-dopa
Other mechanism Sedatives Benzodiazepine Anti-psychotic Hypoglycaemic meds Opiates = confusion Steroids can cause atrophy / affect sugar / infection Anti-convulsants
What are drugs with anti-cholinergic properties
TCA - amitriptyline Anti-emetic Anti-muscarinic Ranitidine Anti-psychotic - clozapine Furosemimde / warfarin = synergistic effect
What causes gait and balance problems
Postural stability
Vertigo
Syncope
What is postural stability determined by
Cerebral perfusion requires CO + vasomotor tone
Posture and balance (vision / somatosensory / vestbular system / muscle mass / central processing)
How do you asses gait and balance
Physio Sit-stand Transfer Get up and go <12s Romberg test Gait Static and dynamic standing FUnctional reach / timed walk / tandem walk
What are the causes of vertigo
Benign Paroxysmal Positional Vertigo Labrynthitis Acute ear infection Meniere's - rare Migraine Cerebellar / brain stem stroke
What is BPPV
Most common vestibular disorder
Dix-Hallpike test to Dx
Epley to Rx and remove otoconia
What does Menieres have
Vertigo - repeated attacks
Tinnitus
Hearing loss
What is labrynthitis
Inner ear infection
HEARING LOSS
What is syncope
Self limited LOC due to global cerebral hypoperfusion
Leads to loss of postural tone + fall
Rapid with rapid recovery
Is syncope common
Very common cause of falls
What is the underlying mechanism of syncope
Neurally mediated Cardiac Orthostatic Cerebrovascular Seizure
What are the neurally mediated reflex causes of syncope
Primary = dehydration, standing, missed meal
Vaso-vagal -= most common cause (vagus nerve stimulated causing dilatation and hyper perfusion)
Carotid sinus hypersensitivity
Situational - haemorrhage / cough / GI stimulation / exercise
What do you do for vasovagal
If Dx certain = no further IV
What causes orthostatic
Cerebral hypoperfusion from lying-standing
Autonomic - Parkinson / neuropathy / MSA / DM
Volume depletion - blood / diarrhoea / Addison
Drugs
Sepsis - hypotension and collapse
What cardiac arrythmia cause falls
Sinus node - brady ./ tachy AV conduction / heart block Paroxysmal supraventrcular tachy (SVT) Long QT Brugada Implanted device Drug
May not be persistent so might not pick up on ECG which is why Holter is important
What structural cardiac disease can cause falls
Valve e.g. AS IHD Acute MI Obstructive cardiomyopathy Pericardial disease / tamponade PE Subclavian steal Dissection
What are red flag indicators for cardiac disease
Exertional syncope or supine FH sudden death HF Recent MI New SOB Murmur Presence of ehart disease Palpitation Abnormal ECG
What are abnormal ECG signs
Bradycardia
Long or short QT
T wav einversion
What are cerebrovascular causes
Stroke / TIA - hemiparesis
Subclavian steal
What is important in history
ALWAYS GET COLLATERAL
When, where, why, previous falls RF for falls Before - Any Sx e.g. dizzy Any trigger / concurrent illness - why do they think During Recovery quick or slow - vasovagal quick Sx - LOC / dizzy / vertigo / amnesia / headache or injury / vomit / After - any long lie Alcohol DM Thick each system Cardiac - SOB or palpitation or pain Neuro - Weakness - Seizure
Background
- How many falls last 6 month
PMH DH SH - ADL / carers / independence - Smoking / alcohol FH sudden cardiac death
What is important to examine
Vital signs / NEWS ALWAYS document fluid status Lying and standing BP CVS / chest Neuro - Asymmetry - Power / tone - Cerebellar - Gait - Balance MSK Vision / hearing Abdo exam Feet exam for neuropathy / DM AMTS Injuries - X-Ray / CT
When would you do a CT
> 65 + fall or on anti-coagulant = within 8 hours
Risk of subdural
Diff criteria if younger
What further tests can be done
Postural BP + CT = main Cardiac evaluation ECHO EEG MRI Cardiac stress Holter test for unknown - 24 hour cardiac monitor to pick up arrythmia Tilt table test Asses gait / balance - clinic
When would you do tilt table test
No cardaic cause or cardiac disease but defo not cause
Possibly exercise induced
See if change in position or HR causes
How do you Dx carotid sinus sensitivty
Carotid sinus massage (massage internal carotid)
If +Ve i.e. 3s block = hypersensitivity
What do you do for unexplained fall in <60
Holter
What do you do for unexplained fall in >60
Carotid sinus massage
If +ve = hypersensitvity
If -ve = holter
How do you differentiate between seizure and syncope
Seizure has 1+ of Bitten tongue Head turning No memory of abnormal behaviouro Unusual posture Prolonged limb - jerk Fast tonic clonic fall May be rigid CYanosis Confused after / prolonged post-octal Prodromal deja vu / aura
What is suggesive of syncope
Prodromal vision / N+V / sweat / tinnitus / light-headed - abolished if sit dwon Trigger Prolonged standing precipitates Slow fall Bradycardia Lumpness Return of consciousness quick and no post-octal Secondary anoxic seizure is possbile
What does acute illness do to cause fall
Limited cerebral reserve
Hypoxia = impaired balance
Infection / dehydration
Often delerium on top
What cognitive impairment cause falls
Dementia
Deleirum
Depression
How does cognition cause falls
Impaired judgement Abnormal gait Visual - spacial perception Can't recognise hazard Immobility
What are 4 important drug
Anti-hypertensive
Diuretic
Benzodiazepine . anxiolytic
Anti-cholinergic
If a person says they dont remember falling what do you write
Found on floor
What is interlinked with falls
Immoblity
Immbolity = sarcopenia
Falls = loss of confidence / injury / immbolity
What is sarcopenia
Low muscle mass
Degenerative loss of muscle mass
Associated with frailty
What causes sarcopenia
DM Elderly Chronic disease Lack of use Inflammation Nutritional deficinecy Endocrine causes
What does rehab look at
Impairment - due to strctural / functional change e.g. hemiparesis due to infarct
Activity restriction - relearn skills / SLT / neuropsychology
Participation restriction - modify environment to not restrict
Set goals and tackle all 3
What will cause rapid decline
Cardiac - MI / arrythmia / hypersensitivity
Brain - haemorrhage ./ tumour
Sepsis
Poisin - new drug?
87 admitted with fall, confused and on the floor
Trimethoprim by GP
History Check for injury Assess cognition with 4AT and capaciy CT ECG Bloods Drug review
80 with fall
New analgesia
Known epileptic
Very confused and off legs
Postural BP Urine dip 4AT ECG Bloods CXR / urine if +Ve Drug review
What is the differential
Drug induced hyponatramia
UTI
Cancer / ulcer = GI bleed = anaemia = fall
What is importnat to look for
Delerium
Subdural haemorrhage
Hip fracture
Dehydration
Outcome after fall
Injury - haemorrhage / fracture Rhabdomyolysis = AKI Pneumonia Immobility Loss of confidence Carer stress Social isolation Terminal deline
Why is Hx important
Differentiate between vertigo / dizzy / syncope
When do you do lying and standing BP
Important to do to look for postural drop
Not if unwell as will be dehydrated / unable to stand
Likely causes
Probably BP
If no BP meds think Addison and do cortisol
What are further tests to do in falls
CK if long lie hbA1c Haematenincs - b12, folate, ferritn Malabsorption screen e.g. coeliac if anaemia Vit D
What should elderly patient get after fall
FRAX score calculated Bone screen - Vit D, Ca, phosphate, PTH, ALP - Mg may be important - Myeloma screen
