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Geriatrics > Falls > Flashcards

Falls Flashcards

1
Q

When should you investigate a fall

A

> 2 in 6 months

Admit and evaluate for a treatable cause

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2
Q

How do you manage syncope / elderly person found on floor

A

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

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3
Q

How do you manage falls

A 
Treat cause
CGA 
Strength and balance training = physio
Home hazard intervention / falls alarm- OT
Medication review
Cardiac pacing if necessary
Anddress and treat osteoporosis
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4
Q

What are the complications of immobility

A

Physical

  • Muscle wasting
  • Pressure sore
  • DVT
  • Constipation / incontinence
  • Hypothermia
  • Pneumonia
  • Osteoporosis

Psychological

  • Depression
  • Loss of confidence

Social
-Isolation

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5
Q

What are the RF for falls (often multifactorial)

A 
Previous Hx = most predictive 
Age >80 
Frailty 
Muscle weakness / sarcopenia 
Impaired mobility - PMR / OA
Poor nutrition 
Weight loss 
Polypharmacy 
Intrinsic / extrinsic / situaitional
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6
Q

What are intrinsic factors

A 
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
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7
Q

What are extrinsic factors

A 
Footwear
Weather
ENvironmental hazard - OT 
Impaired ADL
Social isolation 
Use of assistive device
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8
Q

What are situational factors

A

Medication
Alcohol
Incontience / urgency

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9
Q

What medication is involved with increased risk of falls

A 
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
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10
Q

What are drugs with anti-cholinergic properties

A 
TCA - amitriptyline
Anti-emetic
Anti-muscarinic
Ranitidine 
Anti-psychotic - clozapine 
Furosemimde / warfarin = synergistic effect
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11
Q

What causes gait and balance problems

A

Postural stability
Vertigo
Syncope

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12
Q

What is postural stability determined by

A

Cerebral perfusion requires CO + vasomotor tone

Posture and balance (vision / somatosensory / vestbular system / muscle mass / central processing)

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13
Q

How do you asses gait and balance

A 
Physio 
Sit-stand
Transfer
Get up and go <12s
Romberg test
Gait 
Static and dynamic standing 
FUnctional reach / timed walk / tandem walk
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14
Q

What are the causes of vertigo

A 
Benign Paroxysmal Positional Vertigo
Labrynthitis
Acute ear infection 
Meniere's - rare
Migraine 
Cerebellar / brain stem stroke
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15
Q

What is BPPV

A

Most common vestibular disorder
Dix-Hallpike test to Dx
Epley to Rx and remove otoconia

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16
Q

What does Menieres have

A

Vertigo - repeated attacks
Tinnitus
Hearing loss

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17
Q

What is labrynthitis

A

Inner ear infection

HEARING LOSS

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18
Q

What is syncope

A

Self limited LOC due to global cerebral hypoperfusion
Leads to loss of postural tone + fall
Rapid with rapid recovery

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19
Q

Is syncope common

A

Very common cause of falls

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20
Q

What is the underlying mechanism of syncope

A 
Neurally mediated
Cardiac
Orthostatic
Cerebrovascular
Seizure
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21
Q

What are the neurally mediated reflex causes of syncope

A

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

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22
Q

What do you do for vasovagal

A

If Dx certain = no further IV

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23
Q

What causes orthostatic

A

Cerebral hypoperfusion from lying-standing
Autonomic - Parkinson / neuropathy / MSA / DM
Volume depletion - blood / diarrhoea / Addison
Drugs
Sepsis - hypotension and collapse

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24
Q

What cardiac arrythmia cause falls

A 
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

25
Q

What structural cardiac disease can cause falls

A 
Valve e.g. AS
IHD 
Acute MI
Obstructive cardiomyopathy
Pericardial disease / tamponade 
PE
Subclavian steal 
Dissection
26
Q

What are red flag indicators for cardiac disease

A 
Exertional syncope or supine
FH sudden death
HF
Recent MI 
New SOB
Murmur 
Presence of ehart disease
Palpitation
Abnormal ECG
27
Q

What are abnormal ECG signs

A

Bradycardia
Long or short QT
T wav einversion

28
Q

What are cerebrovascular causes

A

Stroke / TIA - hemiparesis

Subclavian steal

29
Q

What is important in history

ALWAYS GET COLLATERAL

A 
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
30
Q

What is important to examine

A 
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
31
Q

When would you do a CT

A

> 65 + fall or on anti-coagulant = within 8 hours
Risk of subdural
Diff criteria if younger

32
Q

What further tests can be done

A 
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
33
Q

When would you do tilt table test

A

No cardaic cause or cardiac disease but defo not cause
Possibly exercise induced
See if change in position or HR causes

34
Q

How do you Dx carotid sinus sensitivty

A

Carotid sinus massage (massage internal carotid)

If +Ve i.e. 3s block = hypersensitivity

35
Q

What do you do for unexplained fall in <60

A

Holter

36
Q

What do you do for unexplained fall in >60

A

Carotid sinus massage
If +ve = hypersensitvity
If -ve = holter

37
Q

How do you differentiate between seizure and syncope

A 
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
38
Q

What is suggesive of syncope

A 
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
39
Q

What does acute illness do to cause fall

A

Limited cerebral reserve
Hypoxia = impaired balance
Infection / dehydration
Often delerium on top

40
Q

What cognitive impairment cause falls

A

Dementia
Deleirum
Depression

41
Q

How does cognition cause falls

A 
Impaired judgement
Abnormal gait
Visual - spacial perception
Can't recognise hazard
Immobility
42
Q

What are 4 important drug

A

Anti-hypertensive
Diuretic
Benzodiazepine . anxiolytic
Anti-cholinergic

43
Q

If a person says they dont remember falling what do you write

A

Found on floor

44
Q

What is interlinked with falls

A

Immoblity
Immbolity = sarcopenia
Falls = loss of confidence / injury / immbolity

45
Q

What is sarcopenia

A

Low muscle mass
Degenerative loss of muscle mass
Associated with frailty

46
Q

What causes sarcopenia

A 
DM
Elderly 
Chronic disease
Lack of use
Inflammation
Nutritional deficinecy
Endocrine causes
47
Q

What does rehab look at

A

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

48
Q

What will cause rapid decline

A

Cardiac - MI / arrythmia / hypersensitivity
Brain - haemorrhage ./ tumour
Sepsis
Poisin - new drug?

49
Q

87 admitted with fall, confused and on the floor

Trimethoprim by GP

A 
History
Check for injury
Assess cognition with 4AT and capaciy 
CT
ECG
Bloods 
Drug review
50
Q

80 with fall
New analgesia
Known epileptic
Very confused and off legs

A 
Postural BP
Urine dip 
4AT
ECG
Bloods 
CXR / urine if +Ve
Drug review
51
Q

What is the differential

A

Drug induced hyponatramia
UTI
Cancer / ulcer = GI bleed = anaemia = fall

52
Q

What is importnat to look for

A

Delerium
Subdural haemorrhage
Hip fracture
Dehydration

53
Q

Outcome after fall

A 
Injury - haemorrhage / fracture
Rhabdomyolysis = AKI
Pneumonia 
Immobility
Loss of confidence
Carer stress
Social isolation
Terminal deline
54
Q

Why is Hx important

A

Differentiate between vertigo / dizzy / syncope

55
Q

When do you do lying and standing BP

A

Important to do to look for postural drop

Not if unwell as will be dehydrated / unable to stand

56
Q

Likely causes

A

Probably BP

If no BP meds think Addison and do cortisol

57
Q

What are further tests to do in falls

A 
CK if long lie
hbA1c
Haematenincs - b12, folate, ferritn
Malabsorption screen e.g. coeliac if anaemia
Vit D
58
Q

What should elderly patient get after fall

A 
FRAX score calculated 
Bone screen 
- Vit D, Ca, phosphate, PTH, ALP 
- Mg may be important
- Myeloma screen

Geriatrics (8 decks)

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