Falls

Question 1

What systems are involved in maintaining balance

Answer 1

1. Vision
2. Vestibular
3. Proprioception
4. Cognition (judgement and risk-taking)
5. Effector Mechanisms (muscles)

Question 2

What is the Baroreflex

Answer 2

Homeostatic mechanism designed to maintain blood pressure levels (impaired in postural hypotension)

E.g. Elevated BP = HR decrease = BP decrease

Question 3

How do you assess for postural hypotension

Answer 3

Lying standing (5 min supine, 3 min standing up) BP
(>20mmHg syst, >10mmhg diast drop = Postural HT) 

Tilt Table (more specialist)

Question 4

What is the definition of a fall

Answer 4

Event in which a person inadvertently comes to rest on the floor or a lower level, excluding the result of an overwhelming force, seizure or paralysis.

Question 5

What % of people that fall have a hip fracture

Answer 5

1%

Question 6

Whats the 1 year mortality of hip fractures in the elderly

Answer 6

20-25%

Question 7

What disorders may degrade vision

Answer 7

Macular Degeneration
Cataracts
Diabetic retinopathy
New Bifocal Lenses

Question 8

What disorders may degrade Proprioception

Answer 8

Ageing
Joint Replacement
Sensory Neuropathy

Question 9

What disorders may degrade The vestibular system

Answer 9

Ototoxicity
Menieres disease (vertigo + hearing loss + tinnitus)
Chronic/Repeated inner ear infection

Question 10

What disorders may degrade Cognition

Answer 10

Cerebrovascular disease
Dementia
Low BP –> ↓ cerebral blood flow

Question 11

What disorders may affect the muscles

Answer 11

Proximal Myopathy (vit D deficiency, steroids)
Any neurological disorder
Disuse Atrophy

Question 12

What classes drugs are known causes of falls in the elderly, give some specific examples

Answer 12

1. Anti-hypertensives (ACE- ß-B, CCB, Diuretics, A-blockers, AT1RAs, Vasodilators, TCAs, Antimuscarinics, L-DOPA, AChE-is)
2. Sedatives (TCA, Benzo, Opiates, Sedative antihistamines, Antipsychotics, Anticonvulsives)
3. Drugs that ↓ cognition (Eyedrops, Anticholinergics)
4. Drugs that ↓ Muscle strength (Baclofen, Carbamazepine, Phenytoin, Dantrolene)

Question 13

What conditions do NICE identify as particularly risk inducing for falls

Answer 13

1. Dementia
2. Delerium
3. LUTI in Men
4. Stroke
5. Incontinence in Women and neurological disease

Question 14

What are some intrinsic risk factors for Falls

Answer 14

Diabetes
Parkinson's Disease
Thyrotoxicosis
Cataracts
OA
Metastatic Prostate cancer
F>M
Polypharmacy

Question 15

What are some extrinsic risk factors for falls

Answer 15

Highly Polished floors 
Poorly fitting shoes
Carpets/Rugs
Walking stick
Poor lighting

Question 16

How do you investigate a fall

Answer 16

Head to toe Assessment 
History + Examination (especially CV system)
ECG 
Lying/standing BP
Bloods (FBC, CK if long lie, U+E, TFT, LFT, CRP, Bone profile + Vit D, Iron Profile) 
FRAX Score
Visual Assessment
Cognitive Assessment 
Gait Assessment 
Incontinence Assessment 
Home review for hazards 
PNS Exam
Medication Review

Question 17

What indicates postural hypotension on a lying standing BP

Answer 17

> 20mmHg syst, >10mmhg diast drop = Postural HT

Question 18

What interventions are available to prevent a fall

Answer 18

MDT Assessment + Care Plan

Strength and Balance Physiotherapy
Occupational Therapist home review
Medical Review (Diagnose reason for fall, optimise fracture risk (osteoporosis screen), optimise co-morbidity management, optimise medication)
Social Services if necessary for extra care

Question 19

Whats some Lifestyle advice for postural hypotension

Answer 19

Increase Salt diet
Stay Hydrated
Graded Standing
Compression Stockings