Falls Flashcards
What to assess in history?
frequency
context and circumstances
severity
injuries
What examinations should be completed as part of a falls risk assessment?
A functional assessment of their mobility – how do they mobilise, what with and what is their gait like
Cardiovascular examination – include an ECG and a lying and standing BP (at immediate, 3 and 5 minutes)
Neurological examination
Musculoskeletal examination – assess their joints
vision examination
Home and hazards
medication review
What interventions can be done to reduce risk of falls?
strength and balance training
home hazard intervention
correct vision
modification/withdrawal of medication (cardiovascular, psychotropic)
Integrated management of contributing morbidities.
Intrinsic causes of falls?
Typically osteo/rheumatoid arthritis
Also:
Trauma: fractured NoF
Neuro: CNS disease, impaired vision, cognitive impairment, depression, peripheral neuropathy, parkinsonism (eg drugs: prochlorperazine, neuroleptics, metoclopramide)
Pharma (antihypertensives, sedatives), alcohol
Physiological: incontinence, hypothyroidism, renal impairment, hypothermia, muscle weakness (?vit D deficiency), postural hypotension
Infection: Pneumonia, UTI,
Risk factors for falling?
Lower limb muscle weakness Vision problems Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson's disease etc) Polypharmacy (4+ medications) Incontinence >65 Have a fear of falling Depression Postural hypotension Arthritis in lower limbs Psychoactive drugs Cognitive impairment
What questions to ask during falls history?
WHo saw you fall?
Where were you when you fell?
What happened before/during and after the fall?
Before: Any warning? Any dizziness/chest pain/palpitation?
During: Incontinence, LoC, tongue biting, pale/flushed (vasovagal)
When did you fall? - what were they doing at the time (looking upwards - vertebrobasilar insufficiency; out of bed - OH)
Why did you fall?
How many times hae you fell?
Medications that cause postural hypotension?
Nitrates diuretics Anticholinergic medications Antidepressants Beta-blockers L-Dopa (ACE) inhibitors
Medications that cause falls due to mechanisms other than postural hypotension?
benzodiazepines antipsychotics opiates anticonvulsants codeine digoxin other sedative agents
Tests to do for patients with a falls history or at risk?
Turn 180 degree test or the Timed up and Go test
Requirements for a multidisplinary assessment related to falls? What if they don’t meet this criteria?
> 65 with:
2 falls in last 12mo
A fall which requires medical treatment
Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
If they don’t meet the criteria: reviewed annually and given written information on falls.
Three fall risk assessment tools?
Falls Risk Assessment Tool (FRAT)
Morse Fall Scale
St Thomas Risk Assessment Tool in Falling Elderly Inpatients
Investigations to be performed in fall patients?
Basic obs Lying and standing BP Urine dip (infection; rhabdomyolysis) ECG Cognitive screening BM Bloods: FBC, U+Es, LFTs, Bone profile Imaging: CXR, CT head, Echo Specialist: Tilt table test, epley manoeuvre (BPPV), 48hr tape
Mechanisms by which medication can increase risk of falls?
Sedation
hypotension
bradycardia, tachycardia or periods of asystole
increase need for mobility (eg. diuretics increasing number of toilet times)
Mechanism by which benzodiazepines increase risk of falls?
causes drowsiness, slow reactions,
impaired balance.
Mechanism by which antidepressants increase risk of falls?
tricyclics and mirtazapine (+others) have some alpha blocking activity –> can cause orthostatic hypotension
All are antihistamines –> cause drowsiness, impaired balance and slow reaction times
Mechanism by which anti-psychotic drugs increase risk of falls?
some alpha receptor blocking activity –> orthostatic hypotension
also extrapyramidal SEs + Sedation, slow reflexes, loss of
balance
Mechanism for SNRI causes increased risk of falls?
Same as SSRI (?impaired sleep quality, rarely cause OH and bradycardia)
Also orthostatic hypotension (through noradrenaline re-uptake blockade)
Mechanism for alpha recpetor blockers increasing risk of falls?
can cause severe orthostatic hypotension
also stopping them may precipitate urinary retention in men
Mechanism for thiazides increasing risk of falls?
Cause OH, weakness due to low potassium.
Hyponatraemia
Mechanism for ACEis increasing risk of falls?
These drugs rely almost
entirely on the kidney for their elimination and can accumulate in dehydration or renal failure
Causes of fall: CVS, Neuro, GI, Urinary, Endocrine, MSK, ENT
CVS - Arrhythmias; Orthostatic hypotension; Bradycardia; Valvular heart disease
Neuro: Stroke, peripheral neuropathy
Urinary: Incontinence, UTI
ENdocrine: hypoglycaemia
MSK: Arthritis, disuse atrophy
ENT: BPPV; ear wax
When to do a full falls risk assessment? Components and interventions for each?
Completee once a transient loss of consciousness event has been ruled out
- Gait - PT
2 Visual problems -
Eye test and ensure wears glasses
3 Hearing difficulties - Remove earwax; Hearing assessment
4 Medications review - Reduce unnecessary medication
5 Alcohol intake -
Alcohol cessation advice; Alcohol service referral
6 Cognitive impairment - Referral to a psychiatric team
7 Postural hypotension - Review medication
Improve hydration
8 Continence - Treat or rule out infections; Continence assessment
9 Footwear - Ensure good fitting footwear
10 Environmental hazards - Turn on lights; Take up rugs
