Falls Flashcards
Falls can be boadly classified into syncopal and non-syncopal falls. What is syncope?
Syncope= transient loss of consciousness characterised by fast onset and spontaenous recovery. It is caused by reduced perfusion pressure to the brain. Usually self limiting- being horizontal will fix low blood pressure.
What is meant by pre-syncope?
Symptoms preceeding a syncope e.g. light headedness, sweating, pallor, blurred vision
State 3 broad categories of syncope
State any subcategoreis within each
-
Reflex/neurally medaited syncope
- Vasovagal
- Situational
- Carotid sinus massage
- Orthostatic hypotension
- Cardiac/cardiopulmonary disease
Describe the mechanism behind reflex/neurally mediated syncopes
A ‘stress’ of some form causes a sudden, transient change in autonomic efferent activity; inhibition of sympathetic system and increased output from parasympathetic system. Results in bradycardia and peripheral vasodilation leading to reduced cerebral perfusion pressure (below compensatory limits of cerebral autoregulation).
Subcategories of reflex/neurogenic syncope:
- Vasovagal: normally triggerd by reduction in venous return due to prolonged standing, excessive heat or a large meal. Decreased venous return to ventricles causing them to vigouroulsy contract in attempt to maintain cardiac output. Ventricular mechanoreceptors are then triggered causing vasodilation and bradycardia.
- Carotid sinus massage: increase pressure in carotid sinus hence baroreceptors interpet this as high BP so attempt to lower BP
- Situational: identifiable trigger leads to vasovagal reaction e.g. micturtion, defaecation, coughing
State some causes of situational syncope
- Micturition
- Defaecation
- Coughing
- Weight lifting
Cardiopulmonary syncopes can be due to two main reasons; state these and explain how they can lead to syncope
- Arrhythmia: arrythmia leads to inadequete cardiac output
- Structural heart disease: e.g. severe aortic stenosis or hypertrophic obstructive cardiomyopathy can lead to light headedness or syncope on exertion due to fall in cardiac output
State some potential causes of falls
-
Cardiovascular
- Orthostatic hypotension
- Arrhythmias
- Bradycardia
- Valvular heart disease
- ACS
-
Neurological
- Stroke
- Peripheral neuropathy
- Dementia
- Epilepsy
-
Genitoruinary
- UTI
- Incontinence
-
Endocrine
- Hypoglycaemia
- Hypothyroidism
- Anaemia
-
GI
- Chronic diarrhoea
- Diverticulitis
- Chronic liver disease
-
MSK
- Arthritis
- Disuse atrophy
-
ENT
- Benign paroxysmal positional vertigo
- Ear wax
-
Medications
- Beta blockers (bradycardia)
- Antihypertensives (hypotension)
- Benzodiazepines (sedation)
- Anti-depressants
- Daibetic meds (hypoglycaemia)
- Abx (infection going on)
- Polypharmacy
-
Other
- Balance issues
- Muscle weakness
- Visual impairment
- Fatigue
- Environmental hazard
- Alcohol
What are some key questions you must ask someone if they have come in with a fall?
Think: who, when, where, what (before, during, after), why, how
Who
- Who has seen you fall?
- If someone has seen them, get collateral history. Ask what they looked like prior to fall etc..
When
- When did you fall?
- What were you doing?
Where
- Where did you fall? Outside, inside, home, at shop etc…
What
- Before:
- Any dizziness? If so clarify what they mean…
- Any light headedness?
- Any cardiac symptoms e.g. palpitations, chest pain?
- During:
- Did you lose consciousness? If so for how long?
- Was there any tongue biting? Any incontinence?
- Where you pale or flushed?
- What part of body hit floor first?
- Did you injure yourself?
- After
- What happened after fall?
- Could you get yourself off the floor?
- How long did it take?
- Could you resume normal acitivities?
- Was there any confusion?
- Was there any weakness or speech difficulty after the event
Why
- Did you trip over anything?
- What medications are you on?
How
- How many times have you fallen before or had any near misses?
- How do you normally mobilise?
What medications are you particularly interested in when taking a falls history?
- Sedatives e.g. benzodiazepines
- Cadiac medications e.g. beta blockers, antihypertenisves
- Anticholinergics
- Diabetic medications with hypoglycaemia risk e.g. insulin, sulphonylureas
- Opiates
When examining a pt who has had a fall, what are the key things you should examine?
- AMT-10 test to check for confusion
- A functional assessment of their mobility: how do they mobilse, gait, any aids
- Cardiovascular examination
- Neurological examination
- MSK examination: assess joints for stiffness, tenderness etc…
- General inspection of their overall state
What investigations would you consider in a pt who has had a fall, include:
- Bedside
- Bloods
- Imaging
*Assume you have no idea what the cause of the fall is. Justify why you are doing each investigation
Bedside
- ECG (and consider 24hr cardiac monitor): check for arrhythmias
- Lying & standing BP (immediate, 3 mins, 5 mins):check for postural drop
- Urine dipstick and/or urine culture: remember dipstick is often +ve in elderly so may just go straight to culture
- Plasma glucose: check hypoglycaemia
- ?sputum culture: if think chest infection
- Swab any open wounds: if concerned about infection
Bloods
- FBC: may show anaeamia, high WCC for infection
- U&Es: electrolyte imbalances could make confused, if led on floor long time may have rhabodmyolysis leading to AKI
- LFTs: check baseline
- TFTs: thyroid problems can cause confusion
- CRP: infection
- ESR: infection
- Coagulation screen: assess bleeding risk
Imaging
- CXR: if ?chest infection
- Other x-ray: ?fractures
- CT head:?cranial bleed
You must assess the risk of _____ in patients who fall
Osteoporosis.
Assess risk using FRAX tool. Then consider DEXA scan and decide if treatment is needed. If a pt over 75yrs comes into hospital and fractures a long bone with minimal trauma they are often started on treatment for osteoporosis automatically (i.e. don’t bother with FRAX assessment)
Discuss the management of falls
Management involves multifactorial approach and depends on underlying cause:
- Medication review
- Physiotherapy input: exercises, mobility aids, increase confidence
- Occupational therapy input: adaptations at home
- Graded standing if orthostatic hypotension is the cause (lying-sitting-standing) aswell as compression stockings and adequete salt and fluid intake
- Refer to opthalmology if necessary
- Treat any other underlying cause e.g. arrhythmia, stroke, ACS etc…
State some potential complications/consequences of a fall
- Loss of confidence
- Serious injury
- Fragility fracture
- AKI due to rhabdomyolysis as a result of a long lie
State some potential reasons why a pt may report they feel “dizzy/woozy/giddy”
- Vertigo (illusion of rotation or spinning)
- Presyncopal (near faint)
- Unsteady (sense of imbalance)
- Psychogenic (includes anxiety, panic attacks, somatisation)
- Mixed
Syncope summary
