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Medicine for the Elderly > Falls > Flashcards

Falls Flashcards

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1
Q

How common are falls in older people?

A

30% of over 65s and 50% of over 80s fall each year

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2
Q

What are the human costs of falls?

A

Pain, mortality, distress, injury, loss of confidence and independence

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3
Q

What are the implications of falls?

A

40-60% suffer an injury and 5-10% of serious injury results in a fracture
10-20% become institutionalised
1/3 of patients fear falling again

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4
Q

What is the mortality associated with falls?

A

Older people who fall have a 10% probability of dying within 1 year

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5
Q

What is the morbidity of falls associated with?

A

Immobility = hypothermia, dehydration, pressure sores, rhabdomyolysis, VTE, bronchopneumonia

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6
Q

What patients are more likely to suffer from falls?

A

More common in women, residents of long term care, unwell patients in hospital and patients with cognitive impairment

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7
Q

What are the factors that interact to ensure people stay upright?

A

Motor co-ordination, biomechanics, sensory inputs and organisation

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8
Q

What contributes to motor co-ordination?

A

Frontal lobe motor planning, motor cortex, basal ganglia and cerebellar integration, peripheral nerve function

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9
Q

What contributes to biomechanics and sensory inputs and organisation?

A 
Biomechanics = skeletal integrity, joint stability and flexibility, muscle strength
Sensory = visual, vestibular, proprioception
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10
Q

How does the physiology of ageing contribute to falls?

A

Smaller pupils and lens thickening = detect less light
Decreased reaction time and cardiopulmonary fitness
Sarcopenia = loss of muscle mass and function
Decreased peripheral sensation and proprioception
Increased postural sway

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11
Q

What are some chronic conditions that increase the risk of falls?

A

CV disease and syncope, cognitive impairment, neurological disease, vestibular disease, vision problems, MSK and gait

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12
Q

What are some features of syncope as a cause of falls?

A

Accounts for 20% of unexplained falls
Be suspicious if significant facial injuries present
Pre-syncope can also result in falls

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13
Q

What are some common causes of syncope?

A

Arrhythmias, orthostatic hypotension, neurogenic (vasovagal), carotid sinus hypersensitivity, aortic stenosis

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14
Q

What results would allow for a diagnosis of orthostatic hypotension to be made?

A

Fall in systolic BP >20 mmHg or in diastolic BP >10 mmHg after 3 minutes of standing

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15
Q

How does cognitive impairment lead to falls?

A

Increases risk by 2x = accounts for 70-80% per year

Impairs judgement, visuo-spatial perception and orientation

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16
Q

What are some key neurological conditions that can cause falls?

A

Cervical myelopathy = high stepping gait, Romberg’s +
Peripheral neuropathy = altered sensation, wide gait
Lumbar stenosis = pain/paraesthesia, wide gait
Cerebellar ataxia = wide gait, cerebellar signs
Parkinson’s = shuffling gait, tremor, rigidity, bradykinesia, orthostatic hypotension

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17
Q

Why does vestibular disease cause falls?

A

Results in vertigo and dizziness

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18
Q

What is a common vestibular cause of falls?

A

Benign Paroxysmal Positional Vertigo = confirm with Dix-Hallpike manoeuvre, treat with Epley manoeuvre

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19
Q

How may vision affect falls?

A

Decreased vision associated with increased falls
Cataract surgery can decrease falls
Bifocal/varifocal lens high risk = alter depth

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20
Q

How common is gait as a cause of falls?

A

2/3 of falls will have gait disturbance

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21
Q

What are some features of balance and gait as a cause of falls?

A

Often results from specific disease = stroke, Parkinson’s, arthritis
Detectable muscle weakness in 48% of community residents and 80% of nursing home residents

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22
Q

What are some extrinsic risk factors for falls?

A

Medication, alcohol, environmental hazards, inappropriate clothing/footwear, inappropriate walking aids

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23
Q

How common are environmental hazards as a cause of falls?

A

Accounts for 25-45% of falls = clutter, rugs, poor lighting, no hand rails
10% of fall related deaths are due to stairs

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24
Q

Is polypharmacy a risk factor for falls?

A

Yes = use of >=4 medications is independent risk factor

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25
What are some common drugs that increase falls?
Antidepressants, neuroleptics (haloperidol), anticholinergics, benzodiazepines, antihistamines, antiarrhythmics, antihypertensives, diuretics, opiates
26
How are falls screened for routinely?
have you had >=2 falls in the last 12 months? Have you presented acutely with a fall? Do you have problems with walking/balance?
27
What should be covered in the history of a fall?
Events before and after fall, impact of fall, eye-witness account, accurate medication list
28
What should be covered in the examination?
Focused on risk factors/causes of falls ABCDE = precipitants, acute illness signs, signs of head injury, hip tenderness/ROM Gait, balance, joints, feet/footwear, visual acuity
29
What areas should be covered in the neurological examination?
Cortical, extrapyramidal, cerebellar, vestibular, peripheral, Romberg test
30
What should be covered in the CV of a patient after a fall?
Pulse rate and rhythm, murmurs, lying and standing BP
31
How is lying and standing BP measured?
1st BP = taken after lying for at least 5 mins 2nd BP = taken after standing for first minute 3rd BP = taken after standing for 3 mins
32
What symptoms may occur during measurement of a lying and standing BP?
Dizziness, light-headedness, vagueness, pallor, visual disturbance, feelings of weakness and palpitations
33
What are some assessment tools used for falls?
Timed up and go test (TUG), Berg balance scale, Tinetti score
34
How is fracture risk assessed?
Using the FRAX risk assessment tool
35
What is the aim of fall risk modification?
To reduce future falls and injuries = patients usually have more than 1 risk factor
36
What are some interventions used to manage falls?
Strength and balance training, environmental modifications, footwear, visual optimisation, medication review, management of postural hypotension and cardiac pacing
37
What are some features of strength and balance training?
3x weekly for at least 12 weeks = can use Otago exercise programme of falls management exercise (FaME)
38
What might be some features of a medication review for a patient after a fall?
``` STOP = psychoactive medication as priority, >4 medication START = consider calcium or vitamin D ```
39
How is the Dix-Hallpike manoeuvre performed?
Patient sits upright and rotates head to 45 degrees Lie flat quickly and extend head to 20 degrees Observe eyes for 45 seconds
40
What is a positive result after the Dix-Hallpike manoeuvre?
Latency of onset, rotational nystagmus
41
What is the link between psychotropic drugs and falls?
Use of these drugs roughly doubles the risk of falls
42
What are some examples of antidepressants and antipsychotics that can cause orthostatic hypotension?
Duloxetine, venlafaxine, haloperidol
43
How can use of phenytoin lead to falls?
May cause permanent cerebellar damage and unsteadiness = excess levels cause ataxia and unsteadiness
44
What blood pressure is associated with an increased risk of falls?
Systolic BP <= 110mmHg
45
How should CV drugs be managed in the elderly?
ACEi and beta blockers should be maintained | Nitrates, calcium channel blockers and other vasodilators should be stopped
46
What is the most common neurological cause of ataxia in the elderly?
Peripheral neuropathy = results in impairment of distal proprioception and strength
47
What features would make peripheral neuropathy functionally significant?
Loss of heel reflexes Decreased vibratory sense that improves proximally Impaired positional sense at big toe Inability to maintain unipedal stance for 10s in three attempts
48
What is the management of peripheral neuropathy?
Correct cane use, proper shoes and orthotics, balance and strength exercises
49
What is the most common cause of syncope?
Orthostatic hypotension
50
What is a drop attack?
Event where person suddenly collapses without any preceding symptoms or apparent TLOC
51
How common are drop attacks?
Account for 20% of elderly patients presenting to Falls Services
52
What are some causes of orthostatic hypotension?
Decreased autonomic buffering capacity Parkinson's disease and Lewy body dementia Amyloidosis, diabetes, medication, volume depletion, physical deconditioning
53
What is the management of orthostatic hypotension?
Stop causative medication, avoid sudden changes in movement, increase dietary salt, compression stockings, keep legs elevated, calf muscle exercises when standing for prolonged periods
54
What are some drugs used to treat orthostatic hypotension?
Fludrocortisone, midodine
55
How common is carotid sinus syndrome?
Accounts for 40% of drop attacks
56
What is carotid sinus syndrome?
Abnormal activation of the carotid sinus = leads to symptoms secondary to cerebral hypoperfusion
57
Why is carotid sinus syndrome common in the elderly?
Due to increased baroreceptor sensitivity and reduced cerebral auto-regulatory mechanisms
58
How is carotid sinus syndrome investigated?
Carotid sinus massage
59
What are the contraindications to carotid sinus massage?
MI or CVA in last three months, history of VTE, carotid artery stenosis
60
How is a carotid sinus massage treated?
Connect to monitor and BP cuff Obtain baseline BP and HR Lie patient flat and start rhythm strip printout Apply pressure for 5s to carotid sinus whilst colleague hits "mark" to signify start Check BP = maximal drop at 15s Repeat for other side once HR returns to normal
61
What are the sub-categories for positive carotid sinus massge results?
Cardio-inhibitory CSS = pause in HR >3s Vasodepressor CSS = drop in systolic BP of 50mmHg Mixed CSS = simultaneous combination of both
62
What should be done in a patient with clinical signs of carotid sinus syndrome but a negative carotid sinus massage?
Consider referring for tilt-table carotid sinus massage
63
What occurs in a tilt-table carotid sinus massage?
BP and HR measured continuously in supine position and during passive head tilt (usually at 60 degrees)
64
How is a tilt-table carotid massage carried out?
Fast for >2 hours Continuous ECG and BP monitoring Gradual tilt to 60-80 degrees
65
How long can tilt-table carotid sinus massages take?
20-45 mins depending on symptoms
66
How is HR measured during a tilt-table carotid sinus massage?
Using RR intervals on an ECG
67
How should a negative tilt-table carotid sinus massage result be managed in a patient with clinical signs of carotid sinus syndrome?
May give GTN spray to provoke symptoms

Medicine for the Elderly (9 decks)

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