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Medicine for the Elderly > Falls > Flashcards

Falls Flashcards

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
Q

What are some common drugs that increase falls?

A

Antidepressants, neuroleptics (haloperidol), anticholinergics, benzodiazepines, antihistamines, antiarrhythmics, antihypertensives, diuretics, opiates

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26
Q

How are falls screened for routinely?

A

have you had >=2 falls in the last 12 months?
Have you presented acutely with a fall?
Do you have problems with walking/balance?

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27
Q

What should be covered in the history of a fall?

A

Events before and after fall, impact of fall, eye-witness account, accurate medication list

28
Q

What should be covered in the examination?

A

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
Q

What areas should be covered in the neurological examination?

A

Cortical, extrapyramidal, cerebellar, vestibular, peripheral, Romberg test

30
Q

What should be covered in the CV of a patient after a fall?

A

Pulse rate and rhythm, murmurs, lying and standing BP

31
Q

How is lying and standing BP measured?

A

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
Q

What symptoms may occur during measurement of a lying and standing BP?

A

Dizziness, light-headedness, vagueness, pallor, visual disturbance, feelings of weakness and palpitations

33
Q

What are some assessment tools used for falls?

A

Timed up and go test (TUG), Berg balance scale, Tinetti score

34
Q

How is fracture risk assessed?

A

Using the FRAX risk assessment tool

35
Q

What is the aim of fall risk modification?

A

To reduce future falls and injuries = patients usually have more than 1 risk factor

36
Q

What are some interventions used to manage falls?

A

Strength and balance training, environmental modifications, footwear, visual optimisation, medication review, management of postural hypotension and cardiac pacing

37
Q

What are some features of strength and balance training?

A

3x weekly for at least 12 weeks = can use Otago exercise programme of falls management exercise (FaME)

38
Q

What might be some features of a medication review for a patient after a fall?

A 
STOP = psychoactive medication as priority, >4 medication
START = consider calcium or vitamin D
39
Q

How is the Dix-Hallpike manoeuvre performed?

A

Patient sits upright and rotates head to 45 degrees
Lie flat quickly and extend head to 20 degrees
Observe eyes for 45 seconds

40
Q

What is a positive result after the Dix-Hallpike manoeuvre?

A

Latency of onset, rotational nystagmus

41
Q

What is the link between psychotropic drugs and falls?

A

Use of these drugs roughly doubles the risk of falls

42
Q

What are some examples of antidepressants and antipsychotics that can cause orthostatic hypotension?

A

Duloxetine, venlafaxine, haloperidol

43
Q

How can use of phenytoin lead to falls?

A

May cause permanent cerebellar damage and unsteadiness = excess levels cause ataxia and unsteadiness

44
Q

What blood pressure is associated with an increased risk of falls?

A

Systolic BP <= 110mmHg

45
Q

How should CV drugs be managed in the elderly?

A

ACEi and beta blockers should be maintained

Nitrates, calcium channel blockers and other vasodilators should be stopped

46
Q

What is the most common neurological cause of ataxia in the elderly?

A

Peripheral neuropathy = results in impairment of distal proprioception and strength

47
Q

What features would make peripheral neuropathy functionally significant?

A

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
Q

What is the management of peripheral neuropathy?

A

Correct cane use, proper shoes and orthotics, balance and strength exercises

49
Q

What is the most common cause of syncope?

A

Orthostatic hypotension

50
Q

What is a drop attack?

A

Event where person suddenly collapses without any preceding symptoms or apparent TLOC

51
Q

How common are drop attacks?

A

Account for 20% of elderly patients presenting to Falls Services

52
Q

What are some causes of orthostatic hypotension?

A

Decreased autonomic buffering capacity
Parkinson’s disease and Lewy body dementia
Amyloidosis, diabetes, medication, volume depletion, physical deconditioning

53
Q

What is the management of orthostatic hypotension?

A

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
Q

What are some drugs used to treat orthostatic hypotension?

A

Fludrocortisone, midodine

55
Q

How common is carotid sinus syndrome?

A

Accounts for 40% of drop attacks

56
Q

What is carotid sinus syndrome?

A

Abnormal activation of the carotid sinus = leads to symptoms secondary to cerebral hypoperfusion

57
Q

Why is carotid sinus syndrome common in the elderly?

A

Due to increased baroreceptor sensitivity and reduced cerebral auto-regulatory mechanisms

58
Q

How is carotid sinus syndrome investigated?

A

Carotid sinus massage

59
Q

What are the contraindications to carotid sinus massage?

A

MI or CVA in last three months, history of VTE, carotid artery stenosis

60
Q

How is a carotid sinus massage treated?

A

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
Q

What are the sub-categories for positive carotid sinus massge results?

A

Cardio-inhibitory CSS = pause in HR >3s
Vasodepressor CSS = drop in systolic BP of 50mmHg
Mixed CSS = simultaneous combination of both

62
Q

What should be done in a patient with clinical signs of carotid sinus syndrome but a negative carotid sinus massage?

A

Consider referring for tilt-table carotid sinus massage

63
Q

What occurs in a tilt-table carotid sinus massage?

A

BP and HR measured continuously in supine position and during passive head tilt (usually at 60 degrees)

64
Q

How is a tilt-table carotid massage carried out?

A

Fast for >2 hours
Continuous ECG and BP monitoring
Gradual tilt to 60-80 degrees

65
Q

How long can tilt-table carotid sinus massages take?

A

20-45 mins depending on symptoms

66
Q

How is HR measured during a tilt-table carotid sinus massage?

A

Using RR intervals on an ECG

67
Q

How should a negative tilt-table carotid sinus massage result be managed in a patient with clinical signs of carotid sinus syndrome?

A

May give GTN spray to provoke symptoms

Medicine for the Elderly (9 decks)

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