Falls

Question 1

List some intrinsic factors that can contribute to falls?

Answer 1

Medical conditions:

• diabetes > neuropathy > altered proprioception and vision
• arthritis, PD, stroke > altered gait pattern
• incontinence > increased rushing, getting up at night
• cognition > dementia

Impaired vision and hearing
Age related changes in gait, postural reflexes, muscle strength etc.

Question 2

List some extrinsic factors that can contribute to falls?

Answer 2

medications
environmental
inappropriate footwear
inappropriate use of walking aids

Question 3

List some classes of drugs that can increase risk of falls?

Answer 3

diuretics 
anti-hypertensives
sedatives
anti-cholinergics 
hypoglycaemic agents 
anti-arrhythmics 
psychotropics

Question 4

How do anti-hypertensives increase risk of fall?

Answer 4

they cause syncope because they can cause postural hypotension

Question 5

How do anticholinergics increase risk of falls?

Answer 5

they cause blurred vision and drowsiness

Question 6

How do diuretics increase risk of falls?

Answer 6

people need to get up more to go to toilet particularly in night, and may be rushing

Question 7

In older people a systolic BP of ______ is associated with increased risk of falls?

Answer 7

110mmHg or below

Question 8

If someone has systolic of 110mmHg or below what should be stopped and what drugs should be kept going if possible?

Answer 8

stop vasodilators such as CCB and nitrates and stop alpha blockers that cause vasodilation but may be being used in context of prostatism
ACEi and B blockers have a survival benefit in systolic cardiac failure so should be the last drugs to go

Question 9

Presentation of orthostatic hypotension?

Answer 9

typical history of postural symptoms, confirmed by lying/ standing blood pressure

Question 10

List some causes of orthostatic hypotension?

Answer 10

medications
decreased autonomic buffering capacity
peripheral neuropathy > autonomic neuropathy > neurogenic OH
neurogenic OH in PD and LBD

Question 11

Conservative management of orthostatic hypotension?

Answer 11

stop drug culprits, avoid sudden movement changes, water loading (glass of water before getting up), compression stockings, keep legs elevated when sitting/ sleeping, calf muscle exercises when standing for prolonged periods

Question 12

Pharmacological management of orthostatic hypotension?

Answer 12

only done if conservative failed

fludrocortisone

Question 13

More than 40% of drop attacks have what syndrome?

Answer 13

carotid sinus syndrome

Question 14

Explain what carotid sinus syndrome is?

Answer 14

condition in which there is abnormal activation of the carotid sinus (which contains the baroreceptors) which leads to symptoms secondary to cerebral hypoperfusion
it is more common as age increases

Question 15

Tests for carotid sinus syndrome?

Answer 15

can do massage test looking for pause in HR of > 3 seconds
drop in systolic BP more than or equal to 50

or mixture of both of these

in some centres you can also do a tilt test

Question 16

Management of carotid sinus syndrome?

Answer 16

need referral to cardio

patient may need a pacemaker