Falls ☺️

Question 1

Describe the epidemiology of falls

Answer 1

30% of 65+ will fall every year
50% of 80+
60% in residential care every year

Injury rate 10-40%

Hip fracture rate 2-4% in every 100000

Question 2

Describe the vicious cycle of falls

Answer 2

Fall
Fear of pain and falling again
Reduced activity, fitness, balance, muscle strength
Increased risk of falling with less stressful activity

Question 3

How can we prevent falls

Answer 3

Screening

-past falls and injuries, balance problems

Question 4

What are the risk factors for falls

-sociodemographic

Answer 4

Increased age
Past falls
Female
Use of walking aids
Inactivity

Question 5

What are the risk factors for falls

• medical conditions
• medications

Answer 5

CV, neuro causes

Stroke
Dementia/delirium
PD
Depression
Incontinence
Arthritis
Foot problems
Dizziness

Polypharmacy

• hypnotics/anxiolytics
• antidepressants
• antipsychotics
• antihypertensive

Question 6

What are the risk factors for falls

• sensorimotor
• balance and mobility

Answer 6

Visual impairment

• depth perception
• contrast sensitivity

Sensory impairment

• proprioception
• vibration
• tactile

Muscle weakness

Reduced reaction times

Difficulty with sit to stand
Slow walking speed
Unsteady gait
Unsteady when standing still
Difficulty leaning or reaching

Question 7

What are the risk factors for falls

• psychological
• environmental

Answer 7

Fear of falling
Trip hazards in the home
Stairs and uneven ground

Question 8

What is dizziness

Answer 8

Overarching term for

• vertigo (room spinning)
• general unsteadiness (weakness)
• presyncope (feeling faint, sweaty)

May have a CV, neuro, vestibular, sensory, MSK issue
-is it associated with a specific activity or movement

Question 9

How would you assess for syncope?

Answer 9

Falls may also be due to transient loss of consciousness

Is it traumatic or not?

Causes of non traumatic TLOC

• syncope (cardiac, reflex, orthostatic?)
• epileptic seizures (tongue biting, continence?)
• psychogenic

Question 10

How would you assess for explained/unexplained syncope

Answer 10

Unexplained => syncope likely
-amnesia, likely to fall head first

Explained

• impaired gait
• balance
• cognitive status
• environmental hazard
• likely to fall with outstretched hands to break fall

Question 11

What are the CV causes of falls

Answer 11

Neural

• vasovagal syncope (no input from vagus)
• carotid sinus (no feedback from carotid bodies
• orthostatic hypotension
• postprandial hypotension
• situational syncope (cough sneeze, valsalva)

Instrinsic cardiac relating to structure, rhythm

• arrythmias
• MI
• aortic dissection
• tamponade

Cerebral

• PE
• TIA/migraine

Question 12

How would you do a lying and standing BP

Answer 12

5min lying supine
Measure BP

Stand
Measurement after 1min

Measurement after 3mins

Drop in BP due to gravity
Changed sensed in afferents (carotids, aortic arch)

Transient increase to compensate for drop 
Efferents via
-arteriole VC
-SAN increased rate
-increased ventricular contractility  

BP recovery within 30s

Question 13

Why are older adults at increased risk of cardiogenic falls

Answer 13

Hypovolemia, dehydration
CVD
Autonomic impairment -baroreceptor reflex
Medication effects

Question 14

What is orthostatic hypotension

-what are the consequences

Answer 14

Sustained BP drop on standing

• systolic BP of at least 20mmHg
• diastolic BP of at least 10 within 3mins of standing/head uptilt

Greatest risk of falls
May lead to cerebral hypoperfusion, presyncope, syncope

Question 15

How does exercise alter the risks of cardiovascular causes of falls

Answer 15

Short term reduction in BP after exercise in hypertensive patients

Long term hypotension hours after exercise increases the risk

Question 16

How might you manage reflex and orthostatic intolerance => syncope

Answer 16

Unpredictable or high frequency
-specific management

Predictable or low frequency
-education, reassurance and avoidance of triggers

Question 17

How does age affect your vestibular apparatus , posture and balance

Answer 17

Neuronal and hair cell loss => affects otolith (static) and position hair cells (dynamic)

Myotatic stretch reflexes are less responsive => increased postural sway

Question 18

What are the problems associated with prolonged bed rest

Answer 18

Prolonged periods of being horizontal resets vestibular system => increased risk of falls

Question 19

What are the problems associated with visual changes

Answer 19

Neural and eye degeneration
Decreased depth of focus
Reduced light reflexes
-bright light => PNS 
-dim light => SNS

Question 20

Which brain regions are associated with falls

-what neurological disorders are implicated

Answer 20

Premotor cortex
Supplementary motor cortex
Cerebellum
Occipital lobe
Basal ganglia

Chronic stroke
PD
Dementia

Question 21

How does sarcopenia affect the incidence of falls

Answer 21

Diminished muscle function, strength, power

• loss of fibre no
• fibre disuse atrophy
• decreased anabolics, increased catabolics

Question 22

How may you assess someone’s risk of falls from balance, MSK, neuro problems?

Answer 22

Chair stand test
Balance tests
-static and dynamic

Question 23

What are the 2 main components of gait

• factors that affect gait
• assessment

Answer 23

Timing

• steps/min
• time/distance

Sizing

• step length/stride lengths
• width
• foot angle

Neural control (CNS, PNS)
Muscular - sarcopenia
NMJ
Skeletal (joints)
Any pain?

TGUG