Falls and Balance

Question 1

What are the intrinsic RF of falls?

Answer 1

Intrinsic: to do with patient
	• Vision
	• Musculoskeletal
	• Neurological
	• Cardiovascular 
	• Drugs: psychoactive and cardiac medication are worst offenders, benzodiazipines 
	• Fear of falling: become less active,  decondition and become weaker 
- Pain -> weakness -> fall

Question 2

What are the extrinsic RF of falls?

Answer 2

Extrinsic: to do with environment
• Inappropriate footwear, clothing or mobility aids
• Home: poor lighting, loos rugs, slippery floors, stairs, general clutter
• Lack of rails in strategic locations
Uneven or slippery paths outdoors

Question 3

What are the behavioural RF of falls?

Answer 3

Behavioural: undertaking activities that are risky
• Climbing ladder
• Standing on chair
• Turning quickly

Question 4

What is a mechanical fall?

Answer 4

Slip or trip

Question 5

What are the four types of “dizziness”?

Answer 5

○ Central/peripheral NS: vestibular dysfunction, cerebellar dysfunction - “room is spinning, head spinning, or moving when you are not moving” do you feel like you are going to fall when you are standing

○ Syncope: due to postural or anything that lowers your BP. Inidcation for high BP, dehydration, Rx that cause dehydration - diuretics, interuption of HR - ineffect CO in tachyarrhythmia or bradyarrythmia, reduced CO in outflow obstruction - HOCM or AS

○ Feeling of poor balance and sensation of instability: deterioration of sensory factors of balance e.g. visual, proprioception, peripheral numbness; peripheral neuropathy (presents as broad based gait) - see below for sensory causes

• Psychological especially anxiety : this dizziness is prevalent throughout the day

Question 6

What are the main drugs that cause falls?

Answer 6

• Alcohol
• Opioids
• Antipsychotics - causes postural hypotension and also Parkinsonian features (except Seroquel)
• Antihypertensives
• Antihistamines (that are sedative)
• Anti depressants - may cause Parkinsonian features
• Benzos

Question 7

Describe the maintenance of balance.

Answer 7

It requires:

1. Intact motor: ability to keep yourself upright and reactive as well to change in posture
2. Sensory function: vision, vestibular, sensation of touch and proprioception
3. Skeletal system

Question 8

List some common diseases that effect sensory function in balance.

Answer 8

• Macular degeneration
• Peripheral neuropathy leading to loss of sensation - alcohol, chemo, B12 deficiency, DM, MM hyper or hypothyroidism
• Stroke
• PD
• Normal P hydrocephalus

Question 9

List some common diseases that effect the skeletal system in balance

Answer 9

Fixed deformities, previous surgery to bones and joints, leg length discrepancies, pain in joints

Question 10

Questions to ask in falls Hx

Answer 10

• How often do you fall? 
• In what circumstances did you fall? - ways to modify behaviour and improve environment
	• Walking, standing (find cause of postural hypotension) or sitting
	• Day or night
	• Was your fall weakness?
	• Using gait aid?
	• Using glasses?
	• Is house cluttered
	• Steps?
	• Rushing to toilet, answer phone
- Witness history
- PMHx - cardiac, neuro, previous joint surgery

Question 11

Px in a falls patient

Answer 11

CARDIAC
• Need to establish BP and postural BP * be sure to wait long enough (gold standard: 5 mins after standing)
- Check HR for compensatory tachycardia NB b blockers, Ca blockers.
- Listen for AS - dyspnoea, angina, dizziness

NEURO: look for neuropathy, motor weakness and classic presentation of PD, MS and lower motor neuron lesion e.g. foot drop
Do:
• UL neuro exam
• LL neuro exam
• Test for signs of Parkinson’s if appropriate
• Hallpike’s manoeuvre:
Positive test for BPPV: rotational nystagmus

• Eyes: acuity, visual fields, contrast sensitivity

BALANCE TESTS:
Static gait assessment:
-• Romberg’s: standing on floor or foam, with eyes closed, tandem standing and walking
- Single limb stance
- Static stance
* severe level of disability if unable to perform static assessments

Dynamic gait assessment: walking in a line with path modifications e.g. step in the way, weaving around cones, stop and look at different things
• General gait
• Timed up and go (TUG):11 seconds is average. To measure improvement. Sit, walk 3m at normal pace, turn around 3m.
• Standing on heels and toes
• Sternal push or shoulder tug (Pastor’s test): indicator of postural instability. Assess how many steps they take, or if fall.
• Stand and sit test: how many stand ups and sits in 30 seconds
• Functional reach: tests CoG with flexibility and stability. Measures improvement

Question 12

What are the management options for falls?

Answer 12

1. Postural drop:
   • Relax BP target
   • Take off antihypertensives
   • Aim for 150/90
2. Fear of falling
   • Psychology referral
   Clinical psychology is also good for sleep hygiene and weaning off benzodiazepines
3. Drugs causing falls - is it possible to reduce dose or de-prescribe?
4. Physiotherapy referral to strengthen muscles and assessment for gait aid
5. Eye wear
6. OT to improve home environment
7. Podiatry to ensure appropriate foot wear
   * * MULTI DISCIPLINARY APPROACH - i.e. all of the above

Question 13

What complications can arise?

Answer 13

• Sprain
• Bruising
• Joint or tendon damage
• Laceration requiring suturing
• Fracture
- Fear of falling, leading to more falls

Question 14

How can we prevent falls complications?

Answer 14

• Helmet: head strike
• Hip protectors: #NOFs
• Osteoporosis Rx: Vit D, Ca and denusomab (or bisphosphonates)

Question 15

List the precipitating causes of falls.

Answer 15

Trips and slips
Acute medical illness
Drop attacks
Syncope
Dizziness