Falls and Balance Flashcards
What are the first symptoms seen in PD?
- constipation
- anosmia
- REM sleep disturbance
Triad and other symptoms associated with PD?
1) Decrementing bradykinesia 2) tremer (pill-rolling) - not involving head like essential - asymmetrical 3) rigidity (increased tone, described as lead pipe) - cogwheeling Others: - mask like facies - postural instability - cognitive dysfunction (on spectrum with LBD) - psychosis/hallucination - autonomic dysfunction - gastrointestinal dysfunction (gastroparesis)
What do you look for on exam for PD?
- mask like facies (not reactive in face) - tremor - walk (shuffling, limited arm swing, stooped over) - repetitive tapping of toes (bradykinesia - big taps, speed and amplitude) - tone (rigidity - cogwheeling. Use the wrist to move it unpredictably - make a fist in other hand) - pull test for postural instability
What is the pathophysiology of PD?
its an alpha synucleinopathy (related to LBD) which affects to basal ganglia. Its neurodegenerative and is due to decreased dopamine.
What is the treatment of PD? What are some side effects?
Levodopa with Carbidopa (dopamine decarboxylase inhibitor) so it doesn’t get broken down before crossing BBB. - start as soon as possible (best drug) Side Effects: - motor fluctuations as progresses, more fragile and flip into excess state, dyskinesia) - off frozen, on - normal, dyskinesia - chorea (too much) - impulse control Dopamine gives us pleasure, become addictive people (obsessed with particular things) Adjunctive Meds: - dopamine agonists (similar) - MAOI and COMPT inhibitors - amantidine End Stage Therapy: - deep brain stimulation (wire to subthalamic nucleus to inhibit it) motor good but step down in cognitive - constant stream of dopamine - intraduodenal levodopa
What are some examinations you can do for balance after someone has fallen?
Easily an OSCE run through a gait and balance assessment?
Static Tests
- sternal push/shoulder tug
- Romburg’s
- Heel-toe standing
- Hallpike manouvre -
- Functional reach (normal >30cm)
Dynamic tests -
- gait assessment (6m walk test) (symmetry, stride, arm swing) -
- tandem gait -
- timed up and go (should be <13-14 seconds) PT -
- foam mat proprioception -
- gait aids Berg Balance Scale -
What sort of screening should you perform in someone who has just had a fall?
Short term - BSL - ECG - U&Es/FBE - urine dipstick - head CT - Xray of sites of injury Long Term (osteoporosis) - DXA scan (>2.5 from normal in T score or a Z score -2.0) - Vit D - calcium intake? Depression screen Cognition screen
Give some risk factor categories for a fall?
Intrinsic (CNS, PNS) Extrinsic Age Sensory - hearing, visual Neurological - neglect, gait, autonomic dysfunction Cognitive impairment Medication Extrinsic factors Other comorbidities
Give some classifications for hip fractures
Intracapsular - capital - subcapital - transcervical (middle of neck) Extracapsular - intertrochanteric - subtrochanteric Garden Classification for severity Stable = treat with ORIF Stage 1 = undisplaced complete Stage 2 = undisplaced complete Unstable = treat with hemi/total arthroplasty (risk of AVN) Stage 3 = complete fracture with incomplete displacement Stage 4 = complete fracture and displacement
What are some complications of Hip Fractures?
Infection AVN (especially if extracapsular) Risks of treatment: Fat embolus - cement Pelvic reaming (haemorrhage) Small head size
Treatments for osteoporosis in the elderly?
1) HRT/SERMS (e.g. raloxifene) in women - hot flushes - DVT risk - reduced breast cancer 2) bisphosphonates - e.g. IV zolendronate 1x a year. - SE = GIT, ONJ, atypical femoral fractures (not if CrCL <35ml/min) 3) teriparatide - postmenopausal women 2nd line oral agent. 4) denosumab - used in CKD in advanced kidney disease bisphosphonates make osteoporosis worse (its an adynamic bone disease)
What are some risk factors for osteoporosis?
- Age - Post-menopausal - Lifestyle (smoking, inactivity, alcohol) - Drugs (glucocorticoids, anticonvulsants) - Less common: ○ Multiple Myeloma ○ Endocrine (hypogonadism, hyperthyroidism, hyperparathyroidism, hypercortisolism) ○ Malnutrition/malabsorption (CF, Coeliacs, IBD, Anorexia nervosa)
What is the timed up and go test?
time that a person takes to rise from a chair, walk three meters, turn around, walk back to the chair, and sit down. During the test, the person is expected to wear their regular footwear and use any mobility aids that they would normally require.
History of Falls?
History:
- Before the fall
- living arangement
- walking aids
- bracelets
- cognition and continence
- previous falls
- RFs - OP
- meds, alcohol, PMHx
- During fall
- circumstances
- prodromal symptoms
- lose conciousness
- injuries
- After fall
- able to get up after (really important severity marker)
- fear of falling (associated with increased falls)
What can you do to prevent falls?
- balance training with physio (teaching on how to get off the floor)
- treat osteoporosis (bisphosphonates)
- vitamin D and Ca supplements
- decrease bnz and polypharmacy
- cataract surgery
- home hazard assessment and modification
- identify and rectify risk factors (alarms, bracelets)
