Falls and Immobility Flashcards
What is the definition of a fall?
Inadvertently coming to a rest on the ground or other lower level without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force
What is the annual prevalence of falls?
30% of community dwellers > 65 years
40% of community dwellers > 80 years
50% of those in hospital/care facilities
What percentage of falls result in hip fracture?
1%
True or false, accidental injuries cause more deaths in older adults than sepsis?
True
True or false, there is 1 fall-related death every day in the UK?
False - 1 fall-related death every 5 hours in the UK
What is the cost of falls in over 65s to the NHS per day?
£4.6 million
What is the mortality in the elderly who fall compared with that of under 65s?
10 times that of under 65s
What are the possible outcomes of fall?
Injury (50%) - soft tissue, fracture Rhabdomyolysis Loss of confidence Fear of falling Inability to cope Dependency Reduced quality of life Carer stress Institutionalisation Terminal decline
What are the intrinsic factors that affect whether a patient falls/is at risk of falling?
Gait and balance problems e.g. postural instability, vertigo
Syncope e.g. cardiac, vagal
Chronic disease - neurological/musculoskeletal
Visual problems
Acute illness
Cognitive disorder
Vitamin D deficiency
What factors affect postural stability?
Cerebral perfusion - vasomotor tone, cardiac output
Posture and balance - static, dynamic
What factors affect control of balance?
Sensory input - visual, vestibular, proprioceptive
Central processing - cerebrum, cerebellum, basal ganglia, brainstem
Muscular activity
How can gait and balance be assessed?
Sitting to standing ability Transfers Static standing balance Romberg test Dynamic standing balance - functional reach, tandem walking, timed walk etc. Gait Tinetti gait and balance scale Get up and go test (timed)
How can acute illness affect gait and balance?
Limited cerebral functional reserve in illness
Causes hypoxia resulting in impaired central processing of information (impaired correction of imbalance)
What cognitive disorders might affect gait and balance?
Dementia
Delirium
Anxiety/depression
How can dementia affect gait and balance?
Impaired judgment
Abnormal gait
Affects visuospatial perception
Affects ability to recognise and avoid hazards
How can depression and anxiety affect gait and balance?
May precipitate immobility
What are the situational factors that affect whether a patient falls/is at risk of falling?
Medications - antidepressants - antipsychotics - anticholinergics - antimuscarinics - benzodiazepines - antihypertensives - diuretics Alcohol Urgency of micturition
What are the extrinsic factors that affect whether a patient falls/is at risk of falling?
Inappropriate footwear Environmental hazards - uneven paving - carpets - walking aids - stairs Poor lighting
What are the potential causes of syncope?
Neurally-mediated Orthostatic hypotension Cardiac arrhythmias as primary cause Structural cardiac or cardiopulmonary disease Cerebrovascular
What are the types of neurally-mediated syncope?
Vasovagal syncope (common faint)
Carotid sinus hypersensitivity
Situational syncope
What might cause/stimulate situational syncope?
Acute haemorrhage Cough/sneeze Gastrointestinal stimulation e.g. swallowing, defaecation Micturition/post-micturition Post-exercise Others e.g. weight lifting
What are the causes of orthostatic hypotension?
Autonomic failure
Volume depletion e.g. haemorrhage, diarrhoea, Addison’s disease
What are the types of autonomic failure which can cause syncope?
Primary autonomic failure syndromes e.g. multiple system atrophy, Parkinson’s disease with autonomic failure
Secondary autonomic failure syndromes e.g. diabetic neuropathy, amyloid neuropathy
Drug and alcohol induced orthostatic syncope
What cardiac arrhythmias can result in syncope?
Sinus node dysfunction, including bradycardia/tachycardia syndrome
Atrioventricular conduction system disease
Paroxysmal supraventricular and ventricular tachycardias
Inherited syndromes e.g. Long QT syndrome, Brugada syndrome
Implanted device malfunction
Drug-induce pro-arrhythmias
What structure cardiac or cardiopulmonary diseases can result in syncope?
Cardiac valvular disease e.g. aortic stenosis Acute MI or ischaemia Obstructive cardiomyopathy Atrial myxoma Acute aortic dissection Pericardial disease/tamponade Pulmonary embolus/pulmonary hypertension
What cerebrovascular conditions can result in syncope?
Subclavian steal syndrome
What members of the multidisciplinary team are involved in the assessment and management of falls?
Medical Nursing Physiotherapist Occupational therapist Consultant geriatrician
How much energy do falls generate in relation to the energy needed to cause a fracture?
Falls generate at least 10 times the energy necessary to fracture the proximal femur
What will the orientation of the faller affect?
Impact to hip
What responses are insufficient to protect someone when they fall?
Protective response
Local shock absorbers
How is the osteoporosis risk assessed?
Using FRAX or QFRACTURE tool
How is bone mass density assessed?
DEXA scanning (if fracture risk is > 10% at 10 years)
What does a T score between -1 and -2.5 suggest?
Osteopenia
What does a T score of < -2.5 suggest?
Osteoporosis
What are the most common sites of fracture in the elderly?
Hip
Wrist
Vertebrae
What treatments should be given to all patients?
Calcium or vitamin D supplement
What other treatments can be offered?
Bisphosphonates, teriparatide, denosumab
According to NICE guidelines, what should be involved in the multi-disciplinary treatment of falls?
Treat cause if possible Strength and balance training Home hazard and safety intervention Medication review with modification/withdrawal Cardiac pacing (in selected patients)
What is involved in the management of a transient loss of consciousness?
History from patient Collateral history Examination 12 lead ECG Assess for red flags Consider further tests
What is important in the history from the patient following a transient loss of consciousness?
Prodromal symptoms Loss of consciousness First and last things they recall Previous episodes Any injuries PMH Family history (including of sudden death) Medication
What is important in the collateral history of a patient from a witness following a transient loss of consciousness?
Circumstances of the event
Posture immediately before loss of consciousness
Appearance
Presence or absence of movement during the event
Tongue-biting
Duration of the event
Presence or absence of confusion during recovery period
Weakness down one side during the recovery period
What are the most important features of the clinical examination of a patient following a transient loss of consciousness?
Vital signs - including lying and standing BP
Focussed neurological and cardiovascular examination
Look for any injuries
What might a 12 lead ECG detect in a patient who has had a transient loss of consciousness?
Inappropriate, persistent bradycardia Ventricular arrhythmia, including ventricular ectopic beats Long QT and short AT Brugada syndrome Ventricular pre-excitation (Wolff-Parkinson-White syndrome) Left or right ventricular hypertrophy Abnormal T wave inversion Pathological Q waves Atrial arrhythmia Paced rhythm
What are the red flags of a transient loss of consciousness?
ECG abnormality Heart failure Onset with exertion Family history of sudden cardiac death (< 40 years) and/or inherited cardiac condition New or unexpected breathlessness Heart murmur
When should you consider a seizure?
One or more of:
- bitten tongue
- head turning to one side during episode
- no memory of abnormal behaviour that was witnessed before, during, or after the episode by someone else
- unusual posturing
- prolonged, simultaneous limb jerking
- confusion after the event
- prodromal déjà vu or jamais vu
Absence of
- prodromal symptoms that on other occasions have been abolished by sitting or lying down
- sweating before the episode
- precipitation by prolonged standing
- pallor during the episode
Describe the overlap between immobility and falls
Overlap is more of a reciprocal relationship
Immobility results in sarcopenia and elimination problems, both of which can lead to falls
Falls result in loss of confidence, injury and pain, all of which can lead to immobility
What are the main causes of sarcopenia?
DECLINE
D - diabetes/insulin resistance E - elderly C - chronic disease L - lack of use I - inflammation N - nutritional deficiency E - endocrine dysfunction
What are the physical complications of immobility?
Muscle wasting Muscle contractures Pressure sores Deep venous thrombosis Constipation/incontinence Hypothermia Hypostatic pneumonia Osteoporosis
What are the psychological complications of immobility?
Depression
Loss of confidence
What are the social complications of immobility?
Isolation
Institutionalisation
