Falls and Immobility Flashcards by Chloe Mackle

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

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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

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What percentage of falls result in hip fracture?

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True or false, accidental injuries cause more deaths in older adults than sepsis?

True

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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

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What is the cost of falls in over 65s to the NHS per day?

£4.6 million

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What is the mortality in the elderly who fall compared with that of under 65s?

10 times that of under 65s

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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

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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

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What factors affect postural stability?

Cerebral perfusion - vasomotor tone, cardiac output

Posture and balance - static, dynamic

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What factors affect control of balance?

Sensory input - visual, vestibular, proprioceptive
Central processing - cerebrum, cerebellum, basal ganglia, brainstem
Muscular activity

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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)

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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)

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What cognitive disorders might affect gait and balance?

Dementia
Delirium
Anxiety/depression

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How can dementia affect gait and balance?

Impaired judgment
Abnormal gait
Affects visuospatial perception
Affects ability to recognise and avoid hazards

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How can depression and anxiety affect gait and balance?

May precipitate immobility

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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

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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

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What are the potential causes of syncope?

Neurally-mediated
Orthostatic hypotension
Cardiac arrhythmias as primary cause
Structural cardiac or cardiopulmonary disease 
Cerebrovascular

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What are the types of neurally-mediated syncope?

Vasovagal syncope (common faint)
Carotid sinus hypersensitivity
Situational syncope

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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