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Geriatrics > Falls and Immobility > Flashcards

Falls and Immobility Flashcards

1
Q

What is the definition of a fall?

A

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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2
Q

What is the annual prevalence of falls?

A

30% of community dwellers > 65 years
40% of community dwellers > 80 years
50% of those in hospital/care facilities

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3
Q

What percentage of falls result in hip fracture?

A

1%

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4
Q

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

A

True

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5
Q

True or false, there is 1 fall-related death every day in the UK?

A

False - 1 fall-related death every 5 hours in the UK

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6
Q

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

A

£4.6 million

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7
Q

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

A

10 times that of under 65s

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8
Q

What are the possible outcomes of fall?

A 
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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9
Q

What are the intrinsic factors that affect whether a patient falls/is at risk of falling?

A

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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10
Q

What factors affect postural stability?

A

Cerebral perfusion - vasomotor tone, cardiac output

Posture and balance - static, dynamic

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11
Q

What factors affect control of balance?

A

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

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12
Q

How can gait and balance be assessed?

A 
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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13
Q

How can acute illness affect gait and balance?

A

Limited cerebral functional reserve in illness

Causes hypoxia resulting in impaired central processing of information (impaired correction of imbalance)

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14
Q

What cognitive disorders might affect gait and balance?

A

Dementia
Delirium
Anxiety/depression

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15
Q

How can dementia affect gait and balance?

A

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

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16
Q

How can depression and anxiety affect gait and balance?

A

May precipitate immobility

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17
Q

What are the situational factors that affect whether a patient falls/is at risk of falling?

A 
Medications 
- antidepressants
- antipsychotics 
- anticholinergics
- antimuscarinics
- benzodiazepines
- antihypertensives
- diuretics
Alcohol
Urgency of micturition
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18
Q

What are the extrinsic factors that affect whether a patient falls/is at risk of falling?

A 
Inappropriate footwear
Environmental hazards 
- uneven paving
- carpets
- walking aids
- stairs
Poor lighting
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19
Q

What are the potential causes of syncope?

A 
Neurally-mediated
Orthostatic hypotension
Cardiac arrhythmias as primary cause
Structural cardiac or cardiopulmonary disease 
Cerebrovascular
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20
Q

What are the types of neurally-mediated syncope?

A

Vasovagal syncope (common faint)
Carotid sinus hypersensitivity
Situational syncope

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21
Q

What might cause/stimulate situational syncope?

A 
Acute haemorrhage
Cough/sneeze
Gastrointestinal stimulation e.g. swallowing, defaecation
Micturition/post-micturition
Post-exercise
Others e.g. weight lifting
22
Q

What are the causes of orthostatic hypotension?

A

Autonomic failure

Volume depletion e.g. haemorrhage, diarrhoea, Addison’s disease

23
Q

What are the types of autonomic failure which can cause syncope?

A

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

24
Q

What cardiac arrhythmias can result in syncope?

A

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

25
Q

What structure cardiac or cardiopulmonary diseases can result in syncope?

A 
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
26
Q

What cerebrovascular conditions can result in syncope?

A

Subclavian steal syndrome

27
Q

What members of the multidisciplinary team are involved in the assessment and management of falls?

A 
Medical
Nursing
Physiotherapist 
Occupational therapist 
Consultant geriatrician
28
Q

How much energy do falls generate in relation to the energy needed to cause a fracture?

A

Falls generate at least 10 times the energy necessary to fracture the proximal femur

29
Q

What will the orientation of the faller affect?

A

Impact to hip

30
Q

What responses are insufficient to protect someone when they fall?

A

Protective response

Local shock absorbers

31
Q

How is the osteoporosis risk assessed?

A

Using FRAX or QFRACTURE tool

32
Q

How is bone mass density assessed?

A

DEXA scanning (if fracture risk is > 10% at 10 years)

33
Q

What does a T score between -1 and -2.5 suggest?

A

Osteopenia

34
Q

What does a T score of < -2.5 suggest?

A

Osteoporosis

35
Q

What are the most common sites of fracture in the elderly?

A

Hip
Wrist
Vertebrae

36
Q

What treatments should be given to all patients?

A

Calcium or vitamin D supplement

37
Q

What other treatments can be offered?

A

Bisphosphonates, teriparatide, denosumab

38
Q

According to NICE guidelines, what should be involved in the multi-disciplinary treatment of falls?

A 
Treat cause if possible 
Strength and balance training 
Home hazard and safety intervention
Medication review with modification/withdrawal
Cardiac pacing (in selected patients)
39
Q

What is involved in the management of a transient loss of consciousness?

A 
History from patient
Collateral history 
Examination 
12 lead ECG 
Assess for red flags
Consider further tests
40
Q

What is important in the history from the patient following a transient loss of consciousness?

A 
Prodromal symptoms 
Loss of consciousness
First and last things they recall
Previous episodes
Any injuries
PMH 
Family history (including of sudden death) 
Medication
41
Q

What is important in the collateral history of a patient from a witness following a transient loss of consciousness?

A

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

42
Q

What are the most important features of the clinical examination of a patient following a transient loss of consciousness?

A

Vital signs - including lying and standing BP
Focussed neurological and cardiovascular examination
Look for any injuries

43
Q

What might a 12 lead ECG detect in a patient who has had a transient loss of consciousness?

A 
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
44
Q

What are the red flags of a transient loss of consciousness?

A 
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
45
Q

When should you consider a seizure?

A

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
46
Q

Describe the overlap between immobility and falls

A

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

47
Q

What are the main causes of sarcopenia?

A

DECLINE

D - diabetes/insulin resistance
E - elderly
C - chronic disease
L - lack of use
I - inflammation
N - nutritional deficiency 
E - endocrine dysfunction
48
Q

What are the physical complications of immobility?

A 
Muscle wasting
Muscle contractures
Pressure sores
Deep venous thrombosis
Constipation/incontinence
Hypothermia
Hypostatic pneumonia
Osteoporosis
49
Q

What are the psychological complications of immobility?

A

Depression

Loss of confidence

50
Q

What are the social complications of immobility?

A

Isolation

Institutionalisation

Geriatrics (6 decks)

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