Falls, Frailty Flashcards
What is the principle feature of a fall?
Instability
Epidemiology of falls
in community dwelling people, 30% of those over 65 years old and over 40% for those over 75 have had a fall in the past 12 months.
around 50% of the falls are seen in people with a history of falls (twice or more a year )
is the commonest cause of accidental deaths in elders over 75 years (1
Why are falls important to the NHS?
Falls have important implications both on the personal level and on the level of the cost to the NHS - a large burden of care is placed by people falling and needing inpatient treatment, not to mention the considerable morbidity and mortality suffered by this group.
RFs for falls
environmental risk factors
lack of assistive devices in the bathroom
loose throw rugs
low level lighting
obstacles on the walking path
slippery outdoor conditions
medical risk factors
anxiety and aggitation
arrrythmias
dehydration
depression
malnutrition
medications causing over sedation
orthostatic hypotension
poor vision and use of bifocals
previous falls
urgent urinary incontinence
neuro and muculoskeletal risk factors
kyphosis
poor balance
weak muscles
reduced proprioception
other risk factors
fear of falling
Aetiology of falls
Roughly 50% of falls in the elderly follow a trip or an accident, with a mere 5% caused by dizziness. 5% are accompanied by loss of consciousness, 10% are a result of the legs giving way for no reason. The remaining 30% are unexplained.
- history of falls
- gait deficit, balance deficit
- mobility impairment
- visual impairment
- cognitive impairment
- urinary incontinence
- home hazard - poor lighting, loose carpets
- number of medication
- muscle weakness
What are some cardiovascular causes of falls in the elderly
vasovagal (neurocardiogenic) syncope
carotid sinus syndrome
postural hypotension: - secondary to intercurrent illness aggravated by chronic venous insufficiency - age associated autonomic neuropathy - drugs (diuretics, nitrates, tricyclic antidepressants, sedatives hypnotics and neuroleptics)
Cardiac abnormalities
arrhythmias: - Age associated idiopathic fibrosis of conducting tissue may cause sino-atrial exit block, sick sinus syndrome, paroxysmal AF or heart block.
structural abnormalities – valvular stenosis, hypertrophic obstructive cardiomyopathy, aortic dissection
Miscellaneous
pulmonary embolism
TIA
subclavial steel syndrome (1)
Primary complications of Falls
- laceration, contusion
- head injury, possibly with subdural haematoma
- fractured limb, particularly fractured neck of femur
- fractured rib, which may result in pneumonia
- wrist fracture (common between the ages 65 and 75) and hip fracture (after 75) (1)
Secondary consequences of falls
inability to summon help, resulting in:
- pressure sores
- pneumonia
- hypothermia
- rhabdomyolysis
Interventions to prevent falls
- strength and balance training
- home hazard assessment and intervention
- vision assessment and referral
- medication review with modification or withdrawal
HPC - When did you fall?
What time of day?
What were they doing at the time?
Looking upwards (vertebrobasilar insufficiency)
Getting up from bed (postural hypotension)
HPC - Where did you fall?
In the house, or outside?
HPC - What happened before/during and after the fall?
Before
Was there any warning?
Was there any dizziness/chest pain or palpitations?
During
Was there any incontinence or tongue biting? (indicating seizure activity)
Was there any loss of consciousness?
Was the patient pale/flushed? (may indicate vasovagal attack)
Did the patient injure themselves?
What part of the body had the first contact with the floor?
After
What happened after the fall?
Was the patient able to get themselves up off the floor?
How long did it take them?
Was the patient able to resume normal activities afterwards?
Was there any confusion after the event? (head injury)
Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)
HPC - How many times have you fallen over the last 6 months? What does this question show?
Allows you to gauge the severity of the problem
Systems enquiry - General, CV, Resp
Gen - fatigue, weight loss
CV - Chest pain, palpitations
Resp - SOB, cough
Systems enquiry - Neuro, GU, GI, MSK
Neuro - Loss of consciousness, Seizures, Motor or sensory disturbances
GU - incontinence, urgency, Dysuria
GI - Abdominal pain, Diarrhoea, Constipation
MSK - Joint pain, muscle weakness
General examination for falls
Is the patient alert and orientated?
Are they able to perform the timed “up and go” test?: Ask the patient to get up from the chair/bed and walk three metres then turn around and sit down again. The patient should be permitted to use their walking aid.
Cardiovascular examination for falls
Pulse: may have irregularities such as AF or bradycardia
Blood pressure – hypotension
Bruits over carotid arteries (e.g. aortic stenosis, carotid stenosis)
Murmurs: aortic stenosis/regurgitation, mitral stenosis
Resp examination for falls
Inspection: increased work of breathing
Auscultation: coarse crackles (e.g. pneumonia)
Percussion: dullness (e.g. pleural effusion)
Neurological examination for falls
Cranial nerve examination: stroke or visual impairment
Power: weakness (e.g. stroke, disuse atrophy)
Tone: increased in stroke
Reflexes: absent (e.g. diabetic neuropathy), hyperreflexia (e.g. upper motor neuron pathology)
Sensation: may be reduced secondary to upper or lower motor neuron pathology
Co-ordination: may be impaired (e.g. chronic alcohol misuse leading to cerebellar degeneration)
GI exams for falls
Abdominal tenderness
Organomegaly
MSK exams for falls
Check for injuries associated with falls and examine carefully the point of contact with the floor
