Falls History Flashcards
What are your main goals in a falls history
Establish cause
- cardiac
- neuro
- orthostatic
Key questions - timeline of LOC
What are the questions you want to ask for
-who
Has this happened before?
When was the first time?
Are these episodes more or less the same?
Who saw you fall? => establish who to get a collateral from When did you fall -time of day and what they were doing Where did you fall -inside or outside Why do you think you fell -any new medications, tripped How many times has this happened in the past -gauge the severity of the problem
Key questions - before the fall
What were you doing at the time?
- changing position?
- under stress/standing for long time
- straining/coughing
Can you tell when you’re about to fall?
Key questions - onset of fall
Symptoms on onset Syncope -cardiac symptoms (palpitations, chestpain, SOB) and SNS activation Seizure -sensory hallucinations -weakness, tingling -N+V -dejavu, jamaisvu Orthostatic -weakness, lightheaded, dizzy
Do you have time to sit down or steady yourself before the fall? => neural or cardiac
Did anyone see you fall
- unsteady fall => some consciousness
- faceplant => LOC
Key questions - LOC
- awareness
- duration
- symptoms during
Were you aware of what was going on? => yes, PNES?
Seizure - s-mins
- urinary/fecal incontinence?
- tongue biting, abnormal posturing
- tonic, clonic muscle contractions
Syncope - s
- some myoclonic jerks after LOC
- sweaty, pale
Which part of the body made contact with the floor first
Key questions - after
Were you able to return to what you were doing after the fall?
- syncope => mental function recovers quickly
- seizures => post ictal confusion and fatigue (mins-hours)
- neurological cause => dizziness, headache
Systemic review
Medical and drug history
-what may contribute to falls
SPECIFICALLY ASK ABOUT HEART PROBLEMS, HX OF SEIZURES
Cardiac - chest pain, SOB, palpitations
-structural or arrythmias
Resp - coughs
Neuro - weakness/tingling, visual symptoms, headache
- PD and dementia
- peripheral neuropathy/stroke - sensory, balance impairments
- alcohol intox
GU, GI - UTI, fecal/urinary incontinence
MSK - muscle/joint pain
Systemic - infection in elderly
Polypharmacy esp in older adults DM => hypoglycemia HTN => orthostatic Bb => bradycardia BZ => sedation
Social history
Alcohol, smoking, drugs
Home support (family, friends, neighbours, carers)
Use of mobility aids
Examinations
- blodds
- examinations and investigations you may consider
FBC - anemia, infection
LFTs - chronic alcohol use
U&ES - electrolyte abnormalities
Urine dipstick - infection
CV assessment
- murmurs, arrythmias, bruits, HR, BP (lying and standing)
- ECG, Echo
Resp assessment
-anything that causes cough, CXR
Neuro assessment
- cranial nerves
- UL, LL - UMN, LMN issue
- AMTS - cognitive impairment
- CT head - SDH, stroke?
- DixHallpike - vertigo?
MSK
- causes of joint, bone, muscle issues
- bone profile
Causes for syncopal episodes
Brain hypoperfusion
Reflex
- vasovagal - stress, standing for too long, dehydration
- cough/straining
- carotid sinus syndrome
Orthostatic positional - volume depletion
-diuretics, BP meds, autonomic neuropathy
Cardiac
- structural conditions affecting cardiac output
- arrythmias
Before, during and after that would make you think syncope
Before
- positional - prolonged standing, from supine to upright
- reflex - situational
- cardiac and SNS activation from brain hypoperfusion (palpitations, sweating, chest pain, SOB, lightheaded)
Lasts for U1min
- pallor, sweating
- some myoclonic jerks after LOC
Rapid recovery, no confusion
Reduced EEG waves
High short term mortality
AED ineffective
Before, during and after that would make you think seizure
Before
- dejavu, jamaisvu
- olfactory aura
Lasts for minutes
- May lose consciousness
- Bitten tongue
- Head turning to one side
- Abnormal posturing
- Eyes open in epilepsy
- Urinary incontinence
- myoclonic jerks, tonic clonic mv
Post ictal confusion
Amnesia of seizure
Increased EEG activity
Low short term mortality
Postural hypotension
- risk factors
- core features
- investigations
- management
Risk factors
- dehydration - insufficient fluids, excess loss (diarrhea, vomit, sweating)
- medication - antiHTN, diuretics
- cardiac - heart failure, valvulopathy
- endocrine - hypoglycemia, adrenal insufficiency, DM
- neuro - PD, LBD
Core features
Lightheaded on standing up
Investigations - sitting standing BP to confirm => systolic fall of 20+
-other investigations to confirm cause
Management - eliminate aggravating factors, optimise current medication
Arrythmia
- risk factors
- core features
- investigations
- management
Risk factors
-FHx of cardiac issues, arrythmias, SCD
Core features
Palpitations before LOC
Investigations - 12 lead ECG => ambulatory monitoring for 24hrs-1wk
Management
Rate control - Bb or cardiac CCB
Optimise cardiac risk factors
Aortic stenosis
- risk factors
- core features
- investigations
- management
Risk factors
-FHx of cardiac issues
Core features
LOC on physical exertion, straining, Valsalva
Investigations - echo
- ECG
- CXR
Management - AVR
-mechanical - lifelong valve and warfarin
-biological - 10 years
If AVR not suitable due to surgery risks => TAVI
-femoral/subclavian access => balloon catheter used to place valve over old valve
What is the difference between seizures and epilepsy
Seizure - a sign of abnormal electrical signals within brain
Epilepsy - recurrent seizures
Seizures
- risk factors
- core features
- investigations
- management
Risk factors
-past brain injury - stroke, tumour, TBI, drug/alcohol misuse, infection,
Core features
Triggers
-stress, lack of sleep, alcohol, medication, recdrugs, periods, flashing lights
Before
- dejavu, jamaisvu
- olfactory aura
Lasts for U5mins
- May lose consciousness
- Bitten tongue
- Head turning to one side
- Abnormal posturing
- Eyes open in epilepsy
- Urinary incontinence
- myoclonic jerks, tonic clonic mv
Post ictal confusion
Seizure amnesia
Diagnosis - EEG
Look for cause
-DM, blood glucose - hypoglycemia
-Brain CT, MRI
Management
Inform DVLA, assess for triggers, reliable contraception
Medication - carbemazepine, valproate, lamotrigine
Parkinsons disease
- risk factors
- core features
- investigations
- management
Risk factors
- older males
- FHx
Core features
Tetrad of rigidity + bradykinesia + postural instability + resting tremor
Investigations - Datscan => loss of dopaminergic neurones
Management
Medical - levadopa
Lifestyle - physical movement
TIA/stroke
- risk factors
- core features
- investigations
- management
Risk factors
- FHx
- CV risks
- AF, DM, HTN
- smoking, drinking, not enough physical exercise
Core features
Sudden negative neurological symptoms
Investigations - head CT, MRI within 1 hour of hospitalisation
-assess for cause of ischemic - DM, cholesterol, echo, ECG, HTN
Management if TIA
- within 1wk => urgent same day assessment
- post 1wk => urgent same week assessment
Acute management if ischemic
- aspirin 300mg
- U4.5hr => alteplase
- U6hr => thrombectomy
Acute management if hemorrhagic
- neurosurgery coiling, clipping
- lower BP, stop AC
2ndary prevention
- clopidogrel
- statins 80mg
- HTN, DM
- diet, exercise, smoking cessation, alcohol
- DOAC for AF
Vasovagal
- risk factors
- core features
- investigations
- management
Risk factors
- standing for long periods of time
- heat exposure
- seeing something triggering (blood drawn)
Core features
In response to distressing stimuli, standing too much, heat exposure
Before - pallor, lightheaded, tunnel/blurred vision, nausea, cold/clammy
During - abnormal mv, low HR
Lasts U1min
After - feeling ok
Investigations - rule out cardiac, neuro causes, diagnosis of exclusion
Management - manage triggers
