Falls In Older People Flashcards
What is the definition of a fall?
An event which causes a person to unintentionally rest on the ground or lower level that is not a result of a major intrinsic factor (e.g. stroke) or overwhelming hazard
Who has the highest risk of falling?
People aged 65 years and older (older adults)
What are the biological impacts of falling?
- Fractures (femur, pelvis, humerus, vertebra, wrist)
- Head injury (esp. subdural haematoma)
- Soft tissue injuries (e.g. carpet burns, bruising, bleeding)
- Burns
- Pain
- Long lies on floor
- Death
What can occur if after a fall, the person lies on the floor for more than 1 hour?
Pressure sores
Rhabdomyolysis
Hypothermia
Pneumonia
What are the psychological impacts of falling?
- Fears of further falls - loss of confidence, immobility or institutionalisation
- Anxiety disorders e.g. panic disorder, agoraphobia or social anxiety disorder
- Depression due to reduced independence or social interaction
- Anxiety in carers which may lead to elder abuse or moving from familiar home to unfamiliar residential home
What is rhabdomyolysis?
Muscle breakdown causing kidney problems - more problematic if person already has kidney problems
What are the social impacts of falling?
- Loss of independence/dependence on others e.g. hobbies, social interaction
- Need to move to safer surroundings e.g. restricted to 1 room at home, residential/nursing care home (institutionalisation), financial impact
- Impact on others e.g. patient unable to care for others, family tension/stress (inc. financial)
At what time of the day do most falls happen?
Mid-afternoon because you are least alert after the post-prandial dip
What are the different mechanisms by which a fall can happen?
Shifting of body weight Trip/stumble Hit/bump Loss of support Collapse Slip
What activities are usually being carried out when people fall?
Walking forward
Transferring
Standing
In act of sitting
What in syncope?
Sudden transient loss of conciousness/unresponsiveness due to reduced cerebral perfusion where the patient loses postural control but has spontaneous recovery when brain becomes more perfused due to gravity when patient is lying on the ground
What are some intrinsic cause of falls?
Syncope Dizziness/vertigo Seizures Peripheral neuropathy Stroke Visual impairment PD Cognitive impairments (affects assessment of risk) Side effect of drugs/alcohol Age-related frailty (e.g. joint problems, muscle weakness)
What is NOT a common cause of syncope? Why?
TIA/stroke as this is a more focal neurological deficit of the brain rather than widespread unless the patient has brainstem ischaemia
What are the causes of syncope?
- Situational hypotension due to posture, coughing or eating (esp. orthostatic hypotension)
- Vasovagal: vagal stimulation due to pain, fear or emotion
- Carotid sinus syndrome
- Cardiac arrhythmia/ischaemia
- Outflow obstruction e.g. aortic stenosis
- PE
What are some extrinsic causes of falls?
- Poor light esp. steps/stairs
- Clutter around home
- Inappropriate footwear e.g. open-backed slippers or high heels
- Incorrect use of walking aids
- Pets or children
- Trailing cables
- Slippery floors or pavements
- Change in floor surfaces e.g. rugs and carpet folds
- Bath/toilet problems esp. too low, slippery or lack of handles
- Unfamiliar environment esp. hospital or care home
What are the common causes of falls?
D: Drugs - polypharmacy, alcohol
A: Age-related changes - gait, balance, sarcopenia, sensory impairment, peripheral neuropathy
M: Medical - syncope, PD, stroke
E: Environmental - obstacles, trailing wires, lighting
Falls are usually _____.
MULTIFACTORIAL e.g.
- Poor lighting + poor vision
- Peripheral neuropathy + poorly fitted slippers
- Postural instability + orthostatic hypotension
How do you perform a fall history?
S: Symptoms before, during or after fall - dizziness, lightheaded, chest pain, palpitations, LOC, tongue biting?
P: Previous falls
L: Location
A: Activity i.e. what were you doing when you fell?
T: Time - was it soon after taking tablets, a meal or coughing/straining for example?
T: Trauma sustained
D: Drug history
What is orthostatic postural hypotension?
> 20mmHg fall in SBP and/or > 10 mmHg fall in DBP within 3 minutes of standing WITH symptoms
What are the causes of orthostatic postural hypotension?
Drugs Chronic hypertension Volume depletion Autonomic failure (PD, DM) Prolonged bed rest Adrenal insufficiency
How do you treat orthostatic postural hypotension?
- Treat the cause
2. Consider Fludrocortisone or Desmopressin
What is post-prandial hypotension?
A fall of > 20 mmHg in SBP after the ingestion of a meal as blood is being diverted to the gut which can last for up to 90 minutes
How do you treat post-prandial hypotension?
- Alter timing of anti-hypertensives if on them
- Lie down/sit down after meals
- Caffeine, Fludrocortisone or NSAIDs
What would you want to examine when assessing a fall?
General appearance Gait + balance HR + rhythm Postural BP Consider carotid sinus massage (expert only) Listen for murmurs esp. aortic stenosis Neurological exam Look for signs of PD Vision + hearing Examine head/neck movements Consider cognitive impairment screening (MMSE/GPCOG but specialist referral for formal diagnosis/treatment)
What types if visual impairment is common with old age increasing the risk of falls?
Wearing bifocals
Glaucoma
Macular degeneration
Retinopathy (e.g. diabetic)Cataracts
What medical causes may reduce cognitive function?
Hypothyroidism Hyponatraemia Hypoglycaemia Vitamin deficiency Drugs Alcohol
In terms of cognitive impairment, what should you distinguish between?
Delirium (acute) VS dementia (chronic)
What bloods would you want to do on falls patients?
FBC Urea, creatinine + electrolytes (U+Es) Thyroid (TSH) Glucose B12 + folate Calcium + phosphate
What investigations would you want to do on a falls patient?
BP (lying + standing for postural hypotension suspicion)
ECG
24h ECG
Echocardiography
Tilt table (look for vasovagal innervation)
CT head
EEG (if concerned about neurological seizure symptoms)
How do NICE recommended falls are assessed and managed?
- Older people should be routinely asked if they have fallen in the past year
- Refer to specialist falls service if so for specialist assessment
- Multifactorial risk assessment and interventions
What is the “get up and go” test?
Simple GP test to assess risk of falls: ask patient to stand up and walk 3m and walk back in 14 seconds - if they cannot do this for any reason they are at higher risk of falls and should be referred to a specialist falls service
What should be assessed in a multifactorial risk assessment?
Falls history Gait, balance, mobility + muscle weakness Osteoporosis risk Functional ability + fear relating to falling Visual impairment Cognitive impairment + neurological exam Urinary incontinence Home hazards CVD exam Medication review
How should visual impairment be assessed?
Initially by a basic Snellen chart at the GP but ideally an Opticians referral and assessment is needed
Why might urinary incontinence increase a person’s risk of falling?
Patient may be rushing to get to the toilet when they fall over
What intervention is the most likely to reduce falls and injury?
INDIVIDUALIZED strength and balance training set out by a physiotherapist because each person is at different levels (why general exercise may increase risk rather than reduce)
What type of health professional will help reduce hazards in the home?
OTs will assess their home for hazards and intervene accordingly e.g. give the patient a specific walking aid to reduce fall risk
What multifactorial interventions may be performed in patients who have fallen?
Individualised strength + balance training
Home hazard assessment + intervention
Vision assessment + referral
Medication review w/ modification/withdrawal
Management of causes + recognised risk factors
What intervention has been shown to increase fall and fracture rate?
Brisk walking
What interventions have shown to be helpful but with insufficient evidence to be recommended?
Low intensity exercises with incontinence training
Untargeted group exercises
Behavioural/cognitive interventions
Referral for visual impairment correction alone
Vit D supplements
Hip protectors
