Falls in the elderly Flashcards
Falls are a major problem
- 5% of falls result in a # (Colle’s and femoral neck)
- The death rate is significant
The most significant clinical risk factors for falls:
visual impairment
impaired general function
postural hypotension
hearing impairment
low morale/depression
drug usage
especially sedatives
decreased lower limb strength including arthritis
impaired balance and gait
Probability diagnosis
Environmental hazards e.g. slipping, tripping
Postural hypotension
Postural instability e.g. knees, hips, Parkinson
Visual e.g. glaucoma, macular degeneration
Alcohol: acute or chronic
Medication esp. iatrogenic
Serious disorders not to be missed
Vascular:
- Cerebral insufficiency incl. TIAs, stroke
- Acute coronary syndromes
- Cardiac arrhythmias e.g. sick sinus syndrome
- Subdural or extradural haematoma
Infection:
- Any systemic infection esp. sepsis
- Any febrile illness
Tumour/cancer:
- Cerebral tumour
Other:
- Kidney failure
- Head injury
- Cognitive impairment e.g. dementia, delirium
- Fluid and electrolyte disturbance
Pitfalls (often missed)
Parkinson disease—early onset
Peripheral neuropathy
Gait and foot disorders
Labyrinthine e.g. BPPV, labyrinthitis
Rarities:
- Vitamin deficiency esp. Vit. D
- Cerebellar degeneration
- Post prandial hypotension
Masquerades checklist
Depression
Diabetes: hypoglycaemia; neuropathy
Drugs (many—see history)
Anaemia
Thyroid/other endocrine: Addison D, hypothyroid?
Spinal dysfunction esp. myelopathy
Urinary tract infection—nocturia
Is the patient trying to tell me something?
Highly likely, consider conversion reaction.
Key history
A careful history including an interview with family members and any witnesses to the fall.
Investigate the onset, environment and circumstances of the fall.
Consider seizure and loss of consciousness
Situational factors such as;
- rushing to bathroom
- climbing stairs or ladder.
- any witnesses to the fall.
Questions incl any premonitory or associated symptoms e.g.
- vertigo
- lightheadedness
- palpitations chest pain
- dyspnoea
- visual disturbance
- possible unusual
- disturbed behaviour.
Gather past and recent medical history incl;
- diabetes
- hypertension
- CVD
Drug history, esp.
- alcohol or illicit drugs
- sedatives antidepressants
- hypotensives
- hypoglycaemics
- antipsychotics
- diuretics
- NSAIDs.
Check thyroid status.
Key examination
General features:
- central cyanosis
- hydration status
- BP (supine and standing)
- temperature
Look for and exclude obvious extrinsic causes of falls
Comprehensive CVS examination
Examine ears, eyes, oral cavity, head and neck, spine, extremities esp. feet
Neurological examination including muscle features, sensation, coordination, balance and gait
Mini mental state examination
Key investigations
First line:
- urinalysis
- blood sugar
- pulse oximetry
- FBE & ESR
- U&E
- ECG (or 24 hour monitor).
Consider others according to history and findings:
- LFTs (γGT)
- TFT
- Echo
- Spinal X rays
- CT or MRI if indicated
- Doppler studies
Diagnostic tips
Consider rules of 7 in elderly patient:
- check mental status
- eyes
- ears
- mouth (?dentition, xerostomia)
- bladder and bowels
- locomotion including feet
- medication.
Ideally, visit the home to assess patient’s environment and home support, incl. examination of the medicine cabinet.
Management and prevention involves
Correction of any medical disorders and risk factors.
Refer patients of concern to a multidisciplinary team that includes:
- occupational therapists and
- physiotherapists.
Strategies include:
- walking aids
- home hazard control
- exercise training and
- medication reduction.
Electrolyte/metabolic disorders
The following disorders tend to occur in pts with medical problems requiring polypharmacy and with kidney disease.
DxT: malaise + muscle weakness
- but usually asymptomatic until cardiac toxicity, e.g. arrhythmia, cardiac arrest;
- ECG-peaked T waves, small P waves
→ hyperkalaemia: K > 6mmol/L; >6.5—a medical emergency
DxT: lethargy + muscle weakness/hypotonia + muscle cramps + impaired cognition/confusion ± cardiac arrhythmia esp. ectopics
→ hypokalaemia: K < 2.5 mmol/L (severe symptoms); 2.5–3.5 usu asymptomatic
DxT: lethargy + muscle weakness + personality changes ± confusion ± seizures
→ hyponatraemia Na < 125–135 mmol/L
DxT: thirst = oliguria + confusion + muscle twitching & cramps + orthostatic hypotension ± seizures/coma
→ hypernatraemia: Na > 145+ mmol/L
