Falls in the elderly Flashcards
What is the definition of a fall?
An event which causes a person to unintentionally rest on the ground or lower level (in absence of intrinsic factors such as stroke or overwhelming hazard).
A fall is the result of the interplay of multiple risk factors becoming much more likely as people get older.
why are falls important?
- Falls cause a massive burden on the NHS - estimated to cost £435 million, falls are most commonly reported patient safety incident
- falls and fractures are a common and serious health issue faced by older people in england
- people aged 65 and older have the highest risk of falling (around 1/3 of over 65’s and around half of over 80’s fall at least once a year).
- Falling is a cause of distress, pain, injury, loss of confidence, independence and mortality.
What are the consequences of falls in older people?
Biopsychosocial model:
Biological:
Fractures, death, bruising, pain
Psychological fractures:
Distress, anxiety, depression
Social:
Loss of independence, institutionalisation
What are some of the major biological impacts of falls?
- Fractures -> fragility fractures in older osteoporotic patients, neck of femur common, wrist, vertebra, pelvic, humerus
- Head injury -> especially subdural haematoma
- Soft tissue injury -> carpet burns, brusing and bleeding
- Burns -> if falling on fire or radiator
- Long lies on floor >1hr after falling:
- Pressure sores
- rhabdomyolosis -> muscle break down, release of myoglobin which can cause nephrotoxicity
- Hypothermia
- Pneumonia
What are the psychological impacts of falling?
What might be the effect on carers?
-
Fear of further falls leading to:
- loss of confidence
- immobility
- institutionalisation
- Anxiety disorders : panic disorder, agoraphobia, social anxiety
-
Depression:
- reduced independence
- reduced social interaction
-
Anxiety in carers can lead to:
- Elder abuse
- moving to unfamiliar residential home
what is the social impact of falling?
- Loss of independence:
- hobbies
- loss of social interaction
- increased dependence on others
- Need to move to safer surroundings:
- restricted to one room at home
- residential/ nursing care home -> institutionalisation
- financial impact
- Impact on others:
- Patient unable to care for others
- family tension and stress
What time of day do most falls occur?
What are the general causes of falls?
- Midafternoon is most common time
- Falls are multifactorial, split into intrinsic and extrinsic causes
What are some examples of intrinsic factors of falls?
- Syncope/ dizziness/ vertigo
- Seizures
- stroke
- peripheral neuropathy
- visual impairment
- cognitive impairment –> affecting assessment of risk
- parkinson’s
- age related frailty -> joint, muscle weakness
Define syncope
- Sudden, transient loss of conciousness due to reduced cerebral perfusion
- unresponsive loss of postural control
- spontaneous recovery
What are some of the common causes of syncope?
- Situational hypotension –> posture, coughing, eating, orthostatic hypotension
- Vasovagal –> vagal stimulation (pain, fear, emotion)
- Carotid sinus syndrome –> exaggerated response to carotid sinus baroreceptor stimulation
- Cardiac arrhythmia / ischaemia
- outflow obstruction –> aortic stenosis
- PE
- TIA/stroke very rarely cause syncope
What are some extrinsic factors of falls?
- Cluttered home, poor lighting, steps/stairs
- Inapp footwear
- incorrect use walking aids
- pets and children
- Slippery floors and pavements
- rugs/ carpets
- bathroom and toilet problems, lack of handles
- unfamiliar environment
D A M E stands for?
- DAME = mnemonic for common causes of falls
- Drugs –> polypharmacy and alcohol
- Age related –> gait, balance, sarcopenia, sensory impairment
- Medical –> syncope, parkinsons, stroke
- Environmental –> obstacles, wires, lighting
What is a useful acronym to use when taking a falls history?
SPLATTD
S-> symptoms e.g. dizziness, chest pain (MI), palpitations, loss of conciousness, tongue biting
P–> Previous falls
L–> Location
A –> Activity
T–> Time : was it soon after taking tablets, after meal, associated with coughing/ straining?
T–> Trauma sustained?
D–> Drug history
What examinations should be done in a patient who has suffered a fall?
- General appearance
- gait and balance
- pulse rate, pulse rhythm, postural BP
- Consider a carotid sinus massage
- Listen for murmurs –> especially aortic stenosis
- neurological exam –> parkinsons, vision, hearing, head and neck movements
- consider cognitive impairment screen
Define orthostatic/ postural hypertension
What are some of the causes?
- Fall of more than or equal to 20 mmHg in systolic blood pressure
- and/ or fall of 10 mmHg in diastolic blood pressure within 3 minutes of standing and WITH symptoms
- Causes:
- Drugs and chronic hypertension
- volume depletion
- autonomic failure (parkinsons and diabetes)
- prolonged bed rest
- adrenal insufficiency
- Treat the cause
- Consider fludrocortisone (MR receptor agonist, mimick aldosterone) or desmopressin (mimick ADH).
define post prandial hypotension
How long can it have its effect for?
What can be done to treat it?
- Post prandial hypotension = a fall of more than 20 mmHg in systolic blood pressure after ingestion of a meal
- Can have effect for up to 90 minutes
- Treatment:
- Alter timing of antihypertensives
- Lie down or sit down after a meal
- caffiene, fludrocortisone, NSAIDs
What key sense must be checked when a patient has suffered a fall?
is impairment of this sense common and how does it alter with age?
What types of damage are there to this sense?
- Visual system must be checked
- visual impairment is common and increases with age
- Bifocals (glasses) increase the risk of falling
- Type of visual damage:
- glaucoma –> raised intraocular pressure that compresses optic nerve
- macular degeneration –> macula surrounds the fovea, near centre of retina of the eye, region of keenest vision.
- retinopathy –> disease of the retina
- cataracts –> clouding of the lens of the eye
What is the relevance of cognitive impairment in falls?
If suspected what actions need to be taken to assess cognitive impairment?
- Cognitive impairment increases the risk of falls
- If suspected need to:
- distinguish delerium (acute) from dementia (chronic)
- use cognitive assessment tool (e.g. MMSE or GPCOG)
- Consider medical causes for the reduced cognitive function:
- e.g. hypothyroidism, hyponatremia, hypoglycaemia, vitamin deficiency, drugs and alcohol
- Refer to specialist for formal diagnosis and treatment if found
What assessments should be done in the event of a fall?
- Bloods:
- FBC, U and E’s, creatinine
- Thyroid (TSH)
- Glucose
- B12, folate
- Calcium and phosphate
- Blood pressure: BP both lying and standing
- Heart: ECG/ 24 hr ECG , echocardiography
- Tilt table test –> Patient secured to table, BP, vitals and pulse taken when lying down. Then raised to standing position and vitals taken for period of time
- Cranial causes: CT Head scan, EEG
What can GP’s do to assess falls risk and manage it?
- NICE guidelines –> older people routinely asked whether they have fallen in the last year
- GP screen with get and and go test –> walk 3m, turn, come back
- If risk found refer to specialist falls service for assessment by clinician with appropriate skills and expertise
- multifactorial risk assessment and intervention
What is included in a multifactorial risk assessment?
- Identify any falls history
- MSK –> assess gait, balance, mobility or muscle weakness
- Osteoporosis risk
- assessment of older persons perceived functional ability and fear relating to fall
- Assess visual impairment
- assess cognitive impairment and neurological
- assess urinary incontinence
- home hazards
- Cardiovascular exam and medication review
What intervention helps reduce falls and injury?
What helps reduce hazards at home?
- Individualised strength and balance training
- Occupational therapist
What are some examples of multifactorial interventions?
- Individualised strength and balance training –> physiotherapist –> evidence that tailored programmes reduces risk and rate of falls in over 65’s.
- home hazard assessment and intervention -> occupational therapist
- vision assessment and referral –> optician
- medication review and modification/ withdrawal–> GP/Hosp doctor
- management of causes and recognised risk factors –> GP/Hosp doctor
