Falls in the elderly

Question 1

Basic rules for looking after older people?

Answer 1

> There will be more than one thing wrong

> Most illness will present atypically

> One presenting complaint can lead to a multitude of diagnosis
(much more interesting than single organ-ology clinics)

> Be an annoying toddler, keep asking ‘why?’

Question 2

Causes of falls?

Answer 2

1) Musculoskeletal
2) Drugs
3) Neurological
4) Sensory
5) Cardiovascular
6) Incontinence
7) Being generally unwell

Question 3

Causes of falls - Musculoskeletal?

Answer 3

> Arthritis of weight bearing joints
Sarocopenia
Deformities of feet
Muscle weakness - PMR

Question 4

Causes of falls - Drugs?

Answer 4

Anti hypertensives
Sedatives, alcohol
And lots of others

Question 5

Causes of falls - Neurological?

Answer 5

> Stroke, old or new 
> Parkinsonism  
> Dementia 
> Delirium, Ataxia  (Seizure, TIA)
> Other neurological conditions

Question 6

Causes of falls - Sensory?

Answer 6

> Visual impairment
Inattention
(Hearing)

Question 7

Causes of falls - Cardiovascular?

Answer 7

> Postural hypotension
Arrythmia
Heart failure
Aortic Stenosis

Question 8

Causes of falls - Incontinence?

Answer 8

Rushing to the toilet

Question 9

How do drugs cause falls?

Answer 9

Decrease of:

• Blood pressure
• Heart rate
• Awareness

Increases of:

• urine output
• Sedation
• Hallucinations
• qTC
• Dizziness

Question 10

Culprit classes of drugs in falls?

Answer 10

Antihypertensive 
Beta blocker 
Sedatives 
Anticholingerics 
Opioids
Alcohol

Question 11

The falls clinic is a full MDT, what is the role of a nurse?

Answer 11

Eye test, ECG, Lying and standing BP, incontinence questionarrie. MMSE

Question 12

The falls clinic is a full MDT, what is the role of a physiotherapist?

Answer 12

Full assessment of gait and balance

Question 13

The falls clinic is a full MDT, what is the role of a doctor?

Answer 13

Through history and examination, consider bone health and osteoporosis screening. (45 minutes +)

Question 14

History within a fall?

Answer 14

Same as any other medical history

PC/HPC Detail of the fall. What were you doing. Who with? What happened? What happened next. How did you get up off the floor

> Collapse with no memory ?syncope or cognition
Clear history of trip – think sensory (eyes, nerves)
Palpitations preceding fall and no trip - think cardiac
On turning – think postural instability
Any ‘near misses’- unsteady on standing
Syncope on exertion think aortic stenosis

Systmeatic enquiry - Very important – in addition to usual things
> Memory – Ideally ask a relative too
> Urinary symptoms (they won’t tell you if you don’t ask)
> Has walking changed recently

Drugs:
> Yes, I want to know everything. Especially over the counter antihistamines…
> Especially alcohol

Question 15

Examination within a fall?

Answer 15

Top to toe:
1) Head and arms:
> Cranial nerves, apart from smell. Check glasses
> Check neglect,
> Cerebellar signs
> Bradykineasia, ridigidity – signs of PD

2) Pulse, (BP) Heart sounds. Signs of heart failure and respiratory disease
3) Kyphosis
4) Abdominal examination (+PR if prostate)

5) Legs
> Look at feet (footware, toenails). 
> Check sensation, vibration sense, and proprioception – remember usually glove and stocking not dermatomal 
> Co-ordination 
> Romberg's 
> Assess gait

Question 16

Match the gait to the pathology - Ataxic?

Answer 16

Cerebellar damage/disease

Question 17

Match the gait to the pathology - Arthralgia?

Answer 17

Arthritis

Question 18

Match the gait to the pathology - Hemiplegic?

Answer 18

Stroke

Question 19

Match the gait to the pathology - Small steps, shuffling?

Answer 19

Vascular, Parkinsonism

Question 20

Match the gait to the pathology - high stepping?

Answer 20

Peripheral neuropathy

Question 21

If someone has fallen and been there a while what should you check for?

Answer 21

1) Check creatinine kinase for rhabdomyolysis
2) Pneumonia
3) Skin injury

Question 22

Question to think about in an A+E presentation due to a fall?

Answer 22

1) ABCDE Assessment
2) How did they fall?
3) History of falls?
4) Any cognitive impairment
5) Any incontinence
6) Any syncope
7) Any features of seizure (rare but happens)
8) Are they drunk
9) Look at ambulance sheet 10) Talk to relative

Questions to ask yourself:

1) Is Mable injured?
2) Is she sick?
3) Are there any reverseable causes of fall you can correct now (Drugs)?
4) Can she go home?
- Can she go to the toilet on her own?
- Can she get a cup of tea between carer visits?
- Can she walk in A+E ?
- Can she summon help (would she have a long lie)?

Question 23

Examinations and investigations to think about in an A+E presentation due to a fall?

Answer 23

1) Are they acutely unwell? – do bloods and glucose
2) Do a neurological examination as well as Chest / heart / abdomen (skip reflexes!)
3) Look at legs and try and get them to walk (if you can)
4) The best history you can get (include the ambulance sheet)
5) Ensure a full set of obs are done (do yourself if in ‘minors’) do L+S BP
6) ECG for all
7) Bloods for all* check B12, folate, CK, TFTs
8) Check for delirium using 4AT
9) Consider CT head if fall with head injury and neurological signs or anticoagulated

Always start with a ABCDE approach

Question 24

Question to think about in a hospital fall?

Answer 24

Assess both cause and consequence of the fall?

1. Immediately assess for serious injury:
   - Head injury?
   - Seizure?
   - C spine injury?
   - Flail chest?
   - Abdominal injury?
   - Pelvic injury?
   - Limb fracture?
2. Consider cause of fall

Question 25

When is a CT required for a head injury?

Answer 25

Yes immediately if: 
> Low GCS <13 
> Still confused after 2 hours (or not back to baseline cognitive state) 
> Focal neurology
> Signs of skull fracture 
> Basal skull fracture – CSF leak, bruising around eyes, 
> Seizure 
> Vomiting 
> Anti-coagualtion

Question 26

When is a radiograph required in a fall?

Answer 26

> If pain on moving a joint have low threshold of x ray

> If no deformity but pain on weight bearing have low threshold to x ray

> People can walk on fractured hips (I don’t know how either!)

Question 27

Causes of falls within inpatients?

Answer 27

Same as outpatients plus:

1) Patient getting postural hypotension (or just hypotension) due to illness
2) Or new medication
3) Low blood glucose
4) Or getting sicker
5) DELIRIUM DELRIUM
6) De-conditoning
7) Call bell out of reach, no appropriate footwear

Question 28

Tasks for a nurse post fall?

Answer 28

Repeat risk assessment
Datix
Call family
Try and prevent further fall

Question 29

Prevention is better than a cure for falls, what is thought about in prevention care plans?

Answer 29

Ensure vision and mobility aids and call bell are in reach

Consider bed rails
Regular obs
Tell people

If you move something put it back (Eg walking aid, call bell, bed rail, height of bed, drink/table)