Falls in the elderly Flashcards
Basic rules for looking after older people?
> 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?’
Causes of falls?
1) Musculoskeletal
2) Drugs
3) Neurological
4) Sensory
5) Cardiovascular
6) Incontinence
7) Being generally unwell
Causes of falls - Musculoskeletal?
> Arthritis of weight bearing joints
Sarocopenia
Deformities of feet
Muscle weakness - PMR
Causes of falls - Drugs?
Anti hypertensives
Sedatives, alcohol
And lots of others
Causes of falls - Neurological?
> Stroke, old or new > Parkinsonism > Dementia > Delirium, Ataxia (Seizure, TIA) > Other neurological conditions
Causes of falls - Sensory?
> Visual impairment
Inattention
(Hearing)
Causes of falls - Cardiovascular?
> Postural hypotension
Arrythmia
Heart failure
Aortic Stenosis
Causes of falls - Incontinence?
Rushing to the toilet
How do drugs cause falls?
Decrease of:
- Blood pressure
- Heart rate
- Awareness
Increases of:
- urine output
- Sedation
- Hallucinations
- qTC
- Dizziness
Culprit classes of drugs in falls?
Antihypertensive Beta blocker Sedatives Anticholingerics Opioids Alcohol
The falls clinic is a full MDT, what is the role of a nurse?
Eye test, ECG, Lying and standing BP, incontinence questionarrie. MMSE
The falls clinic is a full MDT, what is the role of a physiotherapist?
Full assessment of gait and balance
The falls clinic is a full MDT, what is the role of a doctor?
Through history and examination, consider bone health and osteoporosis screening. (45 minutes +)
History within a fall?
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
Examination within a fall?
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
Match the gait to the pathology - Ataxic?
Cerebellar damage/disease
Match the gait to the pathology - Arthralgia?
Arthritis
Match the gait to the pathology - Hemiplegic?
Stroke
Match the gait to the pathology - Small steps, shuffling?
Vascular, Parkinsonism
Match the gait to the pathology - high stepping?
Peripheral neuropathy
If someone has fallen and been there a while what should you check for?
1) Check creatinine kinase for rhabdomyolysis
2) Pneumonia
3) Skin injury
Question to think about in an A+E presentation due to a fall?
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)?
Examinations and investigations to think about in an A+E presentation due to a fall?
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 to think about in a hospital fall?
Assess both cause and consequence of the fall?
- Immediately assess for serious injury:
- Head injury?
- Seizure?
- C spine injury?
- Flail chest?
- Abdominal injury?
- Pelvic injury?
- Limb fracture? - Consider cause of fall
When is a CT required for a head injury?
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
When is a radiograph required in a fall?
> 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!)
Causes of falls within inpatients?
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
Tasks for a nurse post fall?
Repeat risk assessment
Datix
Call family
Try and prevent further fall
Prevention is better than a cure for falls, what is thought about in prevention care plans?
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)
