falls (ish) + incontinence Flashcards
falls investigation
always do a 4AT +/- MMSE/MOCA on patient admitted with fall
history from patient
collateral history
examination
further tests
investigations
- ECG +/- telemetry
- check blood sugar
- timed up + go
- echocardiogram if indicated
- consider CT head
- consider - ambulatory ECG, carotid sinus massage, tilt table
when is an urgent (plain) CT scan recommeneded?
drop in GCS <13
drop in GCS <15, 2hrs after injury
open or depressed skull fracture suspected
signs of skull base fracture - panda eyes, battle’s sign, CSF leak from nose or ears
post traumatic seizure
new focal neurology
2 or more episodes of vomiting
when is a CT scan within 8hrs required?
anti-coagulated
loss of consciousnness or amnesia since the injury + any of:
- age 65 or over
- history of clotting disorder
- dangerous mechanism of injury (fall from height)
- 30mins retrograde amnesia
multifactorial intervention falls programme
strength + balance training (3times a week for at least 12wks)
home hazard assessment + intervention
vision assessment + referral
medication review + modification
management of falls should include a Comprhensive Geriatric Assessment with the input of a full multidisciplinary team
drop attack / carotid sinus syndrome
increasingly common in old due to baroreceptor dysfunction + reduced cerebral autoregulatory mechanism
carotid sinus hypersensitivity has been found in 17% patients referred to falls clinic with unexplained syncope/falls (aged over 60)
pathophysio of carotid sinus syndrome
carotid sinus = area of dilation in the ICA which contains baroreceptors
in order to maintain homeostasis, as a response to increase pressure within the vessel wall, the resultant effect is peripheral vasodilation + reduction in HR
–> CSS is a condition of abnormal activation of this structure which leads to symptoms of secondary to cerebral hypoperfusion
carotid sinus syndrome investigations
carotid sinus massage
if neg - consider tilt-table CSM
carotid sinus massage findings
positive finding can be divided into 3 categories
- cardio-inhibitory CSS - pause in HR >3secs
- vasodepressor CSS - drop in systolic BP of 50mmHg
- mixed CSS - simultaneous combination of both
carotid sinus massage
connect cardiac monitor + BP cuff - take baseline values
lie flat + start rhythm stip printout
apply pressure for 5 secs to carotid sinus + start timer
check BP - max drop at 15secs
contraindications - MI or CVA in last 3 months, hx of VT, carotid artery stenosis
changes to bladder with age
decreased
- bladder capacity
- urethral closure pressure
increased
- post void residual
- detrusor overactivity
transient causes of incontinence
DIAPPERS
Delirium
Infection - urinary
Atrophic vaginitis/urethritis
pharmaceutical/prostate
psychological - esp depression
endocrine - or excess fluid intake/output
restricted mobility
stool impaction
types of incontinence
Stress = involuntary leakage on effort or exertion, sneezing or coughing
Urge = leakage accompanied by or immediately preceded by urgency
Mixed = urgency + exertion
Functional = inability to reach or use the toilet in time – immobility, cognitive impairment
incontinence investigations
general cognitive examination
abdominal examination
pelvic examination
PR
history - urinary symptoms, bowel symptoms, fluid intake, DH,SH,PMH
only do urinanalysis if result will change your management
bladder diary
things to look out for in bladder diary
- Small frequent amounts of urine passed
- High caffeine intake
- Larger volume first void in the morning
more advance incontinence investigations
- Post void bladder scan
- Consider PSA, U&Es, glucose
- Urodynamic studies – not before starting conservative management
