Geriatrics: Immobility and Falls Flashcards
Define a ‘fall’.
Inadvertently coming to rest on the ground or other lower level without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force
How does the incidence of fall vary with age?
Incidence increases
- 30% of >65s in the community
- 40% of >80s in the community
How serious are fall?
They can be very serious
- There is 1 fall related death every 5 hours in the UK
- 1% of falls result in hip fracture
- Mortality in the elderly who fall is 10x that of the under 65s
What are the possible outcomes after a fall?
- Injury (50%): soft tissue, fracture, subdural etc.
- Rhabdomyolysis (Increased CK)
- Loss of confidence/ fear of falling
- Inability to cope
- Dependency/ decrease in QOL
- Carer stress
- Institutionalisation
- Terminal decline
Give some examples of risk factors for falls.
- Muscle weakness
- History of falls
- Mobility issues
- > 80 years
- Cognitive impairment
- Visual deficits
- Depression
Why do patients fall?
Dependent on 3 things:
- Extrinsic factors
- Intrinsic factors
- Situational factors
What intrinsic factors can cause falls?
- Gait and balance problems
- Syncope
- Chronic disease
- Visual problems
- Acute illness
- Cognitive disorder
- Vitamin D deficiency
What extrinsic factors can cause falls?
- Inappropriate footwear
- Environmental hazards
- Poor lighting
What environmental hazards can cause falls?
- Uneven paving
- Carpets
- Walking aids
- Stairs
What situational factors can cause falls?
- Medications
- Alcohol
- Urgency of micturition
What types of medications can cause falls?
- Antidepressants
- Antipsychotics
- Anticholinergics/ antimuscarinics
- Benzodiazapines
- Anti-hypertensives
- Diuretics
What is postural stability dependent on?
Cerebral perfusion
- Cardiac output
- Vasomotor tone
Posture and balance
- Static
- Dynamic
How is balance controlled?
- Sensory input: visual, vestibular and proprioceptive
- Central processing via cerebrum, cerebellum, basal ganglia and brain stem
- Muscular activity
What is involved in a gait and balance assessment?
- Sitting to standing ability
- Static standing balance
- Romberg test
- Dynamic standing balance ( functional reach, tandem walking, timed walk)
- Gait
- Tinetti gait and balance scale
- Berg balance scale
- Get and go test
How can dizziness be subdivided?
- Vertigo
- Unsteadiness
What pathologies can cause vertigo?
- Labrynthitis
- Acute ear infection
- Benign paroxysmal positional vertigo
- Meniere’s disease
- Cerebellar/brainstem pathology
What can cause syncope?
- Neurally mediated (reflex)
- Orthostatic hypotension
- Cardiac arrhythmias
- Structured cardiac or cardiopulmonary disease
- Cerebrovascular
What reflexes can cause syncope?
- Vasovagal syncope (common faint)
- Carotid sinus hypersensitivity
- Situational syncope
When can situational syncope occur?
- Acute haemorrhage
- Cough, sneeze
- Gastrointestinal stimulation (swallow, defaecation, visceral pain)
- Micturition (post-micturition)
- Post-exercise
- Others (e.g. brass instrument playing, weightlifting)
When may orthostatic hypotension occur?
Autonomic failure
- Primary autonomic failure syndromes (e.g. pure autonomic failure, multiple system atrophy, Parkinson’s disease with autonomic failure)
- Secondary autonomic failure syndromes (e.g. diabetic neuropathy, amyloid neuropathy)
Volume depletion
-Haemorrhage, diarrhoea, Addison’s disease (relative)
What types of cardiac arrhythmias can result in syncope?
- Sinus node dysfunction (including bradycardia/tachycardia syndrome)
- Atrioventricular conduction system disease
- Paroxysmal supraventricular and ventricular tachycardias
- Inherited syndromes (e.g. long QT syndrome, Brugada syndrome)
- Implanted device (pacemaker, ICD) malfunction
- Drug-induced proarrhythmias
Give examples of structured cardiac or cardiopulmonary disease which can cause syncope.
- Cardiac valvular disease i.e. aortic stenosis
- Acute myocardial infarction/ischaemia
- Obstructive cardiomyopathy
- Atrial myoxoma
- Acute aortic dissection
- Pericardial disease/tamponade
- Pulmonary embolus/pulmonary hypertension
How is syncope assessed?
- History from patient
- Collateral history
- Examination
- 12 lead ECG
- Assess for red flags
- Consider further tests
What history do you wish to gather from the patient following syncope?
- Prodromal symptoms
- Loss of consciousness
- What are the last and first things they recall
- Previous episodes
- Injuries
- PMH
- Family history: including sudden death
- Medications
What collateral history do you wish to gather following syncope?
- Circumstances of the event
- Posture immediately before loss of consciousness
- Appearance
- Presence or absence of movement during the event (? Limb jerking)
- Tongue-biting
- Duration of the event (onset to regaining consciousness)
- Presence or absence of confusion during the recovery period
- Weakness down 1 side during the recovery period
What examination do you wish to carry out following a syncope episode?
- Vital signs including lying and standing blood pressure
- Focussed neurological and cardiovascular examination
- Look for any injuries
Give 3 examples of rhythms which you may see on ECG following an episode of syncope.
- Inappropriate, persistent bradycardia
- Long QT syndrome (corrected QT >450ms) and short QT (corrected QT <350ms) intervals
- Abnormal T wave insertion
What red flags are there for syncope?
- An ECG abnormality
- Heart failure
- Onset with exertion
- Family history of sudden cardiac death (<40 years) and/or inherited cardiac condition
- New or unexplained breathlessness
- A heart murmur
What further test may you carry out for a patient >60 years with unexplained syncope?
Carotid sinus massage
What further test may you carry out for a patient <60 years with unexplained syncope?
Holter
When may you think syncope is a seizure?
If there is 1 or more of the following features:
- A bitten tongue
- Head turning to 1 side during episode
- No memory of abnormal behaviour that was witnessed before or during the episode by someone else
- Unusual posturing
- Prolonged simultaneous limb-jerking
- Confusion after the event
- Prodromal deja vu or jamais vus
What features make seizure and unlikely cause of syncope?
- Prodromal symptoms that on other occasions have been abolished by sitting or lying down
- Sweating before the episode
- Precipitated by prolonged standing
- Pallor during the episode
