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Specialities > Geriatrics: Immobility and Falls > Flashcards

Geriatrics: Immobility and Falls Flashcards

1
Q

Define a ‘fall’.

A

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

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2
Q

How does the incidence of fall vary with age?

A

Incidence increases

  • 30% of >65s in the community
  • 40% of >80s in the community
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3
Q

How serious are fall?

A

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
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4
Q

What are the possible outcomes after a fall?

A
  • 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
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5
Q

Give some examples of risk factors for falls.

A
  • Muscle weakness
  • History of falls
  • Mobility issues
  • > 80 years
  • Cognitive impairment
  • Visual deficits
  • Depression
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6
Q

Why do patients fall?

A

Dependent on 3 things:

  • Extrinsic factors
  • Intrinsic factors
  • Situational factors
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7
Q

What intrinsic factors can cause falls?

A
  • Gait and balance problems
  • Syncope
  • Chronic disease
  • Visual problems
  • Acute illness
  • Cognitive disorder
  • Vitamin D deficiency
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8
Q

What extrinsic factors can cause falls?

A
  • Inappropriate footwear
  • Environmental hazards
  • Poor lighting
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9
Q

What environmental hazards can cause falls?

A
  • Uneven paving
  • Carpets
  • Walking aids
  • Stairs
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10
Q

What situational factors can cause falls?

A
  • Medications
  • Alcohol
  • Urgency of micturition
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11
Q

What types of medications can cause falls?

A
  • Antidepressants
  • Antipsychotics
  • Anticholinergics/ antimuscarinics
  • Benzodiazapines
  • Anti-hypertensives
  • Diuretics
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12
Q

What is postural stability dependent on?

A

Cerebral perfusion

  • Cardiac output
  • Vasomotor tone

Posture and balance

  • Static
  • Dynamic
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13
Q

How is balance controlled?

A
  • Sensory input: visual, vestibular and proprioceptive
  • Central processing via cerebrum, cerebellum, basal ganglia and brain stem
  • Muscular activity
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14
Q

What is involved in a gait and balance assessment?

A
  • 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
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15
Q

How can dizziness be subdivided?

A
  • Vertigo

- Unsteadiness

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16
Q

What pathologies can cause vertigo?

A
  • Labrynthitis
  • Acute ear infection
  • Benign paroxysmal positional vertigo
  • Meniere’s disease
  • Cerebellar/brainstem pathology
17
Q

What can cause syncope?

A
  • Neurally mediated (reflex)
  • Orthostatic hypotension
  • Cardiac arrhythmias
  • Structured cardiac or cardiopulmonary disease
  • Cerebrovascular
18
Q

What reflexes can cause syncope?

A
  • Vasovagal syncope (common faint)
  • Carotid sinus hypersensitivity
  • Situational syncope
19
Q

When can situational syncope occur?

A
  • Acute haemorrhage
  • Cough, sneeze
  • Gastrointestinal stimulation (swallow, defaecation, visceral pain)
  • Micturition (post-micturition)
  • Post-exercise
  • Others (e.g. brass instrument playing, weightlifting)
20
Q

When may orthostatic hypotension occur?

A

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)

21
Q

What types of cardiac arrhythmias can result in syncope?

A
  • 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
22
Q

Give examples of structured cardiac or cardiopulmonary disease which can cause syncope.

A
  • 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
23
Q

How is syncope assessed?

A
  • History from patient
  • Collateral history
  • Examination
  • 12 lead ECG
  • Assess for red flags
  • Consider further tests
24
Q

What history do you wish to gather from the patient following syncope?

A
  • Prodromal symptoms
  • Loss of consciousness
  • What are the last and first things they recall
  • Previous episodes
  • Injuries
  • PMH
  • Family history: including sudden death
  • Medications
25
Q

What collateral history do you wish to gather following syncope?

A
  • 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
26
Q

What examination do you wish to carry out following a syncope episode?

A
  • Vital signs including lying and standing blood pressure
  • Focussed neurological and cardiovascular examination
  • Look for any injuries
27
Q

Give 3 examples of rhythms which you may see on ECG following an episode of syncope.

A
  • Inappropriate, persistent bradycardia
  • Long QT syndrome (corrected QT >450ms) and short QT (corrected QT <350ms) intervals
  • Abnormal T wave insertion
28
Q

What red flags are there for syncope?

A
  • 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
29
Q

What further test may you carry out for a patient >60 years with unexplained syncope?

A

Carotid sinus massage

30
Q

What further test may you carry out for a patient <60 years with unexplained syncope?

A

Holter

31
Q

When may you think syncope is a seizure?

A

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
32
Q

What features make seizure and unlikely cause of syncope?

A
  • 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

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