H - Falls Lecture

Question 1

30% of over 65s fall eah year

What percent of over 80s fall each year?

Answer 1

50% of over 80s fall each year

Question 2

75 year old lady falls alone at home and unable to summon help. Only found 48 hours later…….

What are some of the potenital problems this lady could face due to lying for so long?

Answer 2

Dehydration
Rhabdomyolysis

Hypothermia

Pressure sores

VTE - venous thromboembolism

Question 3

What type of drugs can cause rhabdomyolysis? usually in older frail adults

Answer 3

Statins can cause this

Question 4

Do women or men more commonly fall?

What to do with muscle can this be down to?

Answer 4

Women fall more commonly men

Women have a smaller muscle bulk than men usually and therefore can be weaker when sarcopenia begins

Question 5

Sarcopenia contributes towards the risk of falling
What is sarcopenia?

The eyes also change in older people, what happens to the eyes?

Answer 5

Sarcopenia is the loss of muscle mass and function which increases the risk of falling

IN the elderly, the eye lens hardens - known as presbyopia where the lens hardens and therefore light focuses behind the retina when looking at near objects - old age long sightedness

Question 6

loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery.

What is this? and what causes it?

Answer 6

This is syncope and it usually occurs due to a temporary reduction in blood supply to the brain

Question 7

What is another name for orthostatic hypotension?

Answer 7

This is also known as postural hypotension

Question 8

When someone stands up, what is the normal pathway to return blood to the heart?

Answer 8

Blood pulls around the legs, this reduces the venous return to the heart which decreases the preload into the heart , decreasing CO and BP
The baroreceptors of the aortic arch and carotid sinus detect the decrease in blood pressure and increase sympathetic supply to heart to increased contraction and CO

Question 9

What nerve innervates the carotid sinus and the aortic arch baroreceptors?
Name the nuclei of these nerves

Answer 9

Carotid sinus innervated by CN IX
Solitary nucleus, superior salivatory nucleus, spinal nucleus, nucleus ambiguus

Aortic arch innervated by CN X - vagus

Dorsal motor nucleus, spinal trigeminal nucleus, nucleus ambiguus, solitary nucleus

Question 10

What are the values of SBP and DBP for diagnosing postural hypotension?

Answer 10

Fall in systolic blood pressure greater than 20
or

Fall in diastolic blood pressure grater than 10

After 3 minutes of standing

Question 11

If you are cognitively impaired you are twice as likely to fall

What features does cognitive impairment impair?

Answer 11

impairs judgement, visual-spatial awareness, orientation

Question 12

What is a myelopathy?

Answer 12

This is where there is spinal cor compression due to eg stenosis, a disc herniation, degenerative disease

Question 13

What test is a patient positive for in cervical myelopathy?

What type of gait are they said to have?

Answer 13

Rhomberg’s test positive

Said to have a high stepping gait due to lack of sensation in the lower limbs

Question 14

What are the three main features of parkinsons?

What type of gait do they have?

Answer 14

Tremor (pill rolling) , rigidity, bradykinesia

They have a shuffling gait

Question 15

People with BPPV have an increased risk of falls due to vertigo and dizziness

What test is used to confirm and treat?

Answer 15

Diagnosed with Hallpike Test

Treated with Epley manoeuvre

Question 16

When treating somebody with new lens who have eye problems

Which type of lens can increase the risk of falls?

Answer 16

Bifocal and multifocal lenses as they alter depth perception

Question 17

What type of gait can chronic alcohol drinkers have?

Answer 17

A cerebellar ataxia gait

Question 18

Polypharmacy is a common contributor to a falls risk

How many drugs are classified as polympharmacy?

Answer 18

HWn taking 4 or more medications

Question 19

Romberg test – patient stands with their feet tofether and close their eyes – check to see if they have a loss of balance

The exam is based on the premise that a person requires at least two of the three following senses to maintain balance while standing

WHat are the three senses that are reuqired?

Answer 19

2 of the three of
Proprioception - the ability to know one’s body position in space

Vestibular function - knowning ones head position in space

Vision

Question 20

When testing for orthostatic (postural) hypotension, how do you carry out this test?
known as the lying and standing blood pressure

Answer 20

1st BP: taken after lying/sitting for at least five minutes.
2nd BP: taken after standing in the first minute

3rd BP: taken after standing for three minutes

Question 21

What are symptoms of postural hypotension?

Answer 21

Feeling light headed
Dizziness

Nausea

Question 22

Do you become unconscious or not in postural hypotension usually?

Answer 22

Normally you do not become unconscious

Question 23

What is the online fracture assessment tool that can be used for a patients fracture risk?

What scan is used to check for osteoporosis?

Answer 23

Online fracture assessment tool - FRAX

DEXA bone scan is used for osteoporosis

Question 24

The intervention that has the strongest evidence for helping with falls is strength and balance training

How often does this training need to be carried out? (minimum)

Answer 24

Need to carry out the training 3x per week for a minimum of 12 weeks

Question 25

What is an example of strength and balance training?

Answer 25

Otago exercise programme

Tai chi

Question 26

What are the simple things that can be used to help with postural hypotension?
What drug can be used to help treat the problem?

Answer 26

Can ensure to keep yourself hydrated and make sure they salt intake is good enough

The drug used to help treat this could be fludricortisone

Question 27

What type of drug is fludrocortisone?

Answer 27

Fludrocortisone is a mineralocorticoid agent and acts as aldosterone to encourage the uptake of sodium

Question 28

How many drugs is it where it becomes a risk factor for a patient?

Answer 28

When a patient is on at least 4 or more drugs this is polympharacy and is a risk factor for the patient

Question 29

86 year old patient
Presents with:

‘Dizziness, falls and worsening mobility’

PMHx:

Hypertension, IHD, Osteoarthritis, Depression

Dizziness:

2 components - Light-headed on standing & Vertigo

No loss of consciousness

What test could be carried out to see if patient has BPPV?

Answer 29

Carry out Hallpike test

Question 30

How is Hallpike test carried out?

Answer 30

The patient sits upright
Rotates head to 45 degrees

Patient then lies flat and extends head to 20degrees
Observe eyes for 45 seconds and ystagmus and vertgio should be observed

Question 31

How is BPPV treated?
What test and how is it carried out for postural hypotension?
What are the diagnostic features of postural hypotension?

Answer 31

BPPV is treated with the Epley manoevure

Carry out lying and standing BP
1st BP - after the patiet has been lying for at least 5 mins

2nd BP - after the patient has been standing in the 1st min

3rd BP - after the patient has been standing for 3 mins

Systolic decrease greater than 20 or diastolic greater than 10 is diagnostic

Question 32

Patient had
Lying BP 120/80
Standing BP 90/70

What does she have?

Answer 32

Diagnosis of postural hypotension

Question 33

Give the side effects of the patients medication
Furosemide 40mg od

Amlodipine 10mg od

Tramadol 100mg qds

Ramipril 10mg od

Temazepam 10mg od

Amitriptyline 50mg od?

Answer 33

Furosemide - hypokalaemia, fatigue
Amlodopine - decreases BP and ankle oedema

Tramadol - constipation and sedative effects

Ramipiril - hypotension dry cough

Temazepam - benzodiazpeines have a sedative effect

Amitrpytline - also have an increased falls risk due to sedation

Question 34

Why cant the temazepam be stopped straight away?

Answer 34

Have a high withdrawal rate and therefore need to be titrated down

Question 35

86 year old patient – presents with – dizziness, falls and worsening mobility
PMHx
Hypertension, IHD, Osteoarthritis, Depression,

Dizziness – 2 components – light headed on standing and vertigo, no loss of consciousness
Frusemide 40mg od
Amlodopine 10mg od
Tramadol 100mg qds
Temazepam 10mg od
Amitryptyline 50mg od
Patient has orthostatic hypotension, what can be done for a medication review?

Answer 35

Patient has no evidence of requiring the furosemide due to the CCB being the most likely cause of ankle swelling
Therefore take patient of both of these which will also reduce the hypotension

Take patient off co-codamol and start on paracetamol pathway to try help analgesia

And titrate off temazepam as she may not have sleeping issues anymore

Amitryptline is choline heavy so change to 1st line SSRI

Question 36

What is an SSRI and give an example?

Answer 36

This is a selective seratonin reuptake inhibitor
SSRIs are the most widely prescribed type of antidepressants. They’re usually preferred over other antidepressants, as they cause fewer side effects

FLoxetine or citlopram are well known SSRIs