H - Falls Lecture Flashcards
30% of over 65s fall eah year
What percent of over 80s fall each year?
50% of over 80s fall each year
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?
Dehydration
Rhabdomyolysis
Hypothermia
Pressure sores
VTE - venous thromboembolism
What type of drugs can cause rhabdomyolysis? usually in older frail adults
Statins can cause this
Do women or men more commonly fall?
What to do with muscle can this be down to?
Women fall more commonly men
Women have a smaller muscle bulk than men usually and therefore can be weaker when sarcopenia begins
Sarcopenia contributes towards the risk of falling
What is sarcopenia?
The eyes also change in older people, what happens to the eyes?
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
loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery.
What is this? and what causes it?
This is syncope and it usually occurs due to a temporary reduction in blood supply to the brain
What is another name for orthostatic hypotension?
This is also known as postural hypotension
When someone stands up, what is the normal pathway to return blood to the heart?
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
What nerve innervates the carotid sinus and the aortic arch baroreceptors?
Name the nuclei of these nerves
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
What are the values of SBP and DBP for diagnosing postural hypotension?
Fall in systolic blood pressure greater than 20
or
Fall in diastolic blood pressure grater than 10
After 3 minutes of standing
If you are cognitively impaired you are twice as likely to fall
What features does cognitive impairment impair?
impairs judgement, visual-spatial awareness, orientation
What is a myelopathy?
This is where there is spinal cor compression due to eg stenosis, a disc herniation, degenerative disease
What test is a patient positive for in cervical myelopathy?
What type of gait are they said to have?
Rhomberg’s test positive
Said to have a high stepping gait due to lack of sensation in the lower limbs
What are the three main features of parkinsons?
What type of gait do they have?
Tremor (pill rolling) , rigidity, bradykinesia
They have a shuffling gait
People with BPPV have an increased risk of falls due to vertigo and dizziness
What test is used to confirm and treat?
Diagnosed with Hallpike Test
Treated with Epley manoeuvre
When treating somebody with new lens who have eye problems
Which type of lens can increase the risk of falls?
Bifocal and multifocal lenses as they alter depth perception
What type of gait can chronic alcohol drinkers have?
A cerebellar ataxia gait
Polypharmacy is a common contributor to a falls risk
How many drugs are classified as polympharmacy?
HWn taking 4 or more medications
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?
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
When testing for orthostatic (postural) hypotension, how do you carry out this test?
known as the lying and standing blood pressure
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
What are symptoms of postural hypotension?
Feeling light headed
Dizziness
Nausea
Do you become unconscious or not in postural hypotension usually?
Normally you do not become unconscious
What is the online fracture assessment tool that can be used for a patients fracture risk?
What scan is used to check for osteoporosis?
Online fracture assessment tool - FRAX
DEXA bone scan is used for osteoporosis
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)
Need to carry out the training 3x per week for a minimum of 12 weeks
What is an example of strength and balance training?
Otago exercise programme
Tai chi
What are the simple things that can be used to help with postural hypotension?
What drug can be used to help treat the problem?
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
What type of drug is fludrocortisone?
Fludrocortisone is a mineralocorticoid agent and acts as aldosterone to encourage the uptake of sodium
How many drugs is it where it becomes a risk factor for a patient?
When a patient is on at least 4 or more drugs this is polympharacy and is a risk factor for the patient
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?
Carry out Hallpike test
How is Hallpike test carried out?
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
How is BPPV treated?
What test and how is it carried out for postural hypotension?
What are the diagnostic features of postural hypotension?
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
Patient had
Lying BP 120/80
Standing BP 90/70
What does she have?
Diagnosis of postural hypotension
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?
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
Why cant the temazepam be stopped straight away?
Have a high withdrawal rate and therefore need to be titrated down
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?
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
What is an SSRI and give an example?
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
