ILA 4 - Falls

Question 1

Falls history: before the event

Answer 1

• Circumstance (mechanical, syncope, etc.)
• Symptoms
• Position (head up - VBI, from standing - postural hypo)
• Where
• Previous falls
• Bleeding or sepisis etc, precipitating a fall

Question 2

Falls history: during the event

Answer 2

• LOC
• Injury
• Eye witness account
• Seizure: shaking, cyanosis, incontinence, tongue biting

Question 3

Falls history: after the event

Answer 3

• Post-ictal symptoms
• Speech difficulty/weakness or other neurology (CVA)
• Confusion
• Left on floor for a while - rhabdomyolysis

Question 4

Falls history: PMHx

a) General
b) CV
c) Neuro

Answer 4

a) Infection, diabetes, visual impairment, drugs, polypharmacy
b) Arrhythmias, AS, hypotension
c) PD, footdrop, ataxias

Question 5

Falls history: SHx

Answer 5

• Alcohol
• Care needs
• Home hazards etc.

Question 6

Falls history: DHx - offending meds

Answer 6

• Antihypertensives
• Diuretics (urgency! - incontinence)
• Sedatives/hypnotics (eg benzos, TCAs)
• Gliclazides etc.

Question 7

Medication review: what is it?

Answer 7

• Optimise meds
• Stop any unnecessary/intolerable
• Reduce/increase doses

Question 8

Med review: NO TEARS

Answer 8

Need and indication
Open Qs
Tests and monitoring
Evidence and guidelines
Adverse effects
Risk reduction or prevention
Simplification and switches

Question 9

Prescribing cascade

Answer 9

• Medications prescribed to counteract the effects of other medications

Question 10

Polypharmacy

Answer 10

More than 4 meds

Question 11

STOPP START tool

Answer 11

-

Question 12

Hypertension in the over 80s.

a) Target BP
b) Use standing or sitting BP?

Answer 12

a) 150/90 (clinic) or 145/85 (home)

b) Standing

Question 13

Acute (unstable) AF.

a) Presentation
b) Management

Answer 13

a) Shock, syncope, myocardial ischaemia, acute HF

b) DC cardioversion. If that fails - amiodarone?

Question 14

Stable AF

a) Investigations
b) Management if <48h post onset
c) Management if >48h post onset

Answer 14

a) ECG, ECHO, bloods (UEs, TFTs, cardiac enzymes)
b) Rhythm control (DC cardioversion, if fails then fleicainide or amiodarone)
c) Rate control (BB or CCB) and anticoagulate

Question 15

86 year old female admitted to hospital for a fall, due to postural hypotension. Found incidentally to have AF.
- Laboratory Tests: K+ 3.2 mmol, eGFR of 29. Bone profile is consistent with Vitamin D deficiency.
- Discharge Medication: Furosemide 20mg OD, Atorvastatin 20mg OD, Sertraline 50mg OD,
Zopiclone 3.75mg ON, Cholecalciferol 800mg OD

a) What changes should be made to these meds?
b) What investigations should you do before?

Answer 15

a) - Titrate down furosemide (due to hypokalaemia and postural hypotension falls risk)
- Titrate down zopiclone and then stop it (due to falls risk; shouldn’t be on zopiclone for >4 weeks)
- Increase cholecalciferol and consider need for bisphosphonates (FRAX score and DEXA scan)
- Consider rate control and anticoagulation for AF

b) Repeat UEs and eGFR