Immobility and Falls Flashcards
Definition of 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 paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force
Outcomes of a fall
Injury Rhabdomyolysis Loss of confidence / fear of falling inability to cope dependency / decreased QoL Carer stress Institutionalisation Terminal decline
Risk factors for falls
Muscle weakness (highest risk) history of falls gait deficit balance deficit Use assistive device Visual deficit Arthritis Impaired ADL Depression Cognitive impairment Age > 80 y/o
Why do patients fall?
Extrinsic factors
- inappropriate footwear
- environmental hazard (uneven paving, carpets, aids, stairs)
- poor lighting
Intrinsic factors
- gait and balance problems (postural instability, vertigo)
- syncope
- chronic neurological or MSK disorder
- visual problems
- acute illness
- cognitive disorder
- vitamin D deficiency
Situational factors
- alcohol
- urgency of micturition
- medications
Medications that can contribute to falls
Antidepressants (TCAs > SRIs) Antipsychotics Anticholinergics/Antimuscarinics Benzodiazepines Anti-HTNs Diuretics
Control of balance components
- Sensory input
- visual
- vestibular
- proprioceptive - Central processing
- cerebellum
- basal ganglia
- brain stem - Muscular activity
Gait and balance assessment
Sitting to standing ability Transfers Static standing balance Romberg test Dynamic standing balance - functional reach - heel toe walking - timed walk Gait Tinetti gait and balance scale Berg balance scale Timed 'get up and go' test
Causes of syncope
- neutrally mediated (reflex)
- vasovagal syncope (common faint)
- carotid sinus hypersensivity
- “situational syncope” - Orthostatic hypotension
- autonomic failure (primary, secondary, drug and alcohol induced)
- volume depletion (haemorrhage, diarrhoea) - Cardiac arrythmias
- Structural or cardiac or cardio-pulmonary disease
- Cerebrovascular (subclavian steel syndromes)
Situational syncope causes
Acute haemorrhage Cough Sneeze GI stimulation (swallowing, defeacation) Post micturition Post exercise Post e.g. weight lifting, brass playing
Collateral history of a loss of consciousness / blackout would look at what?
circumstances of event posture before fainting appearance presence or absence of moving during event tongue biting duration of event presence/absence of confusion in recovery period weakness down one side during recovery
Red flags for blackouts/syncope
ECG abnormalities - Innapropriate persistent bradycardia - Long QT and short QT intervals - abnormal T wave insertion Heart failure Onset with exertion FH of sudden cardiac death < 40 y/o Inherited cardiac condition new or unexplained breathlessness heart murmur
Seizure indications
Bitten tongue Head turning to one side during episode No memory of abnormal behaviour witnessed before, during or after the episode Unusual posturing Prolonged, simultaneous leg jerking Confusion after events Prodromal De ja vu
Fainting/syncope indications
Prodromal symptoms than on other occasions were abolished by sitting or lying down
sweating before episode
precipitated by prolonged standing
pallor during the episode
Possible tests for seizures/blackouts
ECG CT Cardiac enzymes Postural BP EEG Carotid USS MRI Cardiac stress test
Pathology of acute illness
Limited functional cerebral reserve
Hypoxia
- impaired central processing of information or correction of imbalance
