Immobility and falls

Question 1

main disorders causing falls? - neurological

Answer 1

• Stroke, old or new
• Parkinsonism
• Dementia
• Delirium, Ataxia (Seizure, TIA)
  Other neurological conditions

Question 2

main disorders causing falls?- drugs

Answer 2

Anti hypertensives
Sedatives, alcohol
And lots of others

Question 3

main disorders causing falls? - sensory

Answer 3

Visual impairment
Inattention
(Hearing)

Question 4

main disorders causing falls? - cardiovascular (4)

Answer 4

• Postural hypotension
• Arrythmia
• Heart failure
• Aortic Stenosis

Question 5

main disorders causing falls? - musculoskeletal

Answer 5

• Arthritis of weight bearing joints
• Sarocopenia
• Deformities of feet

Question 6

how do drugs cause falls - what do they decrease

Answer 6

Blood pressure
Heart rate
Awareness

Question 7

how do drugs cause falls - what do they increase

Answer 7

• Urine output
• Sedation
• Hallucinations
• qTC
• Dizziness

Question 8

Culprit drugs that can cause falls?

Answer 8

• Antihypertensive
• Beta blocker
• Sedatives
• Anticholingerics
• Opioids
• Alcohol

Question 9

full MDT - what will nurse carry out

Answer 9

Eye test, ECG, Lying and standing BP, incontinence questionarrie. MMSE

Question 10

full MDT - what will physio carry out

Answer 10

Full assessment of gait and balance

Question 11

full MDT - what will doctor carry out

Answer 11

Through history and examination, consider bone health and osteoporosis screening. (45 minutes +)

Question 12

syncope on excretion - what could this be?

Answer 12

aortic stenosis

Question 13

Collapse with no memory ? think..?

Answer 13

syncope or cognition

Question 14

Clear history of trip – think ?

Answer 14

sensory (eyes, nerves)

Question 15

Palpitations preceding fall and no trip - think ?

Answer 15

cardiac

Question 16

Falling on Turning - think?

Answer 16

postural instability

Question 17

Any ‘near misses’- think?

Answer 17

unsteady on standing

- have they nearly fallen

Question 18

Systematic enquiry - what MUST you ask (3)

Answer 18

• Memory – Ideally ask a relative too
• Urinary symptoms (they won’t tell you if you don’t ask)
• Has walking changed recently

Question 19

Systematic enquiry - drugs

Answer 19

• Especially over the counter antihistamines…

- Especially alcohol

Question 20

Examination steps - first

Answer 20

• assess walking

- Get patient on couch - can they take their shoes off

Question 21

Examination steps - head and arms

Answer 21

• Cranial nerves, apart from smell.
• Check glasses
• Check neglect,
• Cerebellar signs
• Bradykineasia, ridigidity – signs of PD

Question 22

Examination - cardiac

Answer 22

Pulse, (BP) Heart sounds. Signs of heart failure and respiratory disease

Question 23

on examination look out for?

Answer 23

Kyphosis

Question 24

what examination may you carry out?

Answer 24

Abdominal examination (+PR if prostate)

Question 25

examinations - legs - what should you remember

Answer 25

- Look at feet (footwear, toenails). - Check sensation, vibration sense, and proprioception – remember usually glove and stocking not dermatomal - Co-ordination

Question 26

how to asses them standing up?

Answer 26

- Romberg's | - Assess gait

Question 27

ataxic gate?

Answer 27

cerebellar damage

Question 28

Arthralgia gait?

Answer 28

Arthritis

Question 29

Hemiplegic gait?

Answer 29

old stroke (stiff leg)

Question 30

Small steps, shuffling (gait)?

Answer 30

(Vascular) parkinsonism

Question 31

High stepping gait caused by?

Answer 31

Peripheral neuropathy

Question 32

non injured fallers are often?

Answer 32

left at home by paramedics and referred to community falls pathways- including falls clinic

Question 33

non- injured falling patients in A&E are often

Answer 33

- Tired - Injured - In pain - Unable to stand due to injury (so can’t assess gait) - Systemically unwell - Will need MDT assessment later

Question 34

important things to check in a history ?

Answer 34

- How did they fall? Did they trip over? - What did they trip over? - Long lie – check CK for rhabdomyolysis. - Pneumonia and skin injury common as well. - Any other falls. - Any cognitive impairment - Any incontinence - Any syncope - Any features of seizure (rare but happens) - Are they drunk - Look at ambulance sheet – - Talk to relative

Question 35

A falls assessment in A+E - examination and investigations

Answer 35

if acute - do bloods - Do a neurological examination as well as Chest / heart / abdomen (skip reflexes!) - legs can they walk - The best history you can get (include the ambulance sheet) - obs, L+S BP - ECG - Bloods for all* check B12, folate, CK, TFTs - Check for delirium using 4AT - Consider CT head if fall with head injury and neurological signs or anticoagulated

Question 36

Questions to ask yourself?

Answer 36

ARE THEY INJURED - sick? - Is she safe to go home (+ community falls service)? - Can she go to the toilet on her own? - Can she get a cup of tea between carer visits? - Can she walk in A+E ? - Can she summon help (would she have a long lie)?

Question 37

what must you test for

Answer 37

glucose | ABCDE

Question 38

Immediate assessmentfor serious injuries?

Answer 38

- Head injury and extra dural - Seizure - C Spine injury - Flail chest - Abdominal injury - Pelvic injury - Limb fracture

Question 39

when to do a CT head?

Answer 39

- Low GCS <13 - Still confused after 2 hours (or not back to baseline cognitive state) - Focal neurology - Signs of skull fracture - Basal skull fracture – CSF leak, bruising around eyes, - Seizure - Vomiting - Anti-coagualtion

Question 40

when to x-ray

Answer 40

- if they can't move joint - if there is a pain in joint - If no deformity but pain on weight bearing have low threshold to x ray - People can walk on fractured hips (I don’t know how either!)

Question 41

What caused the fall in inpatients ?

Answer 41

- Patient getting postural hypotension (or just hypotension) due to illness - Or new medication - Low blood glucose - Or getting sicker - DELIRIUM - De-conditoning - Call bell out of reach, no appropriate footwear