Immobility and falls

Question 1

Causes of falls in the elderly

Answer 1

• CVS
  
  • Postural hypotension
  • Arrythmia
  • Heart failure
  • Aortic stenosis
• Sensory
  
  • Visual impairment
  • Inattention/distraction
  • (Hearing)
• Neurological
  
  • Stroke
  • Parkinsonism
  • Dementia
  • Delirium
  • Ataxia (seizure or TIA) - degenerative disease of the nervous system - damage to the cerebellum,
  • Other
• Drugs
  
  • Anti-hypertensives
  • Sedatives
  • Alcohol
  • Others
• MSK
  
  • Arthirits of weight bearing joints
  • Sarcopenia
  • Deformities of feet
• Icontinence
  
  • Rushing to the toilet

Question 2

How do drugs cause falls?

Answer 2

Drugs can cause a decrease in:

• BP
• Heart Rate
• Awareness

And an increase in:

• Urine output
• Sedation
• Hallucinations
• qTC - QT interval
• Dizziness

Question 3

What are the main drugs that cause falls?

Answer 3

• Antihypertensives
• Beta blockers
• Sedatives
• Anti-cholinergics/anti-muscarinics
• Opioids
• Alcohol

Question 4

Falls clinic is a full MDT approach - who is involved?

Answer 4

• Nurse
  
  • Eye test, ECG, Lying and standing BP, incontinence questionnaire. MMSE
• Physiotherapist
  
  • Full assessment of gait and balance
• Doctor
  
  • Thorough history and examination, consider bone health and osteoporosis screening. (45 minutes +)
• MDT discussion
  
  • Treatment plan made

Question 5

What do you need to ask in the presenting complaint part of a history in regards to a falls patient?

Answer 5

• Detail of the fall
  
  • What were you doing?
  • Who with?
  • What happened?
  • What happened next?
  • How did you get up off the floor?
• Collapse with no memory? syncope or cognition
• Clear history of trip – think sensory (eyes, nerves)
• Palpitations preceding fall and no trip - think cardiac
• On turning – think postural instability
• Any ‘near misses’- unsteady on standing
• Syncope on exertion think aortic stenosis

Question 6

A full examination of a falls patient should include…

Answer 6

• Head and arms
  
  • Cranial nerves, apart from smell. Check glasses
  • Check neglect
  • Cerebellar signs
  • Bradykineasia (slowness of movements), ridigidity (stiff muscles) – signs of Parkinson’s
• Pulse, heart sounds, signs of heart failure and respiratory disease
• Kyphosis
• Abdominal examination
• Legs
  
  • Look at feet - footwear, toenails
  • Check sensation, vibration sense and proprioception
  • Co-ordination
  • Romberg’s - assesses proprioception - patient closes eyes whilst standing and you assess their balance
  • Assess gait

Question 7

Gait and pathology

Answer 7

• Ataxic - cerebellar damage
• Arthalgic - arthritis
• Small steps, shuffling - Parkinsonism (vascular)
• High stepping - peripheral neuropathy
• Hemiplegic - stroke

Question 8

A falls assessment in A+E: history

Answer 8

• First do ABCDE assessment and assess and treat any injury
• How did they fall? Did they trip over? What did they trip over?
• How long were they on the floor? Check Creatine kinase for rhabdomyolysis (muscle injury), have they got Pneumonia? 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 9

A falls assessment in A+E: examination

Answer 9

• Are they acutely unwell? – do bloods
• Do a neurological examination as well as Chest / heart / abdomen (skip reflexes!)
• Look at legs and try and get them to walk (if you can)
• Ensure a full set of obs are done (do yourself if in ‘minors’) do L+S BP
• ECG for all
• 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 10

You should immediately do a CT for a head injury in the following situations…

Answer 10

• 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 11

Should I do an x-ray?

Answer 11

• If pain on moving a joint have low threshold of x ray
  
  • 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 12

What causes falls in inpatients?

Answer 12

• All the same things as outpatients and….
• Patient getting postural hypotension (or just hypotension) due to illness
• Or new medication
• Low blood glucose
• Or getting sicker
• DELIRIUM DELRIUM DERLIRUM
• De-conditoning
• Call bell out of reach, no appropriate footwear.