Immobility & Falls Flashcards
What is the epidemiology of falls?
Annually:
- 40% of those > 80 years old fall in community
- 50% of those in hospital fall
Other:
- 1 fall-related death every 5 hours in UK
- 1% of falls result in hip fracture
In which age groups are falls the biggest problem?
80+’s
What are the most common outcomes after a fall?
1 - Injury: soft tissue, fracture, subdural etc.
2 - Rhabdomyolysis (release of muscle contents into blood following death of muscle fibres)
3 - Loss of confidence/ ‘fear of falling’
4 - Inability to cope
5 - Increased dependency
6 - Reduced QOL
What are the risk factors for falls?
1 - Muscle weakness
2 - History of falls
3 - Gait problems
4 - Balance problems
5 - Using a walking aid
6 - Visual deficit
Into what categories can the reasons for falls in the elderly be divided?
Intrinsic
Extrinsic
Situational
What are some of the intrinsic factors for elderly people falling?
1 - Gait and balance problems (postural instability or vertigo)
2 - Syncope (cardiac or vagal)
3 - Chronic disease (neurological or MSK)
4 - Visual problems
What are some of the situational factors that can cause the elderly to fall?
1 - Medications
2 - Alcohol
3 - Urgency of micturition
What are some of the extrinsic factors that can cause elderly people to fall?
1 - Inappropriate footwear
2 - Environmental hazards
3 - Poor lighting
What factors can affect gait and balance of an elderly person?
1 - Cerebral perfusion (reduced cardiac output or vasomotor tone)
2 - Posture & balance
What are the stages of controlling balance?
1) Sensory input (e.g. visual)
2) Central processing (e.g. cerebellum)
3) Muscular activity
How are gait and balance assessed in elderly patients?
- Sitting to standing ability
- Static standing balance
- Rombergs test (patients stand and closes their eyes - reduced balance = +ve rombergs test)
- Heel-toe walking
- Gait
- ‘Get up and go’ test
Which medical conditions could cause dizziness in an elderly patient?
1) Labrynthitis
2) Acute ear infection
3) Benign paroxysmal positional vertigo
4) Meniere’s
5) Cerebellar/brainstem pathology
What are the broad categories of causes of syncope?
1 - Neurally-mediated
2 - Orthostatic hypotension
3 - Cardiac arrythmias
4 - Structural cardiac
5 - Cerebrovascular
What are some of the neurally-mediated causes of syncope?
1 - Vasovagal syncope (common faint)
2 - Carotid sinus hypersensitivity
What are some of the causes of orthostatic hypotension?
1 - Autonomic failure
2 - Volume depletion (haemorrhage, diarrhoea)
What are some of the causes of syncope under cardiac arrythmias?
- Sinus node dysnfunction
- AV conduction disease
What are some of the causes of syncope under structural cardiac diseases?
- Aortic stenosis
- Acute MI
- Obstructive cardiomyopathy (thickening of the heart muscle)
- Acute aortic dissection
- Pericardial tamponade
What is subclvian steal syndrome
Subclavian steal syndrome:
- Subclavian artery becomes narrowed
- Blood to the brain bypasses the subclavian artery and instead travels through the right and left vertebral arteries
- The blood from the brain must then supply the upper limb (due to the blockage), so is considered as ‘stolen’ blood
How are patients with a transient loss of consciousness (blackouts) managed?
1 - History from patient
2 - Collateral history (history from a relative, friend or observer)
3 - Examination
4 - 12 lead ECG
5 - Assess for red flags
According to NICE guidelines, what are important aspects of the patient history to ask for syncope patients?
1 - Prodromal symptoms (early signs and symptoms they experienced)
2 - Loss of consciousness
3 - What are last and 1st things they recall?
4 - Previous episodes
5 - Injuries due to syncope
6 - PMH
7 - FM (any sudden deaths)
8 - Medications
According to NICE guidelines, what are important aspects of the collateral history to ask for syncope patients?
1 - Circumstances of the event
2 - Posture immediately before loss of consciousness
3 - Appearance
4 - Presence or absence of movement during (limb-jerking?)
5 - Tongue-bitting
6 - Duration of the event (onset to regaining consciousness)
7 - Confusion during recovery
8 - Weakness on 1 side during recovery
According to NICE guidelines, what are important aspects of the general examination for syncope patients?
1 - Vital signs (incl lying and standing blood pressure)
2 - Focussed neurological and cardiovascular examination
3 - Look for any injuries
According to NICE guidelines, what are important features to look out for on a 12 lead ECG in a syncope patient?
1 - Inappropriate, persistent bradycardia
2 - Long QT (>450ms) and short QT intervals (<350ms)
3 - Abnormal T wave inversion
According to NICE guidelines, what are considered red flags when assessing syncope patients?
1 - ECG abnormality (abnormal T-wave inversion, too long or short QT intervals, persistent inappropriate bradycardia)
2 - Heart failure (history of or physical signs)
3 - Onset with exertion
4 - Family history of sudden cardiac death at < 40 y.o.
5 - New or unexplained breathlessness
6 - Heart murmur
What features of a syncope incident might indicate it was a seizure?
1 - A bitten tongue
2 - Head-turning to 1 side during episode
3 - No memory of abnormal behaviour that was witnessed before, during or after episode by someone else
4 - Unusual posturing
5 - Prolonged, simultaneous limb-jerking
6 - Confusion after event
7 - Prodromal deja vu
What features of a syncope incident might indicate it was not a seizure?
1 - Prodromal symptoms which on other occasions have been abolished by sitting or lying down
2 - Sweating before the episode
3 - Precipitate by prolonged standing
4 - Pallor during the episode
What are the most common tests performed on syncope patients?
1 - ECG
2 - Telemetry (remotely monitor vital signs)
3 - Measure cardiac enzymes
4 - CT scan
5 - Echocardiogram
6 - Postural BP
What acute illnesses can bring on episodes of falls?
1 - Infection (chest, urinary)
2 - Dehydration
What cognitive disorders are often associated with falls?
1 - Dementia (impaired judgement, adnormal gait)
2 - Delirium
3 - Depression/anxiety
Deficiency of which vitamin is associated with falls?
Vitamin D
Which medications can predispose a patient to increased risk of falls?
1 - SSRI’s
2 - Antipsychotics
3 - Anticholinergics/muscarinics
4 - Benzodiazepines
5 - Anti-hypertensives
6 - Diuretics
Which healthcare team members are involved in assessing patients who are suffering with falls?
1 - Medical
2 - Nursing
3 - Physio
4 - OT’s
What are the roles of the various healthcare team members who work with patients suffering from falls?
Medical - Visual impairement, falls history, osteoporosis risk, medications, cognitive impairment
Nursing - Cognitive impairment, urinary incontinence
Physio - Gait, balance, mobility and functional awareness
OT - Functional ability, Home hazards
How are patients assessed for risk of osteoporosis?
1 - FRAX or QFRACTURE tool
2 - DEXA scan (measures BMD)
How are patients with a high risk of osteoporosis treated?
1 - Calcium & Vit D supplement
2 - Bisphosphonates
3 - Denosumab
What are the components of the FRAX assessment?
1 - Age, sex, weight, height
2 - Previous fractures
3 - Parent fractured hip
4 - Current smoker
5 - Taking glucocorticoids
6 - Rheumatoid Arthritis
7 - > 3 units alcohol/day
What is sarcopenia?
The degeneritive loss of skeletal muscle mass and strength associated with ageing
What are some of the complications of immobility?
1 - Muscle wasting
2 - Pressure sores
3 - DVT’s
4 - Osteoporosis
5 - Depression
6 - Social isolation
