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Integration for clinical application > Lecture 3- Managing falls > Flashcards

Lecture 3- Managing falls Flashcards

1
Q

falls reduce

A

Falls reduce quality of life, loss of confidence and impendence and ultimately, mortality

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2
Q

Causes of falls

A

Causes of falls

  • Trips
  • UTI
  • Stroke
  • Delirium
  • Syncope
  • etccccccc
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3
Q

how to think about a fall

A

who

when

what

how

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4
Q
  • Who?
A
  • How much they remember about the fall
  • Did anyone else witness the fall? If so take a collateral history
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5
Q
A
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6
Q
  • When?
A
  • When did it occur?
    • At night? Vision an issue?
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7
Q
  • Where?
A
  • In the house?
    • Which room?
    • Any trip hazards?
    • Flashing lights from tv? Can cause a seizure in old people
  • In the shop?
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8
Q
  • What?
A
  • What where they doing at the time?
    • Looking up?
    • Just got up from chair/bed?
    • Just been to toilet? Post micturition syncope
  • Before?
    • Any symptoms prior to fall (light headedness/dizziness)
    • Chest pain
    • Did they trip or slip
  • During
    • Loss of consciousness
    • Incontinence, tongue biting, shaking
    • Any injuries? E.g.head injury, broken hip etc
  • After
    • What happened after?
    • Diff they regain consciousness quickly?
    • Were they able to get up without help?
    • Any confusion or neurological symptoms?
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9
Q
  • How?
A
  • How long were they on the floor for?
  • How many times has this happened before?
  • How many in last 6 months
  • Any serious injuries
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10
Q

Essential part to any history-

A

did they pass out before or after fall?

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11
Q

What is syncope?

A
  • Transient loss of consciousness characterised by fast onset and spontaneous recovery
  • Caused by a reduced perfusion in the brain
  • Syncope is usually self-limiting- being horizontal will fix low blood pressure
  • Beware of people who have been held in an upright position
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12
Q

Pre-syncope symptoms?

A
  • Symptoms preceding a syncopal episode include
    • Light-headedness
    • Sweating
    • Pallor
    • Blurred vision
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13
Q

types of syncope

A

reflex syncope

orthostatic (postural) hypotension

cardiac/cardiopulmonary disease

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14
Q

reflex syncope

A
  • Disorder of the autonomic regulation of postural tone
  • Activation of part of medulla leads to decrease in sympathetic output and increase in parasympathetic
    • Decreased CO
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15
Q

Orthostatic (postural) hypotension​

A
  • Symptoms occur after standing from a sitting or lying position
  • Can cause syncope if drop in blood pressure is severe enough
  • Normally defined as a drop of 20mmHg or more
  • The problem with standing
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16
Q

why can standing up caue hypotension

A
  • standing up causes 500-800ml of blood to pool i t he lefs
  • reeduction in end diastolic volume
  • reduced cardiac stretch, therefore reduce stroke volume and cardiac output
  • normally managed by the baroreceptor reflex
  • if this fails then cerebral perfusion will drop and syncope occurs
17
Q

baroreceptor reflex

A
  • aBP normally regulated within a narrow range
  • accomplished by negative feedback system incorporating pressure sensors i.e. baroreceptors that sense aBP
18
Q

where are baroreceptors found

A

carotid sinus

aortic arch

19
Q

carotid sinus

A
  • (bifurcation of external and internal carotids)
    • Innervated by the sinus nerve of Hering (branch of the glossopharyngeal nerve)
    • Glossopharyngeal synapses in the nucleus tractus solitarius (NTS) located in the medulla of the brainstem
20
Q
  • Aortic arch
A
  • Innervated by the aortic nerve, which combines with the vagus nerve travelling to the NTS (medulla)
  • NTS modulates the activity of sympathetic and parasympathetic (vagal) neurones in the medulla, which in turn regulates the autonomic control of the heart and blood vessels
21
Q

If BP rises

A
  • the walls of the vessels expand passively
  • which increases firing frequency of action potential generated by the receptors
22
Q

If BP falls

A
  • decreased stretch of arterial wall
  • decrease firing of AP
23
Q

Why does the baroreceptor reflex fail?

A
  • Baroreceptors become less sensitive with age
  • Also become less sensitive with hypertension
  • Medications such as anti-hypertensive can impair this response
  • Dehydration
24
Q

Seizures

A
  • A generalised tonic-clonic seizure is a cause of loss of consciousness and will cause a fall
  • However it is not syncope
  • Be are of new epilepsy in the elderly
  • 2nd peak in incidence rate is in over 80s
  • Seizure can often be subtle
25
Q

Aortic stenosis

A
  • Narrowing of aortic valve
  • Harder to push blood through aortic valve
  • During exercise, when the heart has to work harder, the stenosis can limit CO and therefore fail to adequately perfuse the brain
  • If AS with syncope- survival of 2-5 year if untreated
26
Q

Non-syncopal falls

A
  • Fall in which the cause is not a syncope
  • A fall with loss of consciousness following a head trauma is still a non-syncopal fall
  • Trips and slips fall in the category
  • Often the fall can be the end result of an intercurrent illness such as an infection
27
Q

Multifactorial falls

A
  • Many falls will be a result of more than one thing
  • Imagine a pt with OA and Diabetic neuropathy
  • Add infection on top of this
28
Q

Medications which may cause falls

A
  • Antihypertensives
    • hypotension
  • Drugs which reduce blood glucose
    • Hypoglycaemia
  • Medications which effect the brain
    • i.e. cause sedation of drowsiness
29
Q

Is this patient safe to be at home?

A
  • Need to complete a full history
    • Presenting complaint
    • History of presenting complaint
    • Past medical history
    • Family history
    • Drug history
    • Social history
30
Q

Drug history

A
  • Polypharmy
  • Any new medications
  • Anti-hypertensives/ anti-arrhythmias
  • Any drug which may induce drowsiness?
    • Analgesia
    • Benzodiazepine
    • Antidepressants
    • Antipsychotics
  • Have they had a recent medication review
31
Q

Social history

A
  • Who does she live with?
  • Does she have any help
  • Family close by?
  • Any stairs?
  • Any walking aids?
  • Does she drink alcohol?
  • Does she smoke?
32
Q

Examination after fall- patient guided

A
  • Only 1% of falls result in a fracture
  • Don’t just stick to where the pt say it hurts
    • Ideally palpate all bony prominences if patient unsure
    • Other injuries can be masked due to pain elsewhere
  • Full neurovascular, cranial nerve, CVS and respiratory exam – at a min
33
Q

Investigations

A
  • LSBP (lying and standing BP)
  • ECG
  • FBC and U&Es
  • CK if long lie (rhabdomyolysis)
34
Q

Be guided by the symptoms- not all falls require scans

A
  • X-ray
  • Echo
  • 24hr tape
  • CT
35
Q

To CT or not to CT

A
  • Age >65
  • History of bleeding or clotting disorder
  • Dangerous mechanism of injury ( a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a heigh of >1 m or 5 stairs)
  • More than 30 minutes retrograde amnesia or events immediately before the head injury
36
Q

Action after being a fall

A
  • Basic advice
    • Drink plenty
    • Stand up slowly
    • Remove loose carpets/leads
    • Sensible slippers
    • Good lighting
  • OT assessment
  • Social work/ PCC assessment
    • Do they need more help at home?
  • Opticians/audiologists
  • If A and E write a complete GP letter
    • Needs a medication review
37
Q

Common clinical challenges in assessing older people

A
  • Cant give proper history of falls/ other ailments that may increase likelihood of fall due to poor memory
  • Not wanting to lose independence
  • Lack of resources to assess older people
  • Elderly may not want to move house around to make it safe
38
Q

Practical solutions to minimise risk of falls

A
  • Clean up clutter
  • Remove tripping hazards
  • Install grab bars and handrails
  • Avoid loose clothing
  • Ensure lighting is right
  • Wear shoes
  • Make it nonslip
  • Live on one level
39
Q

Rhabdomyolysis

A
  • Rhabdomyolysis may result from any traumatic or medical injury to the sarcolemma (muscle)
  • Release of intracellular ions, myoglobin, CK and urates into the circulation
  • Can lead to electrolyte disturbances, disseminated intravascular coagulation (DIC), renal failure and multi-organ failure
  • Serum CK levels- 5 times the upper limit of normal
  • Common complications of a fall with a ‘long life’- prolonged immobilisation

Integration for clinical application (13 decks)

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