managing falls in elderly

Question 1

how would you take a falls history

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Answer 1

Factors around the fall
• Who?
• When?
• Where?
• What? – Before, During, After
• How?

Question 2

what is the key factor to determine about a fall?

Answer 2

The most important part of any fall history is to establish the presence or absence of loss of consciousness leading to the fall

helps determine if this is syncope

Question 3

what is synocope

Answer 3

A transient loss of consciousness characterised by fast onset and spontaneous recovery
• Caused by a reduced perfusion pressure in the brain
• Syncope is usually self limiting- being horizontal will fix low blood pressure

 Symptoms preceding a syncopal episode, includes:
• Light-headedness
• Sweating
• Pallor
• Blurred vision

seizures such as tonic clonic do happen in the elderly but it is not syncope

Question 4

what are 3 general reasons for syncope ?

Answer 4

Reflex Syncope

• Orthostatic Hypotension
• Cardiac/Cardiopulmonary Disease

Question 5

outline what reflex syncope is

Answer 5

• Disorder of the autonomic regulation of postural tone
• Activation of part of medulla leads to decrease in sympathetic output and increase in parasympathetic
• Fall in CO (reduced HR) and BP leads to reduced cerebral perfusion
• Examples:
• Vasovagal- ‘simple faint’- from prolonged standing, stress, sight of blood, pain
• Situational syncope e.g coughing, straining, lifting heavy weight
• Carotid sinus massage

Question 6

outline what orthostatic hypotenison

Answer 6

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, with pre-syncopal symptoms on standing

• Standing up causes 500-800ml of blood to pool in the legs
• Reduction in end diastolic volume
• Reduced cardiac stretch, therefore reduced stroke volume and cardiac output
• Normally managed by the baroreceptor reflex

• If this fails then cerebral perfusion will drop and syncope occurs
Baroreceptors become less sensitive with age
• Also become less sensitive with hypertension
• Medications, such as anti-hypertensives
can impair this response, or venous return
• Dehydration

Question 7

outline cardiac syncope

Answer 7

Syncope caused by a cardiac disease or abnormality

• Can be an electrical (rhythm), structural or coronary cause
• Electrical
• Bradycardias
• Tachycardias
• Structural
• Aortic Stenosis - narrow valve - less blood to brain when needed
• Hypertrophic Obstructive Cardiomyopathy
• Coronary
• MI/IHD

Question 8

cardiac syncope is key to pick for CHD what are some red flags

Answer 8

Exertional syncope

• Family history of cardiac disease or sudden cardiac death
• Preceding chest pain or palpitations
• Past medical history of heart disease
• Abnormal ECG

Question 9

drug history for polypharmacy - anti hypertensives ect may cause falls

social history - who does she live with/have help ?

are key to consider if this patient can still live at home

if they have fallen, fully check for fractures and breaks

Full neurovascular, cranial nerve, CVS and respiratory examination at an absolute minimum!

Answer 9

key info

Question 10

what is rhabdomyolysis?

Answer 10

• Rhabdomyolysis may result from any traumatic or medical injury to the sarcolemma - stuck on floor for hours
• release of intracellular ions, myoglobin, CK, and urates into the circulation - lots of excess ions is BAD
• Can lead to electrolyte disturbances, disseminated intravascularcoagulation (DIC), renal failure, and multi-organ failure

Serum CK levels - 5 times the upper limit of normal
• Common complication of a fall with a “long lie” – prolonged immobilisation