OPIC - Falls Flashcards
Differential Diagnosis of a Fall
Vascular
Cardiac
Neurological
Genitourinary
Endocrine
MSK
ENT
General
1.) Vascular
- postural/orthostatic hypotension, anaemia
- reflex syncope: vasovagal, situational (straining), carotid sinus massage
2.) Cardiac
- arrhythmias, valvular heart disease (VHD)
- bradycardia, ACS
3.) Neurological
- seizures, stroke/TIA, peripheral neuropathy
- Parkinson’s disease, delirium
- vertebrobasilar insufficiency - poor blood flow to the posterior brain (vertebral and basilar arteries)
4.) Genitourinary - UTI, incontinence
5.) Endocrine - hypoglycaemia
6.) MSK - arthritis, muscle (disuse) atrophy
7.) ENT - BPPV, ear wax
8.) General - multifactorial, polypharmacy
History of Presenting Complaint
Who
What
Where
When
Why
How
1.) Who - who has seen you fall? collateral history?
2.) What - what happened, before, during and after?
3.) Where - inside the house or outside?
4.) When - time of day, what were they doing:
- getting up from bed (postural hypotension)
- looking upwards (vertebrobasilar insufficiency)
5.) Why - why do you think you fell?
6.) How - how many times have you fallen? (last 6mths)
What Happened Around the Fall
Before
During
After
1.) Before - was there any warning?
- dizziness: BPPV, postural hypotension, anaemia
- chest pain/palpitations: arrhythmia, ACS, VHD
- muscle jerking: seizure
2.) During
- LOC: orthostatic (severe), vasovagal, cardaic, seizure
- incontinence or tongue biting: seizure
- patient pale/flushed?: possible vasovagal fall
- any injuries? head trauma? what hit the floor first?
3.) After - what happened after the fall?
- confusion: head injury (?subdural)
- weakness or speech difficulty: stroke/TIA
- did they get themselves up off the floor?
- was there a long lie? ?rhabdomyolysis/AKI
- were they able to resume normal activities after?
History Taking for a Fall
History of Presenting Complaint
Systems Review
Past Medical History
Drug History
Social History
Others
1.) History of Presenting Complaint
- who, what, where, when, why, how
2.) Systems Review
- general, neuro, cardio, resp, GI, GU, MSK
3.) Past Medical History - specific questions:
- visual or hearing impairment
- anaemia, cardiac disease, MSK
- stroke/TIA, Parkinson’s, cognitive impairment
- peripheral neuropathy: diabetes, vitamin deficiency
4.) Drug History - polypharmacy? specific drugs:
- sedation: benzos, opioids
- anti-psychotics, anti-epileptics, hypoglycaemics
- anti-hypertensives: postural hypotension
- beta-blockers: bradycardia
- antibiotics: intercurrent infection
- diuretics, anti-depressants
5.) Social History
- mobility, support at home, alcohol history
- fear of falling
6.) Others
- family history, allergies, ICE
Examinations and Investigations after a Fall
Examinations
Bedside
Bloods
Imaging
Specialist
1.) Examinations
- general: AVPU/GCS, A-E? timed up-and-go test
- cardiac: HR, BP, murmurs
- neuro: cranial nerve, peripheral nerve
- MSK: gait? joints examination? hip fracture?
- ENT: ear wax, intact TM?
- frailty risk assessment: PRISMA-7 (3+ suggests at risk and requires further clinical review)
- fall risk assessment tool: e.g. FRAT, JHFRAT
- FRAX tool assesses risk of a fracture
2.) Bedside Investigations
- vital obs (?sepsis, bradycardia)
- lying-standing BP: ↓ >20mmHg in sysBP or >10mmHg diasBP that occurs within three minutes of standing
- ECG (?arrhythmia, bradycardia)
- urine dip (?infection, rhabdo), blood glucose (?hypo)
- cognitive screen: AMT-10 or 4
3.) Bloods
- FBC: anaemia, infection, LFTs: chronic alcohol abuse
- U+Es: dehydration, AKI, electrolyte abnormalities
- confusion screen: if warranted
4.) Imaging
- CT-Head: stroke, subdural haemorrhage
- CXR: pneumonia
- ECHO: VHD e.g. aortic stenosis
5.) Specialist
- epley manoevure: BPPV
- cardiac monitoring: e.g 24/48 hour tape
Pathophysiology of Postural Hypotension
Pathophysiology
Neurogenic Causes
Non-Neurogenic Causes
1.) Pathophysiology - gravity-induced reduction in venous return –> ↓pre-load –> ↓CO –> ↓BP
- ↓BP triggers baroreflexes to ↑sympathetic outflow and ↓vagal nerve activity to normalise BP
- postural hypotension occurs when mechanisms to regulate blood pressure are impaired
2.) Neurogenic Causes - ↓ release of NA from the sympathetic neurones limits vasoconstriction
- seen in disorders that cause autonomic dysfunction:
- T2 DM, Parkinson’s disease, small cell lung cancer
- monoclonal gammopathies: multiple myeloma, non-Hodgkin lymphoma, primary amyloidosis
3.) Non-Neurogenic Causes - hypovolaemia, cardiac failure or venous pooling
- cardiac impairment: inc MI and aortic stenosis
- ↓intravascular volume: dehydration, adrenal insuffi…
- states inducing vasodilation: e.g. fever/sepsis
- medications: anti-hypertensives, alpha-blockers, diuretics, insulin, levodopa, tricyclic antidepressants
Postural Hypotension
Clinical Features
Non-Pharmacological Mangement
Pharmacological Management
1.) Clinical Features - due to cerebral hypoperfusion
- dizziness, weakness, confusion, blurred vision, nausea
- syncope in severe cases (esp in elderly)
- exacerbating factors include:
- rising quickly after prolonged sitting
- prolonged motionless standing, early morning,
- dehydration, physical exertion, straining in toilet, carbohydrate-heavy meals, alcohol, fever
2.) Non-Pharmacological Mangement - first-line
- avoid exacerbating factors: rising quickly, straining, dehydration, hot environment, large meals
- ↓venous pooling: encourage physical activity, compression stockings and abdominal binders
- counter-manoeuvres: exercises such as toe raising, leg elevation and leg crossing
- ↑blood volume: ↑salt and water intake, keeping head of the bed elevated (reverse Trendelenburg)
3.) Pharmacological Management - approach cautiously for polypharmaceutical patients, medication review
- fludrocortisone: ↑plasma volume, can cause severe hypokalaemia so K+ levels must be monitored
- midodrine: short-acting vasopressor useful in neurogenic postural hypotension
- pyridostigmine: AChEi, has a vasoconstrictive effect only while standing
Osteoporosis
What is it?
Important Risk Factors
Other Risk Factors
Secondary Causes
Diagnosis
1.) What is it? - low bone mass, deterioration of bone tissue, and disruption of bone architecture
- compromised bone strength and ↑risk of fracture
2.) Important Risk Factors - used in the FRAX assessment
- current smoking, alcohol excess, low BMI (<21)
- history of glucocorticoid use, rheumatoid arthritis
- history of parental hip fracture
3.) Other Risk Factors
- ↑age (>65s), female, Caucasian/south Asian, FH
- hx of low trauma fracture e.g. fall at walking speed
- ↓exercise tolerance, calcium/vitD deficiency
- premature menopause, use of aromatase inhibitors
4.) Secondary Causes
- ↓Ca/vitD absorption: coeliac disease, eating disorders
- hypogonadism: must check testosterone in a non-elderly man with osteoporosis/fragility fracture
- other endocrine: hyperparathyroidism, hyperthyroid…
- malignancy: multiple myeloma, bone metastasis
5.) Diagnosis - DEXA
- DEXA (Dual Energy X-ray Absorptiometry) of the lumbar spine and hip is the gold standard
- T score: based on bone mass of young reference population
- T score of -1.0 means bone mass of one standard deviation below
- normal bone mean density = > -1
- T-score < -2.5 = osteoporosis, -2.5 to -1 = osteopenia
- Z score adjusts for age, gender and ethnicity
- a DEXA scan is not required in post-menopausal women with a fracture
- FRAX tool assesses risk of a fracture
Management of Osteoporosis
Lifestyle Management
Pharmacological Management
Ca/VitD Supplements
Bisphosphonates
1.) Lifestyle Management - to reduce risk factors
- smoking cessation, ↓alcohol intake, ↑exercise
2.) Pharmacological Management
- Rx: PO/IV bisphosphonates (1st) (inhibits osteoclasts)
- post-menopausal women with a fracture are started on bisphosphonates without the need of a DEXA scan
- Denosumab or teriparatide (2nd line)
3.) Ca/VitD Supplements - e.g. Adcal D3
- has calcium carbonate (1500mg) and vitD (400IU)
- BD, should be chewed (do not swallow whole)
- should not be taken with antacids, should not take within 4 hours of taking bisphosphonates
- side effects: constipation, diarrhoea, nausea, skin rash, hypercalcaemia/hypercalciuria
4.) Bisphosphonates - alendronate, zoledronate
- MOA: prevents osteoclastic bone resorption
- calcium and vitamin D deficiencies must be corrected before starting bisphosphonates in order to prevent hypocalcaemia
- after 5 years of oral use, patients should be re-assessed with an updated FRAX score and DEXA scan
- PO taken with water while sitting/standing, on an empty stomach and should remain sitting/standing for >30 mins after taking the tablet
- needs to be prescribed with a PPI
- contraindicated in GFR <35, consider stopping if sx of indigestion (dyspepsia)
- side effects: oesophagitis, oesophageal ulcers, osteonecrosis of the jaw, fever, myalgia and arthralgia
