S2 L2 Managing falls

Question 1

Why is it important to learn about falls?

Answer 1

• Make up a huge amount of A and E attendances
• 30% of over 65s and 50% of over 80s fall at least once year, some several times a week
• Can lead to reduced quality of life, loss of confidence, and independence and ultimately mortality

Question 2

What are the differential diagnosis for falls?

Answer 2

SO many!!!!
Helpful to use system approach
- Cardiovascular → arrhythmias, orthostatic hypotension, bradycardia, valvular heart disease
- Neurological → stroke, peripheral neuropathy
- Genitourinary → incontinence, urinary tract infection
- Endocrine → hypoglycaemia
- Musculoskeletal → arthritis, disuse atrophy
- ENT → BPPV, ear wax

Question 3

What are the factors around falls?

Answer 3

Who?, When?, Where?, What?, How?
1- Who?
→Who was it?- do they remember much about it?
Did anyone witness? - if yes, get a collateral history
2- When?
→ What time of day/night?
- Low/ no light- visual problems? etc…
→What were they doing at the time?
- Were they looking up? - vertigo disorder
- Just got up from a chair/bed?- change body position, supine to upright?
- Just been to the toilet?
3- Where?
→ In the house? At the shops?
→ At home- which room? trip hazards? TV flashing light?
4- What? → Before, during, after
→Before- symptoms leading up to it? Chest pain? Did they trip or slip?
→ During- Loss of consciousness, incontinence, tongue biting, shaking, any injuries? etc…
→ After- what happened after? did they regain consciousness quickly? Were they able to get up quickly? were they able to get up without help? Any confusion or neurological symptoms?
5- How?
→ How long where they on the floor for? How many times has the patient fallen over before? How many in the last 6 months? Any serious injuries?

Question 4

What is one of the most important things to try and establish from the history?

Answer 4

Establish the presence or absence of loss of consciousness leading to the falls

Question 5

What is syncope?

Answer 5

• Transient loss of consciousness characterised by fast onset and spontaneous recovery
• Reduced perfusion pressure in the brain
• Usually self limiting- being horizontal redistribute the blood- fix the low blood pressure
• Beware of people who have been held in an upright position

Question 6

What symptoms might a patient present with pre-syncope?

Answer 6

Light headedness
Sweating
Pallor
Blurred vision

Question 7

What is another common reason for loss of consciousness in elderly patients?

Answer 7

Seizure
- Generalised tonic clonic seizure
New epilepsy in patients 
2nd peak of incidence in the over 80s 
Can be subtle

Question 8

What are the different types of syncope?

Answer 8

Reflex syncope
Orthostatic (postural) hypotension
Cardiac/ cardiopulmonary disease

Question 9

What is reflex syncope?

Answer 9

• Fainting due to disorders 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 reduce cerebral perfusion

Question 10

What are some examples of reflex syncope?

Answer 10

Vasovagal- simple faint- from prolonged standing, stress, sight of blood, pain
Situational syncope e.g. coughing, straining, lifting heavy weight
Carotid sinus massage

Question 11

What is orthostatic hypotension?

Answer 11

Symptoms occur after standing from a sitting or lying position
Can cause syncope if drop in BP is severe enough
Normally defined as a drop of 20mmHg or more, with pre-syncopal symptoms on standing

Question 12

What is the pathophysiology of orthostatic hypotension?

Answer 12

• Standing- 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

Question 13

Where are baroreceptors located?

Answer 13

In the carotid sinus - bifurcation of external and internal carotids
Aortic arch

Question 14

What is the baroreceptor reflex?

Answer 14

Negative feedback system incorporating pressure sensors
Receptors respond to stretch in the arterial wall
- ↑BP → arterial walls stretch → ↑firing rate
- ↓BP → arterial wall decreased stretch → ↓firing rate
Carotid sinuses → Sinus nerve Hering (branch of glossopharyngeal CNIX) → synapse Nucleus tractus solitarius (NTS) → Located in the brainstem
Arch aortic → aortic nerve combine vagus nerve CNX → NTS → modulates activity of sympathetic and parasympathetic (vagal) neurones in the medulla → regulate autonomic control of the heart and BV
- Sympathetic → ↑contractility, ↑HR, ↑Venous return

Question 15

Why does this reflex fail?

Answer 15

• Baroreceptor become less sensitive with age
• Less sensitive with hypertension
• Medications such as anti-hypertensives can impair this response
• Dehydration
  Median and large arteries are less compliant unable to respond to changes

Question 16

What is cardiac syncope?

Answer 16

Syncope caused by cardiac disease or abnormality
Can be an electrical (rhythm), structural or coronary cause
Electrical
- Bradycardia
- Tachycardia
Structural
- Aortic stenosis
- Hypertrophic Obstructive Cardiomyopathy
Coronary
- MI/ IHD

Question 17

How does an aortic stenosis lead to syncope?

Answer 17

• Narrowing of aortic valve
• Harder to push blood through the aortic valve
• During exercise, when the heart has to work harder- the stenosis can limit the CO and therefore fail to adequately perfuse brain
• If AS with syncope then patients have a mean survival of 2-5 years untreated

Question 18

What are the features of cardiac syncope?

Answer 18

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

Question 19

What are the non-syncopal falls?

Answer 19

• Fall not caused by syncope e.g. trips and slips
• End result of an intercurrent illness, such as an infection
• Can still loose consciousness (LOC) from head injury/trauma when they are falling

Question 20

What is meant by multifactorial falls?

Answer 20

Many falls are a result of more than one thing

e.g. Chronic illness and infection on top

Question 21

What else needs to be considered before a patient can be discharged following a fall?

Answer 21

Drug history

Social history

Question 22

Why is it important to consider the drug history?

Answer 22

Polypharmacy→ medication might be interacting with each other - side effects
New medication? → might not be working for them? might be too much?
Anti-hypertensives/ anti-arrhythmias? → long term- maybe too strong
Any drug which may induce drowsiness? e.g. new analgesia, benzodiazepines, antidepressants, antipsychotics
Have they had a recent medication review?

Question 23

Why is it important to consider the social history of patient?

Answer 23

Is the patient capable of being safe on their own?
Do they have help at home?
Family close by?
Any stairs?
Any walking aids?- or other helpful household aids?
Do they drink alcohol?
Do they smoke cigarettes?

Question 24

Why do we need to consider walking aids?

Answer 24

Some of them, especially wheeled ones, move when the patient leans on them
If they are a bit unsteady on their feet then it can cause them to fall

Question 25

What examinations would you do on a patient that has fallen?

Answer 25

1% of falls result in fracture- don’t just stick to where patient says it hurts, do a full body scan
Full neurovascular, cranial nerve, CVS and respiratory examination at the absolute minimum

Question 26

What investigation do you order?

Answer 26

Lying and standing BP
ECG 
FBC and U and Es 
Creatine kinase if lying for a while 
X-ray 
Echo
24hr tape 
CT

Question 27

What is rhabdomyolysis?

Answer 27

Result from any traumatic or medical injury to the sarcolemma
Release of intracellular ions, myoglobin, CK and urates
Lead to electrolyte disturbances, disseminated intravascular coagulation (DIC- clotting all over the place), renal failure and multi organ failure
Indicated by Serum CK 5 times upper limit if normal

Question 28

How do you know whether to do a CT scan?

Answer 28

• Glascocoma scale- how conscious someone is
• Signs of skull fracture or seizure, neurological deficit or vomiting after head injury
  -Warfarin
  → Yes upset clotting risk of haemorrhage
  → No- memory loss or LOC after head injury
• Risk factors
  → Age >65s
  → Hx of bleeding or clotting disorder
  → Dangerous mechanism of injury
  → More than 30 mins retrograde amnesia of events immediately before head injury

Question 29

What advice would you give to a patient?

Answer 29

1. Basic environment - drink plenty, stand slowly, remove loose carpets, sensible slippers, good lighting
2. OT assessment
3. Social work/ primary care assessment e.g. GP- do they need increased help at home
4. Opticians/ Audiologists if needed
5. If in A&E - write complete GP letter- fully explain what happened, what you have thought about and considered etc… medication review if needed

Question 30

What classes of drugs can increase the likelihood of falls?

Answer 30

• Beta blockers (bradycardia)
• Diabetic medications (hypoglycaemia)
• Antihypertensives (hypotension)
• Benzodiazepines (sedation)
• Antibiotics (intercurrent infection)

Question 31

What are risk factors for falls?

Answer 31

Environmental → obstacles,

Non-environmental → elderly, co-morbidities- parkinsons