S2 L2 Managing falls Flashcards
Why is it important to learn about falls?
- 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
What are the differential diagnosis for falls?
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
What are the factors around falls?
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?
What is one of the most important things to try and establish from the history?
Establish the presence or absence of loss of consciousness leading to the falls
What is syncope?
- 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
What symptoms might a patient present with pre-syncope?
Light headedness
Sweating
Pallor
Blurred vision
What is another common reason for loss of consciousness in elderly patients?
Seizure - Generalised tonic clonic seizure New epilepsy in patients 2nd peak of incidence in the over 80s Can be subtle
What are the different types of syncope?
Reflex syncope
Orthostatic (postural) hypotension
Cardiac/ cardiopulmonary disease
What is reflex syncope?
- 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
What are some examples of reflex syncope?
Vasovagal- simple faint- from prolonged standing, stress, sight of blood, pain
Situational syncope e.g. coughing, straining, lifting heavy weight
Carotid sinus massage
What is orthostatic hypotension?
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
What is the pathophysiology of orthostatic hypotension?
- 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
Where are baroreceptors located?
In the carotid sinus - bifurcation of external and internal carotids
Aortic arch
What is the baroreceptor reflex?
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
Why does this reflex fail?
- 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
What is cardiac syncope?
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
How does an aortic stenosis lead to syncope?
- 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
What are the features of cardiac syncope?
- Exertional syncope
- Family history of cardiac disease or sudden cardiac death
- Preceding chest pain or palpitation
- Past medical history of heart disease
- Abnormal ECG
What are the non-syncopal falls?
- 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
What is meant by multifactorial falls?
Many falls are a result of more than one thing
e.g. Chronic illness and infection on top
What else needs to be considered before a patient can be discharged following a fall?
Drug history
Social history
Why is it important to consider the drug history?
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?
Why is it important to consider the social history of patient?
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?
Why do we need to consider walking aids?
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
What examinations would you do on a patient that has fallen?
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
What investigation do you order?
Lying and standing BP ECG FBC and U and Es Creatine kinase if lying for a while X-ray Echo 24hr tape CT
What is rhabdomyolysis?
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
How do you know whether to do a CT scan?
- 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
What advice would you give to a patient?
- Basic environment - drink plenty, stand slowly, remove loose carpets, sensible slippers, good lighting
- OT assessment
- Social work/ primary care assessment e.g. GP- do they need increased help at home
- Opticians/ Audiologists if needed
- If in A&E - write complete GP letter- fully explain what happened, what you have thought about and considered etc… medication review if needed
What classes of drugs can increase the likelihood of falls?
- Beta blockers (bradycardia)
- Diabetic medications (hypoglycaemia)
- Antihypertensives (hypotension)
- Benzodiazepines (sedation)
- Antibiotics (intercurrent infection)
What are risk factors for falls?
Environmental → obstacles,
Non-environmental → elderly, co-morbidities- parkinsons
