Week 1 - Falls Flashcards
What does the mnemonic DAME stand for in grouping the causes of a fall?
D - drugs
A - Age-related
M - Medical causes
E - Environmental
Give some examples of drugs that may cause a fall (DAME)
D - Drugs
- Polypharmacy i.e. drug interactions or compounded effects
- Antihypertensives → hypotention
- Sedatives → ↓ awareness
- Opiods → depressant/dizziness
- Psychotropics
Give examples of age-related causes of falls (DAME)
A - Ageing
- Vision changes
- Cognitive decline
- Gait abnormalities
- Osteoarthritis
- Sarcopenia / reduced proximal muscle strength
Give examples of medical causes of falls (DAME)
M - Medical causes
- Cardiac e.g. hypotension, arrhythmias → syncope
- Neuro e.g. PD, strokes, neuropathy, cateracts e.g. ↓ sensation to feet → trip
Give examples of Environmental causes of falls (DAME)
E - Environmental
- Walking aids
- Footwear
- Home hazards
- Fear of falling
How do you structure a history of a fall?
- Before - what caused the fall? symptoms?
- During - was it syncope or seizure? did they # something? LOC + for how long?
- After - how did they get help? complications e.g. #, head injury, long lie, skin break?
What could “dizzy” mean?
- Pre-syncopal symptoms - light-headed, pale, about to faint, relieved by lying - postural hypotension
- Unsteady
- in the legs
- in the head
- Vertigo - room spinning
- Psychogenic - associatied with and exacerbates organic dizziness. Fear of falling, ↓ confidence, anxiety, somatisation
What is Vertigo?
Vertigo = the false sense that the body or environment is moving in any direction
- Often described as “sensation of room spinning”
- Is suggestive of a problem with vestibulo-labyrinthine system
- i.e. anywhere between the ear (peripheral vertigo)
- and the central vestibular pathways (central vertigo)
Name 4 causes of peripheral vertigo
- Benign Paroxysmal Vertigo
- Meniere’s disease
- Acute vestibular neuronitis
What medications can be given buccal/IM in severe nausea and vomiting and orally in less severe?
→ To rapidly relieve severe nausea and vomiting administer buccal prochlorperazine or a deep IM injection of the same or cyclizine.
→ A short course of prochlorperazine or cyclizine can help alleviate symptoms over days.
What is the most common cause of central vertigo?
Vestibular migraine
Name 4 causes of central vertigo
- Vestibular migraine
- Posterior circulation stroke
- Cerebellar or brainstem tumour
- MS
What is Zopiclone?
Is a non-benzodiazepine hyponotic used to treat insomnia
What are 4 features of acoustic neuroma?
Acoustic neuroma
- Hearing loss
- Tinnitus
- Absent corneal reflex
- Associated with neurofibromatosis type 2
what details might suggest their dizziness is a presyncopal sensation?
- Feeling like “about to faint” or “light-headed”
- Often occurs when patient is; standing, seated or upright
- Associated with pallor - relieved by lying down
- Suggests cerebral hypoperfusion due to hypotension
What is a common cause of presyncopal symptoms, especially in the elderly?
Orthostatic (postural) hypotension
- When BP ↓ as a result of standing from seated/lying position
- Diagnosed by doing a lying standing BP
How is a lying + standing BP performed?
- Acquire assistance (needed for standing BP)
- Ask patient to lie down for > 5 mins
- Measure BP
- Ask patient to stand (assist if needed)
- Measure BP (within 1st minute of standing)
- Measure BP again after pt has been stood for 3 mins
- Repeat BP is it is still falling
What qualifies at a +ve result on a lying + standing BP test?
Positive result = :
- A drop in systolic BP of ≥ 20 mmHg (with or without symptoms)
- A drop to < 90 mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
- A drop in diastolic BP of 10 mmHg with symptoms (although clinically less significant than a drop in systolic BP)
What features might the patient have if there was a psychogenic cause for dizziness?
- Psychogenic causes of ‘dizziness’ are common!
- Fear of falling
- Loss of confidence in movement
- Anxiety / panic attacks / somatisation (psychological stress manifested as physical symptoms)
- Psychogenic causes of dizziness are often associated with + exacerbate organic causes
What is an AMT-10 test? What is involved?
Abbreviated Mental Test (10 questions - correct/incorrect)
- Age
- Time (nearest hour)
- Current year
- Patient’s home address
- What jobs do these people do? (show pictures e.g. postman + cook)
- Date of birth
- Year WW1 started?
- Current Primeminister
- Count backwards from 20 to 1
- Ask to recall address given at start “42 west street”
What highly effective intervention is offered to falls patients?
strength and balance (re)training
- ↓ risk of further falls
- ↓ fear of falling
- Show pts how to get up off the floor if they do fall
What 4 interventions have a lot of evidence behind them for falls?
- Strength + balance training
- Home hazard assessment and intervention
- Vision assessment and referral
- Medication review with modification/withdrawal
When, according to NICE guidelines, should the following be assessed for fracture risk?
- Pt with history of falls
- Women
- Men
should be assessed for fracture risk:
- Patients > 50 yrs + history of falls or any risk factors e.g. low BMI
- Women > 65 yrs
- Men > 75 yrs
What are some secondary causes of osteoporosis?
- Hypogonadism in either sex, including untreated premature menopause (menopause before 40 years of age), treatment with aromatase inhibitors (such as exemastane) or gonadotrophin-releasing hormone agonists (such as goserelin).
- Endocrine conditions:
- diabetes mellitus,
- Cushing’s disease,
- hyperthyroidism,
- hyperparathyroidism,
- hyperprolactinaemia
- Conditions associated with malabsorption including
- inflammatory bowel disease,
- coeliac disease,
- chronic pancreatitis.
- Rheumatoid arthritis and other inflammatory arthropathies.
- Haematological conditions such as multiple myeloma and haemoglobinopathies.
- Chronic obstructive pulmonary disease.
- Chronic liver failure.
- Chronic kidney disease.
- Immobility.
When might the FRAX tool tell you to do a DEXA scan?
- If your # risk is > 10% in 10 years
- If you are over 50 years old and have a history of fragility #s
- If you are < 40years with a major risk factor:
- premature / untreated menopause
- previous fragility fracture
- long term oral corticosteroids
What is the FRAX calculator for?
To assess future fracture risk
It gives 10-year probability of:
- Hip fracture
- Osteoporotic fracture (spine, forearm, hip or shoulder)
FRAX not only calculates risk of a fracture as a % but classifies the patient as: low risk, intermediate risk and high risk. For each what is the next course of action?
- Low risk (green) - lifestyle advice and reassure
- Intermediate risk (yellow) - Measure BMD (bone mineral density)
- High risk (red) - treat
What are the 9 major risk factors for osteoporosis (these are used by FRAX tool)?
- Age
- Female
- Previous #
- Hx of parental hip #
- Hx of glucocorticoid use
- RA
- Low BMI
- Alcohol excess
- Smoking (current)
What other risk factors for osteoporosis are there besides those accounted for in FRAX?
- Sedentary lifestyle
- Caucasians and Asians
- Premature menopause
- Endocrine disorders:
- Hyperthyroidism, hypogonadism (e.g. Turner’s, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus
- Multiple myeloma
- Lymphoma
- GI disorders:
- IBD, malabsorption (e.g. Coeliac’s), gastrectomy, liver disease
- CKD
- Osteogenesis imperfecta
Which 7 medications worsen osteoporosis?
- Glucocorticoids (main one)
- SSRIs e.g. Citalopram, Fluoxetine, Sertraline
- Antiepileptics e.g. Clonazepam, Carbamazepine
- PPIs
- Glitazones e.g. pioglitazone
- Heparin therapy (long term)
- Aromatase inhibitors e.g. anastrozole - used in treatment of post-menopausal breast cancer and gynecomastia in men
A DEXA scan is used to measure BMD (bone mineral density) - your results include T-scores and Z-scores, what are each of these?
- T-score = BMD is compared to a healthy 30-year old adult
- Z-score = BMD is compared to someone the same age, gender and ethnicicity (often misleading as everyones BMD reduces with age, so might not deviate far from the norm, but put a pt at risk of osteoporotic fractures)
For the following DEXA T-scores what does each represent?
- < -1.0
- -1.0 to -2.5
- -2.5 or less
- Normal = < -1.0
- Osteopenia = -1.0 to -2.5
- Osteoporosis = -2.5 or less
What is the first line management for osteoporosis?
-
Alendronic acid (bisposphonate) - ↓ bone turnover –> ↓ bone resorption = ↓ blood [Ca2+}
- 10 mg PO OD OR 70mg PO once weekly
- ~ 25% of pts can’t tolerate Alendronic acid - GI side effects
- aka alendronate
- Vitamin D + calcium supplementation
What is second line treatment for Osteoporosis?
If Alendronic acid can’t be tolerated then (both bisphosphonates):
- Risedronate
- Etidronate
If bisphosphonates aren’t tolerated then:
- Strontium ranelate
- Raloxifene
Whichinvestigations should be done routinely in older people who present with falls?
- Glucose
- ECG
- Gait
- Lying + standing BP
When might you need to wait before starting bisphosphonates?
If the pt is severely deficient in Vit D then these stores need to be repleted first
What is the loading regimen for vitamin D?
20’000 units twice a week for 6 weeks
What is the maintenance calcium and vitamin D regimen?
10-20 micrograms of vitamin D and 1000mg of calcium daily
what should everyone with a TLOC have according to NICE?
12-lead ECG
What special instructions need to be given to a patient for taking bisphosphonates?
- Take on empty stomach
- Remain upright for 30 mins (after taking)
- Likely to take it for 3-5 years
Taking bisphosphonates in this way reduces the risks of developing side effects i.e. reflux, indigestions, oesophageal and gastric ulcers
