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Year 4 - ACH ANNA > Week 1 - Falls > Flashcards

Week 1 - Falls Flashcards

1
Q

What does the mnemonic DAME stand for in grouping the causes of a fall?

A

D - drugs

A - Age-related

M - Medical causes

E - Environmental

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2
Q

Give some examples of drugs that may cause a fall (DAME)

A

D - Drugs

  • Polypharmacy i.e. drug interactions or compounded effects
  • Antihypertensives → hypotention
  • Sedatives → ↓ awareness
  • Opiods → depressant/dizziness
  • Psychotropics
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3
Q

Give examples of age-related causes of falls (DAME)

A

A - Ageing

  • Vision changes
  • Cognitive decline
  • Gait abnormalities
  • Osteoarthritis
  • Sarcopenia / reduced proximal muscle strength
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4
Q

Give examples of medical causes of falls (DAME)

A

M - Medical causes

  • Cardiac e.g. hypotension, arrhythmias → syncope
  • Neuro e.g. PD, strokes, neuropathy, cateracts e.g. ↓ sensation to feet → trip
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5
Q

Give examples of Environmental causes of falls (DAME)

A

E - Environmental

  • Walking aids
  • Footwear
  • Home hazards
  • Fear of falling
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6
Q

How do you structure a history of a fall?

A
  1. Before - what caused the fall? symptoms?
  2. During - was it syncope or seizure? did they # something? LOC + for how long?
  3. After - how did they get help? complications e.g. #, head injury, long lie, skin break?
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7
Q

What could “dizzy” mean?

A
  1. Pre-syncopal symptoms - light-headed, pale, about to faint, relieved by lying - postural hypotension
  2. Unsteady
    1. in the legs
    2. in the head
  3. Vertigo - room spinning
  4. Psychogenic - associatied with and exacerbates organic dizziness. Fear of falling, ↓ confidence, anxiety, somatisation
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8
Q

What is Vertigo?

A

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)
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9
Q

Name 4 causes of peripheral vertigo

A
  1. Benign Paroxysmal Vertigo
  2. Meniere’s disease
  3. Acute vestibular neuronitis
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10
Q

What medications can be given buccal/IM in severe nausea and vomiting and orally in less severe?

A

→ 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.

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11
Q

What is the most common cause of central vertigo?

A

Vestibular migraine

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12
Q

Name 4 causes of central vertigo

A
  1. Vestibular migraine
  2. Posterior circulation stroke
  3. Cerebellar or brainstem tumour
  4. MS
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13
Q

What is Zopiclone?

A

Is a non-benzodiazepine hyponotic used to treat insomnia

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14
Q

What are 4 features of acoustic neuroma?

A

Acoustic neuroma

  • Hearing loss
  • Tinnitus
  • Absent corneal reflex
  • Associated with neurofibromatosis type 2
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15
Q

what details might suggest their dizziness is a presyncopal sensation?

A
  • 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
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16
Q

What is a common cause of presyncopal symptoms, especially in the elderly?

A

Orthostatic (postural) hypotension

  • When BP ↓ as a result of standing from seated/lying position
  • Diagnosed by doing a lying standing BP
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17
Q

How is a lying + standing BP performed?

A
  1. Acquire assistance (needed for standing BP)
  2. Ask patient to lie down for > 5 mins
  3. Measure BP
  4. Ask patient to stand (assist if needed)
  5. Measure BP (within 1st minute of standing)
  6. Measure BP again after pt has been stood for 3 mins
  7. Repeat BP is it is still falling
18
Q

What qualifies at a +ve result on a lying + standing BP test?

A

Positive result = :

  1. A drop in systolic BP of ≥ 20 mmHg (with or without symptoms)
  2. A drop to < 90 mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
  3. A drop in diastolic BP of 10 mmHg with symptoms (although clinically less significant than a drop in systolic BP)
19
Q

What features might the patient have if there was a psychogenic cause for dizziness?

A
  • 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
20
Q

What is an AMT-10 test? What is involved?

A

Abbreviated Mental Test (10 questions - correct/incorrect)

  1. ​Age
  2. Time (nearest hour)
  3. Current year
  4. Patient’s home address
  5. What jobs do these people do? (show pictures e.g. postman + cook)
  6. Date of birth
  7. Year WW1 started?
  8. Current Primeminister
  9. Count backwards from 20 to 1
  10. Ask to recall address given at start “42 west street”
21
Q

What highly effective intervention is offered to falls patients?

A

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
22
Q

What 4 interventions have a lot of evidence behind them for falls?

A
  1. Strength + balance training
  2. Home hazard assessment and intervention
  3. Vision assessment and referral
  4. Medication review with modification/withdrawal
23
Q

When, according to NICE guidelines, should the following be assessed for fracture risk?

  1. Pt with history of falls
  2. Women
  3. Men
A

should be assessed for fracture risk:

  1. Patients > 50 yrs + history of falls or any risk factors e.g. low BMI
  2. Women > 65 yrs
  3. Men > 75 yrs
24
Q

What are some secondary causes of osteoporosis?

A
  • 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.
25
Q

When might the FRAX tool tell you to do a DEXA scan?

A
  • 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
26
Q

What is the FRAX calculator for?

A

To assess future fracture risk

It gives 10-year probability of:

  1. Hip fracture
  2. Osteoporotic fracture (spine, forearm, hip or shoulder)
27
Q

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?

A
  • Low risk (green) - lifestyle advice and reassure
  • Intermediate risk (yellow) - Measure BMD (bone mineral density)
  • High risk (red) - treat
28
Q

What are the 9 major risk factors for osteoporosis (these are used by FRAX tool)?

A
  1. Age
  2. Female
  3. Previous #
  4. Hx of parental hip #
  5. Hx of glucocorticoid use
  6. RA
  7. Low BMI
  8. Alcohol excess
  9. Smoking (current)
29
Q

What other risk factors for osteoporosis are there besides those accounted for in FRAX?

A
  • 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
30
Q

Which 7 medications worsen osteoporosis?

A
  1. Glucocorticoids (main one)
  2. SSRIs e.g. Citalopram, Fluoxetine, Sertraline
  3. Antiepileptics e.g. Clonazepam, Carbamazepine
  4. PPIs
  5. Glitazones e.g. pioglitazone
  6. Heparin therapy (long term)
  7. Aromatase inhibitors e.g. anastrozole - used in treatment of post-menopausal breast cancer and gynecomastia in men
31
Q

A DEXA scan is used to measure BMD (bone mineral density) - your results include T-scores and Z-scores, what are each of these?

A
  • 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)
32
Q

For the following DEXA T-scores what does each represent?

  1. < -1.0
  2. -1.0 to -2.5
  3. -2.5 or less
A
  1. Normal = < -1.0
  2. Osteopenia = -1.0 to -2.5
  3. Osteoporosis = -2.5 or less
33
Q

What is the first line management for osteoporosis?

A
  • 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
34
Q

What is second line treatment for Osteoporosis?

A

If Alendronic acid can’t be tolerated then (both bisphosphonates):

  • Risedronate
  • Etidronate

If bisphosphonates aren’t tolerated then:

  • Strontium ranelate
  • Raloxifene
35
Q

Whichinvestigations should be done routinely in older people who present with falls?

A
  1. Glucose
  2. ECG
  3. Gait
  4. Lying + standing BP
36
Q

When might you need to wait before starting bisphosphonates?

A

If the pt is severely deficient in Vit D then these stores need to be repleted first

37
Q

What is the loading regimen for vitamin D?

A

20’000 units twice a week for 6 weeks

38
Q

What is the maintenance calcium and vitamin D regimen?

A

10-20 micrograms of vitamin D and 1000mg of calcium daily

39
Q

what should everyone with a TLOC have according to NICE?

A

12-lead ECG

40
Q

What special instructions need to be given to a patient for taking bisphosphonates?

A
  • 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

Year 4 - ACH ANNA (10 decks)

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