ACH - Falls

Question 1

What is Zopiclone?

Answer 1

Is a non-benzodiazepine hyponotic used to treat insomnia

• MoA: binds GABA_A-receptors enhances inhibitory actions of GABA to cause hypnotic + anxiolytic effects
• Adult = 7.5 mg OD PO for up to 4 weeks NOCTE
• Elderly = 3.75 mg OD PO for up to 4 weeks NOCTE (can be increased)

Question 2

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

Answer 2

• D - Drugs
  
  • Polypharmacy i.e. drug interactions or compounded effects
  • Antihypertensives
  • Sedatives
  • Opiods
  • Psychotropics
• A - Ageing
  
  • Vision changes
  • Cognitive decline
  • Gait abnormalities
  • Osteoarthritis
• M - Medical causes
  
  • Cardiac e.g. hypotension, arrhythmias
  • Neuro e.g. PD, strokes, neuropathy, cateracts
• E - Environmental
  
  • Walking aids
  • Footwear
  • Home hazards
  • Fear of falling

Question 3

What things should you be thinking about in a patient who has fallen, in regards to Before, During and After the fall?

Answer 3

• Before:
  
  • Where was the person?
  • What time of day was it?
  • Is there a pattern to the falls?
  • Did they have any symptoms before falling?
  • Why do they think they fell?
• During:
  
  • Did they lose consciousness?
  • Have they injured themselves?
• After:
  
  • How did they get help?
  • Were they able to get up?
  • Have they suffered any complications (i.e. long lie, fracture, head injury etc)?

Question 4

What is a good follow up question what a patient describes themselves as having felt ‘dizzy’?

Answer 4

“People say dizziness to mean a lot of different things. Can you tell me what you mean when you say ‘dizziness’?

• If this doesn’t help then follow up with specific questions e.g. did you feel light headed? was the room spinning?

Question 5

What is Vertigo?

Answer 5

Vertigo = the false sense that the body or environment is moving

• 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)

Question 6

What are some peripheral causes of Vertigo and their common features?

Answer 6

Peripheral veritgo causes:

• Benign paroxysmal positional vertigo (BPPV) - common!
  
  • Gradual onset
  • Triggered by change in head position
  • Episodes last 10-20 secs (can be up to 1 min)
  • Diagnosed by Dix-Hallpike manoeuvre and treated using Epley manoeuvre
• Meniere’s disease
  
  • Hearing loss
  • Tinnitus
  • Sensation of fullness/pressure in one or both ears
• Vestibular neuritis
  
  • No hearing loss
  • Recent viral infection
  • Recurrent vertigo attacks (last hrs - days)
• Acoustic neuroma
  
  • Hearing loss
  • Tinnitus
  • Absent corneal reflex
  • Associated with neurofibromatosis type 2

Question 7

Patient presents with repeated episodes of vertigo lasting a couple hours at a time, no hearing loss, recent URTI, no nausea / vomiting - likely cause?

Answer 7

Vestibular neuritis

Question 8

How is benign paroxysmal position vertigo diagnosed and what does the diagnosis involve?

Answer 8

Dix-Hallpike manoeuvre

https://www.youtube.com/watch?time_continue=135&v=8RYB2QlO1N4

1. Sit upright, straight legged on a couch, with arms folded across chest
2. Put your hands on either side of their head and turn it 45 degrees towards you, ask them to stare at your nose
3. Lower patient smoothly backwards so their head is extended roughly 20 degrees over the back of the couch
4. If patient has BPPV –> nystagmus within 20-30 secs (can take up to 1 min)
5. Do on both sides (with head turned left/right), do asymptomatic side first
6. Patient must keep eyes OPEN!!

Question 9

How is Benign paroxysmal positional vertigo treated?

Answer 9

Epley manoeuvre

https://www.youtube.com/watch?time_continue=32&v=jBzID5nVQjk

1. Perform the Dix-Hallpike manoeuvre
2. Then once nystagmus has resovled, turn pts head 90 degrees so that it is now tilted by 45 degrees facing the opposite side
3. Ask patient to roll onto the side they are now tilted towards, as they do this rotate their head so that it continues to be rotated 45 degrees to that side
4. Take control + weight of patient’s head, then ask patient to sit up with legs over side of couch and finish with their head facing downwards in the midline

Question 10

A patient describes having felt ‘dizzy’, what other details might suggest their dizziness is a presyncopal sensation?

Answer 10

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

Question 11

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

Answer 11

Orthostatic (postural) hypotension

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

Question 12

What symptoms should you note and record in a pt with confirmed or suspected orthostatic hypotension?

Answer 12

• Dizziness
• Light-headedness
• Vaugeness
• Pallor
• Visual disturbance
• Feeling weak
• Palpitations

Question 13

How is a lying + standing BP performed?

Answer 13

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

Question 14

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

Answer 14

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)

Question 15

A patient reports dizziness, if this was due to psychogenic causes what features might the patient have?

Answer 15

• 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

Question 16

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

Answer 16

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”

Question 17

What sessions can be offered to patients who are at risk of falls due to ageing?

Answer 17

Physiotherapist can offer ‘Balance retraining’ - can be run either as a group or individual sessions

• ↓ risk of further falls
• ↓ fear of falling
• Show pts how to get up off the floor if they do fall

Question 18

NICE suggest which interventions have a good evidence base for elderly falls patients?

Answer 18

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

Question 19

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

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

Answer 19

Should be assessed for fracture risk:

1. Patients > 50 yrs + history of falls
2. Women > 65 yrs
3. Men > 75 yrs

Question 20

What is the FRAX calculator for?

Answer 20

To assess future fracture risk

It gives 10-year probability of:

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

Question 21

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?

Answer 21

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

Question 22

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

Answer 22

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)

Question 23

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

Answer 23

• 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

Question 24

Which 7 medications worsen osteoporosis?

Answer 24

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

Question 25

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

Answer 25

* **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)

Question 26

For the following DEXA T-scores what does each represent? 1. \< -1.0 2. -1.0 to -2.5 3. -2.5 or less

Answer 26

1. Normal = \< -1.0 2. Osteopenia = -1.0 to -2.5 3. Osteoporosis = -2.5 or less

Question 27

What is the first line management for osteoporosis?

Answer 27

* **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 * **Vitamin D + calcium supplementation**

Question 28

What is second line treatment for Osteoporosis?

Answer 28

If Alendronic acid can't be tolerated then (both bisphosphonates): * **Risedronate** * **Etidronate** If bisphosphonates aren't tolerated then: * Strontium ranelate * Raloxifene

Question 29

A 92 year old woman presents to the Emergency Department following a fall in her care home. Which of the following investigations should be done routinely in older people who present with falls? 1. Ambulatory ECG, Blood Glucose, CT Brain, Urine Dip 2. Blood Glucose, ECG, Electroencephalogram (EEG), Gait assessment 3. Blood Glucose, ECG, Gait assessment, Lying and standing blood pressure 4. CT Brain, ECG, Electroencephalogram (EEG), Urine dip 5. CT Brain, Gait assessment, Lying and standing blood pressure, Urine dip

Answer 29

Blood **Glucose**, **ECG**, **Gait** assessment, **Lying** and **standing BP** 1. Glucose 2. ECG 3. Gait 4. Lying + standing BP Note: ambulatory ECG (suspect transient arrhythmia), CT brain (suspicion of head injury), EEG (unreliable in elderly and only for specialists), urine dip (unrelaible in elderly due to high incidence of asymptomatic bacteriuria)

Question 30

An 88 year old man presents to hospital after a fall in his home. He is reviewed by the Geriatrician on the assessment unit. He has a past medical history of cataracts, osteoporosis, and chronic obstructive pulmonary disease. Physical examination and routine investigations are all unremarkable. Which of the following interventions has been shown to reduce the risk of falls? 1. Cataract surgery 2. Education programme 3. Exercise programme 4. Falls clinic review 5. Vitamin D supplementation

Answer 30

**Exercise programme** * Meta-analysis showed exercise programmes (involving strength + balance training) **↓ risk of falls** + **↓ rate of falls** (only other intervention that does this is **home hazard assessmen**t) * All the listed interventions ↓ rate of falls but not risk of falling

Question 31

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

Answer 31

* 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