1
Q
What should a falls hx include?
A
- Cirumstances surrounding the fall, including preceding symptoms suggesting medical cause i.e. lightheadedness, vertigo, palpitations
- Look for other potential causes, vision cognition and continence
- Risk factors for osteoporosis
2
Q
What are the drugs causes of falls?
A
- Polypharmacy
- Antihypertensives
- Sedatives
- Opioids
- Psychotropics
3
Q
What are the ageing related causes of falls?
A
- Presbyopia
- Cognitive decline
- Gait abnormalities
- Reduced postural sway
- Reduced muscle mass
- Slower reflexes
4
Q
What are the medical causes of falls?
A
- Cardiac - hypotension, arrhythmias
- Neurological - Parkinson’s, stroke, myopathy
- Osteoarthritis
- Eye problems e.g. cataracts
5
Q
What are the environmental causes of falls?
A
- Walking aids
- Footwear
- Home hazards
- Glasses - varifocals
- Fear of falling
6
Q
What do you want to ask about before the fall?
A
- Where were they
- 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
7
Q
What do you want to ask about during the fall?
A
- Did they lose consciousness
- Have they injured themselves
8
Q
What do you want to ask about after the fall?
A
- How did they get help
- Were they able to get up
- Have they suffered any complications i.e. long lie, fracture, head injury etc
9
Q
What would a positive result of BP for postural hypotension?
A
- Drop in >20mmHg systolic or more (with or without symptoms)
- Drop to below 90mmHg on standing, even if drop is <20mmHg (with or without symptoms)
- Drop in diastolic BP of >10mmHg with symptoms
10
Q
What are the routine investigations for falls?
A
- Blood glucose
- ECG
- Gait assessment
- Lying and standing BP
11
Q
What is vertigo?
A
Sensation of room spinning around, suggests problem is in vestibulo-labyrithine system.
12
Q
What are the peripheral causes of vertigo?
A
- BPPV
- Meniere’s disease
- Vestibular neuritis
- Acoustic neuroma
13
Q
What are the central causes of vertigo?
A
- Migraine
- Brainstem ischaemia
- Cerebellar stroke
- MS
14
Q
What is BPPV?
A
Patients complain of short spells of vertigo (up to 1 min) that settle spontaneously. It occurs when they move their head (either getting in/out of bed, looking up or turning quickly). It can be diagnosed by the Dix-Hallpike manoeuvre and treated by the Epley maoeuvre.
15
Q
What is pre-syncopal?
A
- Feeling as if they are about to faint or complain of feeling lightheaded
- Often when the patient is standing/seated/upright
- Often associated with pallor/relieved by lying
- Suggests cerebral hypoperfusion due to hypotension
- Postural hypotension is a common cause of pre-syncopal symptoms in older patients
16
Q
What does unsteady mean?
A
A general feeling of unsteadiness or feeling unbalanced that usually comes from a patients legs rather than their head.
17
Q
What are the psychogenic causes of falling?
A
- Fear of falling
- Loss of confidence
- Anxiety/panic attacks/somatisation
- Often associated and exacerbates organic dizziness
18
Q
What are the causes of transient loss of consciousness?
A
- Uncomplicated faint or situational syncope
- Orthostatic hypotension
- Dysfunction of the nervous system (epilepsy)
- Dysfunction of CV system (syncope)
- Dysfunction of the psyche (psychogenic attacks)
19
Q
What are the investigations for TLoC?
A
- Assess TLoC - details, medications, PMH, FH, general obs
- ECG
- EEG
20
Q
What do you examine for falls?
A
- Neurological - upper and lower limb, cognition (AMT, CAM, MMSE)
- Vision/vestibular
- Cardiorespiratory (check peripheral oedema)
- BP
- MSK
21
Q
What investigations do you do for falls?
A
- U+E’s (electrolyte abnormalities)
- TFTs/B12/folate - potential causes of peripheral neuropathy
- Vit D level
- ECG - arrhythmias or other abnormalities
- Bone profile - evidence of low or high calcium
- FBC - anaemia and infection markers
- CK - only if long lie for rhabdomyloysis
22
Q
What would results show for mild dehydration?
A
- Mild hyponatraemia
- Raised urea
23
Q
What can increase the risk of falls?
A
- Medication causing excess fluid loss and sedatives
- Functional deterioration secondary to ageing - postural sway, decreased muscle tone/bulk, impaired sensory input
- Urinary incontinence
24
Q
What is the management for falls?
A
- Strength and balance training (exercise is one of the most effective)
- Home hazard assessment and intervention
- Vision assessment and referral
- Medication review with modification/withdrawal
- Manage co-morbidities e.g. diabetes, osteoporosis
25
In osteoporosis when should the assessment of fracture risk be done?
- Any person over the age of 50 with a hx of falls
- All women over the age of 65
- All men over 75
26
What is the intervention for a low FRAX score?
Reassure, give lifestyle advice and reassess in 5 years or less depending on the clinical context.
27
What is the intervention for an intermediate risk FRAX score?
Measure bone mineral density (BMD) and recalculate fracture risk to determine whether individuals' risk less above or below intervention threshold.
28
What is the intervention for a high risk FRAX score?
Can be considered for treatment without the need for BMD, although BMD measurement may sometimes be appropriate, particularly in younger menopausal women.
29
When is BMD recommended?
If starting treatments that may have adverse effects on bone density AND if they have one of:
- People <40 with major risk factor e.g. hx of multiple fragility, major osteoporotic fracture
- Current or recent use of high dose oral/systemic glucocorticoids (>7.5mg prednisolone or equivalent per day for >/= 3 months)
30
What is the 1st line treatment for osteoporosis?
- Bisphosphonate (usually alendronic acid 70mg once weekly) and calcium and vitamin D supplements.
- Vit D needs to be at 50 before starting bisphosphonates - 20,000 units 2x wkly for 6 wks then maintenance dose,
31
What are age related changes related to falls?
- Sarcopenia: ageing leads to decreased muscle mass due to multiple reasons such as hormonal loss, denervation atrophy and exacerbated by inactivity
- Decreased BMD: increased risk of osteoporosis which can make falls more hazardous as increases risk of fractures
- Decreased baroreceptor sensitivity: can potentiate postural hypotension
32
What ageing related changes can cause postural instability?
- Reaction time
- Vision: visual acuity, contrast sensitivity
- Vestibular function: visual field dependence
- Peripheral sensation: tactile sensitivity, vibration sense, proprioception
- Muscle force: knee flexion/extension, ankle dorsiflexion
33
What changes in the cardiovascular system can make older people prone to falls and pre-syncope?
- Reduction in baroreceptor sensitivity: usually compensates decreased BP with increasing HR. Can be exacerbated by BP/HR lowering drugs or HTN can damage baroreceptors.
- RAS works less effectively: excessive salt wasting in kidneys > reduced blood volume - exacerbated by ACEi and diuretics
- Left ventricular diastolic dysfunction: inability to increase SV effectively
- Conduction system disease: SAN and AVN age through loss of pacemaker cells, generalised atrophy and amyloid deposits.
34
What are the common causes of postural hypotension?
- Drugs
- Dehydration
- Anaemia
- Sepsis
- Alcohol
- Prolonged bed rest following illness
- Adrenal insufficiency
35
What drugs are linked to falls by causing postural hypotension?
- Nitrates
- ACEi
- Diuretics
- Anticholinergics
- L-Dopa
- Anti-platelet agents
- Anti-depressants e.g. SSRIs
36
What drugs are linked to falls via other mechanisms e.g. sedation/confusion/unsteadiness?
- Benzodiazepines
- Antipsychotics e.g. opiates
- Codeine-based analgesics
- Anticonvulsants
- Digoxin
- Class 1a anti-arrhythmics
37
What helps with falls prevention?
- Reduce deconditioning
- Prevent delirium
- Ensure call bell and walking aid are in reach
- Ensure glasses and hearing aids are on
- Correct footwear
- Check lying/standing BP
- Review medications
- Review devices e.g. catheters, cannulas
Ageing and Complex Health
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