What are the 3 components of normal gait?
Normal gait involves:
- The neurological system
- Basal ganglia and cortical basal ganglia loop
- The musculoskeletal system
- Which must have appropriate tone and strength
- Effective processing of the senses such as sight, sound, and sensation
- Fine touch and proprioception
Give examples of neuropsychiatric risk factors for falling
- Visual impairment e.g. diplopia, loss of peripheral vision or blurred vision
- Peripheral neuropathy
- Vestibular dysfunction e.g. BPPV
- Gait and balance disturbance
- Fear of falling itself can increase the risk of falls
- Cognitive or mood impairment e.g. dementia, depression, or delirium
- Seizure disorder
- Subdural haematoma
- Stroke or transient ischaemic attack
What can cause a possible gait or underlying balance disturbance?
Possible history of lumbar disc disease, peripheral neuropathy, arthritis or prior injury/fracture; specific abnormalities in gait or movement (shuffling gait, tremors, bradykinesia) may suggest underlying disorder such as Parkinson’s disease.
Give examples of cardiovascular risk factors for falling
- Syncope
- Orthostatic hypotension
- Carotid sinus syndrome
- Post-prandial hypotension
Give examples of musculoskeletal risk factors for falling
- Joint buckling, instability or poor mechanical mobility
- Deconditioning
Give examples of environmental risk factors for falling
- Medications
- Polypharmacy
- Substance abuse
- Environmental hazards
What medications may increase the risk of falling?
Benzodiazepines, antidepressants, and anxiolytics; others associated with an increased risk of orthostatic hypotension include alpha-blockers, antihypertensives, diuretics, beta-blockers, bromocriptine, levodopa, non-steroidal anti-inflammatory drugs, marijuana, opioids and sedatives, hypnotics, sildenafil, tricyclic antidepressants, highly anticholinergic medications such as diphenhydramine and vasodilators.
What is the risk of polypharmacy in contributing to falls?
Use of 5 or more medications increases the risk of falls by 30% in community-dwelling people, and by at least a factor of 4 in nursing-home patients
Give examples of environmental hazards that may contribute to falling
Loose rugs or tiles, poor lighting, uneven floors, presence of clutter; recent use of a walking stick or frame, or living alone: these factors are of increased importance with age.
What are the red flag for falling?
- Any history of sudden change in alertness or level of consciousness
- Possible causes include cerebrovascular (transient ischaemic attack, stroke, seizure), cardiovascular (hypotension, bradycardia or tachycardia), medication adverse effects (especially newly prescribed) or infection
- New head trauma
- Concurrent use of anticoagulation or antiplatelet therapy raises concern for a subdural haematoma
- Pain suggesting a potential fracture
- Persistent pain, inability to bear weight, or any obvious anatomical abnormality should prompt a quick evaluation for fracture, along with appropriate orthopaedic consultation
Briefly describe the history taking for a patient presenting with a fall
- Circumstances surrounding a fall should be elicited:
- Location
- Activity at the time of the fall (e.g. fall while standing, while walking down steps, while walking on uneven surfaces)
- Injury related to the fall (e.g. head trauma, bruise, fracture)
- Associated symptoms concurrent with a fall should be assessed, including:
- Any change in level, or loss, of consciousness
- Cardiovascular symptoms such as chest pain, palpitations, dizziness, vertigo or lightheadedness
- Symptoms related to a change in position (e.g. supine to sitting or sitting to standing)
- Pain or neurological symptoms (e.g. headache, weakness/tingling/numbness or acute change in mental status)
Medicines should be reviewed (with particular reference to psychotropic medications and opioids.
A history of comorbidities such as diabetes, Parkinson’s disease or osteoporosis should be elicited.
Briefly describe the examination of a patient presenting with a fall
The focus is on:
- Factors contributing to a fall
- Identification of any fall-related injury (e.g. a fracture or subdural haematoma from head trauma)
- Fall risk factors that can be reduced/modified/corrected to prevent future falls
Evaluation and examination may include:
- Cardiovascular examination
- Musculoskeletal examination
- Neurological examination
- Visual examination
- Gait examination
What testing and imaging may be performed to investigation falls?
- Blood tests
- X-rays
- CT or MRI of the brain
- ECG
- Echocardiogram
- An electroencephalogram
- Testing of vision, hearing or vestibular function
- Orthostatic challenge
What blood tests are used to investigate a fall?
Blood tests such as full blood count, serum B12, blood glucose (including glycated haemoglobin [HbA1c] to assess level of control in diabetic patients), electrolytes and thyroid-stimulating hormone are useful in evaluation of peripheral neuropathy or a change in mental status.
Give examples of medications that cause postural hypotension
- Nitrates
- Diuretics
- Anticholinergic medications
- Antidepressants
- Beta-blockers
- L-Dopa
- ACE inhibitors
Give examples of medications associated with falls due to other mechanisms
Note: not related to postural hypotension
- Benzodiazepines
- Antipsychotics
- Opiates
- Anticonvulsants
- Codeine
- Digoxin
- Other sedative agents
Briefly describe the management of falls as an inpatient
Identify those who are at high risk of further falls to help reduce the chance of an in-patient fall:
- 1-1 nursing may be required for confused/delirious patients
- Low-rise beds and mattresses on the floor to reduce the risk of injury
- Non-slip socks
- Adjustment of medication regimens to reduce falls risk
- Training how to use appropriate walking aids is very important to help reduce falls
Additional support:
- POC if going back home
- May require placement to ensure safety, either residential home or nursing home based on level of dependence
Briefly describe the management of falls as an outpatient
Home visits can be helpful in frail patients who might have cluttered houses with uneven floors.
Modification of the home environment:
- Downstairs living
- Commode
- Hand rails
- Stair lift
- Hospital bed
- Hoist
Pendant alarms can be beneficial.Newer models have in-built impact sensors that are set-off as a fall happens
Regular follow-up:
- Specialist geriatric clinic follow-up
- Falls clinic
- Balance classes
Briefly describe how to perform a lying and standing BP
Ideally the patient should be lying down for 10 minutes. Take their blood pressure. Keep the blood pressure cuff on. Ask them to stand up. Take the BP again at 1 minute, 3 minutes, and 5 minutes.
Significant postural drop is: >20 systolic or >10 diastolic from the lying position.
When may patients require a MDT approach with falls?
Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:
- >2 falls in the last 12 months
- A fall that requires medical treatment
- Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
What patients require a bone health assessment?
They advise that all women aged >65 years and all men aged >75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
- Previous fragility fracture
- Current use or frequent recent use of oral or systemic glucocorticoid
- History of falls
- Family history of hip fracture
- Other causes of secondary osteoporosis
- Low BMI (less than 18.5 kg/m²)
- Smoking
- Alcohol intake of more than 14 units per week for women and more than 14 units per week for men
What tools are used to assess bone health?
NICE recommend using a clinical prediction tool such as FRAX or QFracture to assess a patients 10 year risk of developing a fracture.
Briefly describe the role of FRAX in assessing bone health
Estimates the 10-year risk of fragility fracture.
Valid for patients aged 40-90 years.
Based on international data so use not limited to UK patients.
Assesses the following factors: age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis and alcohol intake.
Bone mineral density (BMD) is optional, but clearly improves the accuracy of the results.
NICE recommend arranging a DEXA scan if FRAX (without BMD) shows an intermediate result.
Briefly describe the role of QFracture in assessing bone health
Estimates the 10-year risk of fragility fracture.
Developed in 2009 based on UK primary care dataset.
It can be used for patients aged 30-99 years (this is stated on the QFracture website, but other sources give a figure of 30-85 years).
Includes a larger group of risk factors than FRAX e.g. cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants.
