1
Q
Falls are multifactorial - only 15% of falls have a single underlying medical cause. What are the most common risk factors for falls?
A
- previous falls
- impairment of balance/gait
- visual impairment
- cognitive impairment
- drugs (>4 drugs)
- fear of falling
- urinary incontinence
- poor foot care/footwear
- postural hypotension
- acute medical illness (virtually anything in the elderly)
2
Q
How might drugs and alcohol cause falls?
A
- use of >4 drugs poses a significant risk factor
- some drugs inc propensity of falling more than others
- antihypertensives + sedatives
- iatrogenic falls eg due to postural hypotension (diuretics), cardiac arrhythmias (TCAs) and extrapyramidal effects (neuroleptic medications)
- prevention should be aimed at reducing the use of unnecessary drugs
- excessive alcohol consumption also a key risk factor for falls
3
Q
How does vision in the elderly result in falls?
A
- the eye needs double the illumination every 13 years from the age of 15 to maintain recognition in subdued lighting
- transparency of the cornea and lens declines and corneal flattening occurs (astigmatism)
- diameter of pupil is decreased (1mm or less commonly found in older ppl)
- there is reduced accommodaiton
- reduced photoreceptor number
- presbyopia (long-sightedness caused by loss of elasticity of the lens)
4
Q
How is the vestibular system affected by age, resulting in falls?
A
- progressive reduction in hearing predominantly of higher frequency
- due to loss of hair cells, ganglion cells + nerve fibres in cochlea
- paralleled by a reduction in vestibular function leading to reduced balance + increased risk of falling
5
Q
Which aspects of the environment may pose a risk for falls?
A
- lighting
- wet floor, loose rugs
- electrical flex
- beds + chairs
- cupboards
- bathing
6
Q
What are the neurological causes of falls?
A
- visual impairment (visual acuity of 6/12 or less)
- VIII nerve problems (labyrinthitis, BPPV)
- epilepsy
- stroke/TIAs
- parkinson’s disease
- neuropathy
- cerebellar syndromes
7
Q
What are the cardiovascular causes of falls?
A
- hypotension (OH, MI, sudden bleed)
- arrythmias (brady or tachy)
- obstructive lesions (aortic stenosis, HOCM)
- vasovagal attacks
- carotid sinus hypersensitivity (CSH) - cardioinhibitory, vasodepressor or mixed
- situational syncope (cough, micturition, defacation)
8
Q
What are GI causes of falls to be considered?
A
- sudden bleed
- diarrhoea
9
Q
What are MSK causes of falls?
A
- unstable joints
- osteomalacia
10
Q
What are metabolic causes of falls?
A
- hypo or hyperthyroidism
- addison’s (hypotension)
- cushing’s (myopathy, hypokalaemia)
- hypoglycaemia
11
Q
What are physical injury consequences of falls?
A
- soft tissue bruising - may require analgesia, trauma reflected by raised CK
- breaks in the skin - may be slow to heal + require grafting
- fracture - orthopaedic treatment required
- friction burns - from synthetic carpet when trying to get back up
- falls on a hot surface may result in a burn
- central cord lesions leading to quadriplegia in those w/ spinal cord compromised by spondylosis
- head injuries
12
Q
What can prolonged periods unable to rise from the floor result in?
A
- hypothermia
- pressure sores
- hypostatic pneumonia
- dehydration
- rhabdomyolysis
13
Q
What are psychological consequences of falling?
A
- fear of falling (50%) - leads to even greater risk + social isolation
- loss of confidence + mobility
14
Q
What points need to be considered when taking a falls history?
A
- WHO - any witnesses, adequate collateral needed
- WHEN - what time of day? what were they doing at time of?
- WHERE - in house or outside?
- WHAT
- before - any warning? associated symptoms?
- during - incontinence, tongue biting, LOC, pale, injury, contact to floor?
- after - what happened, who got them up, how long did it take, resume normal activites, any confusion or amnesia, any weakess or speech difficulty?
- WHY - why do you think you fell?
- HOW - how many times fallen? gauge severity of problem
- SYSTEMS ENQUIRY
- PMHX
- SOCIAL - alcoohl, support at home, mobility
- MED REVIEW - polypharmacy!
15
Q
What is the role of the physiotherapist?
A
- correction prescription and use of walking aids
- improve gait pattern (longer steps)
- improve stability (strength + balance)
- teach patient how to get up from the floor without help
- individually tailored exercise plans to prevent future falls
16
Q
What is the role of the occupational therapist?
A
- identify + remove environmental hazards
- provide equipment to facilitate mobility at home
17
Q
If no obvious causes of falls are found in a patient, how might you want to prevent risks and adverse consequences?
A
- osteoporosis prevention w/ vit D + calcitonin or bisphosphonates
- hip protectors
- arrange for personally worn alarm systems
- continual visits to the home (by carers, neighbours, family) to reduce duration of a ‘lie’ post-fall
- maintain constant environmental temperature
- soften floor coverings
- remove obstacles + dangers
- place emergency bedding where it can be reached from floor
- give advice regarding appropriate footwear
- reduce stressors (limiting walking to indoors, use walking stick, asking help)
- change of accommodation
18
Q
Up to 50% of men presenting with vertebral or hip fractures have an underlying secondary cause of osteoporosis. What is osteoporosis?
A
- skeletal disease characterised by low bone mass and micro architectural deterioration of bone tissue
- consequent increase in bone fragility and susceptibility to fracture
- around 50% of women and 20% of men aged 50 will have a fragility fracture in their remaining lifetime
19
Q
What is the most devestating consequence of osteoporosis?
A
- hip fractures
- most occur after a fall from a standing height or less
- 90% occur in ppl 50+
- 80% occur in women
- incidence of hip fractures increases exponentially w/ age
- lifetime risk of hip fracture for 50yr olds is 11.4% and 3.1% for women and men respectively
20
Q
What is the outcome in hip fracture?
A
- often poor
- 1 in 3 adults 50+ dies within 12 months of suffering hip fracture
- cause of death is not usually directly attributable to fracture itself, but to other chronic diseases
- loss of physical function, decreased social engagement, increased dependence, worse quality of life
Geriatric Medicine
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