1
Q
Falls History
Falls History can be split into 4 categories:
A
- Before the fall
- During the fall
- After the fall
- Now
2
Q
Falls History
Questions to ask about “Before the Fall”
A
- clarify when the fall occured
- ask about activities before the fall
- ask about warning signs & physical symptoms
3
Q
Falls History
Questions to ask in a Falls History about what happened “During the Fall”
A
- the nature of the fall (how?what direction?did anything break fall? did you hit head?)
- How the patient fell (fall onto something? what position when landed?)
- Loss of consciousness? (did you black out at all? do you remember falling? remember hitting the ground?)
- **What they did when they started to fall? **(what did you do when you felt yourself falling? Did you try to break your fall?)
4
Q
Falls History
Questions to ask in Falls History about “After the Fall”
A
- **How long **where they lying on the floor?
- did they get up by themselves?
- How they **sought help **and by who?
- How they **felt **after fall
5
Q
Falls History
Questions to ask during a falls history about how the patient feels “Now”
A
- How are you feeling Now?
- Ask about specific symptoms that may indicate injuries
- Have they had any further falls?
- How the fall has affected them? (worried them, stopped any activities?)
6
Q
Falls History
What score can be used to calculate a risk of future falls
A
FRAT Score
7
Q
What tool can be used to assess fracture risk? (specifically the risk of an osteoporotic fracture)
A
FRAX Tool (fracture risk assessment tool)
8
Q
Conditions that are relevant to falls
Fall causes that affect mobility, strength or balance?
A
- BPPV
- Parkinson’s disease
- Orthostatic Hypotension
- Arthritis syndromes
- Sarcopoenia
9
Q
Conditions that are relevant to falls
Fall causes that affect** cognition**?
A
- Dementia syndromes
- other neurological conditions
10
Q
Conditions that are relevant to falls
Fall Causes that affect sensory elements?
A
- visual impairment
- peripheral neuropathy
11
Q
Conditions that are relevant to falls
Fall causes that affect bone health?
A
- osteoporosis (increased fracture risk)
12
Q
Conditions that are relevant to falls
Fall causes that lead to urgent movement? (more likely for someone to fall)
A
- urinary conditions eg. UTI, incontinence & oevractive bladder
13
Q
conditions that are relevant to falls
**Cardiovascular **conditions that can cause falls?
A
- aortic stenosis
- atrial fibrillation
- pacemakers
- other arrythmias
14
Q
Types of medical conditions that are relevant in the context of a fall?
eg. affect cognition
A
- affect mobility, strength & balance
- affect cognition
- affect sensory elements
- affect bone health
- lead to urgent movement
- cardiovascular
15
Q
What 3 bodily functions/systems does normal gait involve?
A
- 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).
16
Q
Risk factors for Falls
A
- Lower limb muscle weakness
- Vision problems
- Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
- Polypharmacy (4+ medications)
- Incontinence
- > 65
- Have a fear of falling
- Depression
- Postural hypotension
- Arthritis in lower limbs
- Psychoactive drugs
- Cognitive impairment
17
Q
Why are diuretic drugs a falls risk?
A
They cause postural hypotension
18
Q
Why are anticholinergic medications a falls risk?
A
They cause postural hypotension
19
Q
Why are antidepressants a falls risk?
A
They cause postural hypotension
20
Q
Why are beta-blockers a falls risk?
A
They cause postural hypotension
21
Q
Why is Levodopa a falls risk?
A
It causes postural hypotension
22
Q
Why are ACE inhibitors a falls risk?
A
They cause postural hypotension
23
Q
Why are Nitrate drugs a falls risk?
A
They cause postural hypotension
24
Q
Why are benzodiazepines (anxiolytics eg. diazepem & lorazepem) a falls risk?
A
Some side effects of them are dizziness, confusion, vision impairment and loss of coordination- all of which can affect walking
25
Why are antipsychotics a falls risk?
They can cause sedation, dizziness and postural hypotension
26
Why are opiates a falls risk?
They can cause sedation, impaired balance, slow reactions, dizziness and postural hypotension
27
Why are anticonvulsants a falls risk?
They can cause dizziness, gait disorder and sedation.
28
Why is codeine a falls risk?
It can cause sedation, slow reactions, impair balance and cause delirium
29
Why is digoxin a falls risk?
It can cause postural hypotension, dizziness, syncope, bradycardia and impaired cerebral perfusion
30
Bedside tests to consider for a Fall
* basic obs
* BP
* Blood Glucose
* Urine dip
* ECG
31
What blood tests should be considered for a Fall?
* FBC- anaemia, infection
* U&Es- dehydration, rhabdomyolysis
* Bone Profile- osteoporosis
32
What imaging should be considered for a person who has had a fall?
* X-ray of chest/injured limbs
* CT head
* Echocardiogram
33
Intrinsic causes of Falls
* Female Gender
* Neurological disease
* Cognitive decline
* visual defect
* muscle weakness
34
Extrinsic causes of Falls
* Polypharmacy
* Bifocals
* Walking aids
* Footwear
* Home hazards (eg. rug)
35
What are potential consequences of a fall?
* loss of confidence/fear of falling
* serious injury
* fragility fracture
* complications from a long lie
36
What do occupational therapy do after a fall?
Home hazards assessment
37
What can physiotherapy do after a fall?
* strength and balance training
* aerobic exercise
* exercise programmes
38
What could be done in a medical review following a fall to prevent it happening again?
* optimise comorbidities
* diagnose new medical conditions
* medication review
* manage postural hypotension
* cognitive screening
* bone health assessment
* referal for cataract surgery if necessary
39
What could be part of a systems review for a fall?
* Vision
* Cognition
* Continence
* neurological & gait
* MSK
* cardio
* resp
40
Are there any drugs to treat postural hypotension?
Fludrocortisone can be prescribed to help with venous return but treatment is often limited by side effects such as ankle oedema and hypokalaemia
41
Lifestyle management to help Postural Hypotension
* ensure adequate hydration
* ensure adequate salt intake
* graded standing (lying to sitting, sitting to standing, in different stages)
* compression stockings
* avoiding warm and crowded environments
42
Why do bifocal lenses increase Falls risk?
They alter depth perception
43
A primary gait disorder is usually caused by either of 2 things:
1. a porgressive central or peripheral neurological condition
2. a musculoskeletal condition
44
What manouvre should be considered if a patient complains of dizziness symptoms in their fall?
Dix-Hallpike- to test for vestibular symptoms eg. BPPV
45
What does Romburg's test test for?
Proprioception-related balance problems
46
What are the causes & features of a hemiplegic gait?
Cause: Cerebrovascular disease
* circumduction of hip
* hyperextension of knee
* other UMN signs
47
What are the causes & features of a cerebellar gait?
Causes: cerebrovascular disease or alcohol
* ataxic gait
* staggering
* broad base
* other cerebellar signs
48
What are the causes & features of a Parkinsonism gait?
Causes: Parkinson's disease & other causes of parkinsonism
* short, shuffling gait
* hestitant
* festinant (involutary tendency to take short accelerating steps when walking)
* loss of postural reflexes (difficulty balancing)
* loss of arm swing
* stooped posture
* difficulty turning
49
What does an apraxic gait mean?
Difficulty initiating and maintaining gait depite intact basic motor function of the legs, associated with bilateral medial frontal lobe pathology
50
What are the causes of an apraxic gait?
* Normal pressure hydrocephalus (NPH)
* Dementia
* Cerebrovascular disease
51
What are the features of an apraxic gait?
* feet "glued" to the floor
* difficulty initiating
* shuffling, often wide based
* arm swing preserved
* other UMN signs
* difficulty turning, some freezing
52
What are the common features of an osteoarthritic gait?
* antalgic, limping gait
* affected joint held in abnormal posture
53
What are the features of a gait affected by a peripheral motor deficit?
* distal weakness
* poor dorsiflexion
* high stepping
54
To test gait and falls risk for those with a falls history or at risk what tests can be completed?
'Turn 180° test' or the 'Timed up and Go test'.
55
What is the definition of syncope?
Syncope may be defined as a transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery
56
What is reflex syncope?
Transient loss of consciousness due to inappropriate cardiovascular responses of vasodilation or bradycardia, leading to a systemic hypotension and cerebral hypoperfusion. It is the most common cause of syncope. It is neurally mediated.
57
Types of reflex syncope:
* Vasovagal: triggered by emotion, pain or stress. Often referred to by "fainting"
* Situational: Cough, micturition, gastrointestinal, post-exercise, after eating, weight-lifting
* Carotid sinus syncope
58
What is orthostatic syncope?
Orthostatic syncope is due to orthostatic hypotension. Orthostatic hypotension is defined as a symptomatic systolic BP drop of 20mmHg or diastolic drop of 10mmHg within 3 minutes of standing. It occurs as a consequence of impaired vasoconstriction due to chronic impairment of autonomic sympathetic activity.
59
Types of orthostatic syncope:
* Primary autonomic failure: Parkinson's, Lewy body dementia
* Secondary autonomic failure: diabetic neuropathy, amyloidosis, uraemia
* Drug-induced: diuretics, alcohol, vasodilators etc
* Volume depletion: haemorrhage, V & D, dehydration
60
What is cardiac syncope?
cardiac syncope arises as a consequence of haemodynamic compromise in the setting of cardiac arrythmias or structural heart disease. it is the second most common cause of syncope.
61
Types of cardiac syncope
* Arrythmias: bradycardias (SA node dysfunction, AV conduction disorders), tachycardias (supraventricular, ventricular)
* Structural: valvular, MI, hypertrophic obstructive cardiomyopathy
* Others: PE
Year 4- OPIC👵🏻
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