Falls

Question 1

Define fall

Answer 1

Coming to rest on a lower level, with or without LOC, not due to external force or medical problem

Question 2

What questions should you ask someone who has had a fall?

Answer 2

• How did the fall happen?
• What were they doing at the time?
• How did they feel before the fall?
• Was there and dizziness or a lightheaded feeling?
• Did they lose consciousness?
• Did they have any cardiac symptoms?
• Are they weak anywhere?
• Has this happened before?
• How do they normally mobilise?
• What medication do they take? Think sedatives, cardiac medications, anticholinergics, hypoglycaemics, opiates that can contribute to falls

Question 3

Common causes of falls?

Answer 3

Muscle weakness/sarcopenia
Poor balance/instability
Hypotension
Vision loss

Question 4

Key investigations for underlying cause of a fall?

Answer 4

CGA - general frailty and functional ability
FBC - anaemia/bleeds
Lying and standing bp- orthostatic hypotension
ECG - arrhythmias
AXR- faecal impaction
CT head- subarachnoid haemorrhage

Question 5

Multidisciplinary interventions for discharge post fall?

Answer 5

Pharmacist- review TTO
Physios - improve strength and mobility
Occupational therapists- AODL
GP follow up

Question 6

Commonly prescribed drugs that increase falls risk?

Answer 6

Antihypertensives
Alpha blockers
Diuretics
Benzodiazepines

Question 7

Define postural hypotension

Answer 7

Drop in systolic BP > 20 mmHg or diastolic BP > 10 mmHg within 3 mins of standing

Question 8

How do you test someone for postural hypotension?

Answer 8

• Lie for 5 minutes
• Stand and take BP at 1 min, 3 min and 5 mins

Question 9

What can cause postural hypotension?

Answer 9

Idiopathic

Hypovolaemia: dehydration, haemorrhage

Drugs: antihypertensives, anti-anginals, antidepressants, alcohol

Prolonged bed rest

Autonomic failure:
primary (eg MSA, PD)
secondary (DM)

Question 10

How is postural hypotension managed?

Answer 10

• Hydration
• Review polypharmacy
• Reduce adverse outcomes from falls (e.g. fall alarm, soft flooring)
• Behavioural changes (e.g. rising from sitting slowly, calf pumping before standing)
• Compression stocking
• Fludrocortisone (poor evidence base) or Midodrine

Question 11

How can you explain postural hypotension to a patient?

Answer 11

your heart is a pump
when you are standing, you have to pump against gravity to get the blood to your brain

so if you aren’t able to pump hard enough against gravity your brain is the first thing to go which causes these sxs (blurred vision, black spots, headache, nausea, feeling hot)

when you lie down your heart and brain are on the same level so the blood can get there more easily and you recover

so when you notice these symptoms, the best thing you can do to help your brain is to lie down

Question 12

when should you refer a patient for multidisciplinary assessment by a qualified clinician after they have had a fall?

Answer 12

all over 65 who:
had more than 2 falls in 1 year,
a fall that requires medical treatment,
Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’

Question 13

list some complications of falls

Answer 13

trauma,
pain,
loss of confidence,
loss of independence,
distress,
mortality

Question 14

what lifestyle advice should you give to someone with osteoporosis?

Answer 14

regular exercise to improve muscle strength,
smoking cessation,
balanced diet,
drink alcohol within recommended limits

Question 15

When is bone sparing treatment recommended for those with osteoporosis?

Answer 15

T-score -2.5 or lower

Question 16

What is a fragility fracture?

Answer 16

fracture from a fall from standing height

Question 17

What calculation tool is used to assess the risk of frailty fractures?

Answer 17

FRAX

Question 18

What should you check before prescribing bisphosphonates?

Answer 18

Calcium levels,
Vitamin D levels,
Renal function

Question 19

Give some vestibular causes of dizziness

Answer 19

BPPV
Neuritis / Labyrinthitis
Meniere’s
Vertiginous Migraine
Persistent Postural Perceptive Dizziness
SOLs

Question 20

Give some non-vestibular causes of dizziness

Answer 20

Light-headedness
Pre-syncope / (Syncope)
Postural intolerance
Drug S/Es
Anxiety
SOLs

Question 21

What is a transient loss of conciousness?

Answer 21

Short Duration
Abnormal Motor Control
Loss of responsiveness
Amnesia

Usually 90 seconds or less

Question 22

What is syncope?

Answer 22

Transient global cerebral hypo-perfusion which causes TLOC and loss of voluntary muscle tone

Rapid onset, spontaneous & prompt recovery

Full recovery

Question 23

What causes should you be thinking about when someone presents with dizziness / collapse?

Answer 23

1. Significant inter current illness?
2. Epilepsy?
3. a Fall?
4. a Vestibular problem?
5. Cardiac Syncope?
6. Reflex Syncope?
7. Orthostatic Hypotension?
8. Functional Neurological Disorder?

Question 24

What are the 3 main reflex syncopal syndromes?

Answer 24

Situational syncope (e.g. when seeing blood)
Vasovagal syncope (common faint)
Carotid sinus syndrome

Question 25

What are the red flags for a cardiac cause of syncope?

Answer 25

New onset chest pain or SOB Sudden onset palpitations immediately prior Collapse during exercise/ when seated

Question 26

What should you think about asking when considering if a patient has a cardiac cause of syncope?

Answer 26

do they have cardiac hx? do they have structural heart disease? do they have a fam hx of sudden cardiac death (esp before 50)? do they have an abnormal ECG?

Question 27

How can you differentiate between vasovagal syncope and postural hypotension based on clinical features?

Answer 27

presence / absence of autonomic activation in vasovagal syncope autonomic sxs are often present - rising heat, blurred vision, muffled hearing, feeling sick in postural hypotension, autonomic sxs are not present

Question 28

What questions might you ask someone about the cirumstances surrounding vasovagal syncope?

Answer 28

Prolonged standing Dehydration Hot weather

Question 29

How can you investigate suspected vasovagal syncope?

Answer 29

1. Tilt table 2. ECG 3. Beat to beat BP monitor

Question 30

How can you manage simple vasovagal syncope?

Answer 30

Recognition & avoidance of triggers * Warmth * Alcohol * Caffeine (low levels increase bp, lots of caffeine increases urination and vasodilates) * Prolonged stand Can keep a diary of pre-syncopal sxs Increase fluid intake (2-3 L), salt Physical Counter-pressure manoeuvres (PCM) Compression Stockings/Abdominal binders Midodrine

Question 31

Add in falls prevention programme (2x a week for 6 weeks, safe falling) and support with ADLs e.g. putting bin out