What should you ask during a falls history?
Before:
- Time, date, place
- Pattern to falls?
- ICE on reasons for falling
- Lightheadedness
- Vertigo
- Palpitations
During: - Loss of consciousness - Jerking - Seizures After - Post-ictal - Incontinence - Able to get up? - Injuries? - Did they get help? - Complications (ex long lie, fractures, head injury)
Causes:
- Medication history
- Vision
- Cognition
- Osteoporosis risk factors
What are some causes for falls that come under DAME?
Drugs
- Polypharmacy
- Antihypertensives
- Opioids
- Psychotropics
- Anticholinergics
Age:
- Vision changes
- Cognitive decline
- Gait abnormalities
- Osteoarthritis
Medical:
- Hypotension
- Arrhythmias
- Neurological disease (ex Parkinson’s, strokes, neuropathy)
- Cataracts
Environmental:
- Walking aids
- Footwear
- Home hazards
What is Vertigo?
- Sensation of the room spinning around
- Suggests problem in the vestibulo-labyrinthine system, anywhere between the ear (peripheral vertigo) and the central vestibular pathways (central vertigo)
Peripheral causes
- Benign paroxysmal positional vertigo (BPPV) (common)
- Meniere’s disease
- Vestibular neuritis
- Acoustic neuroma
Central causes
- Migraine
- Brainstem ischaemia
- Cerebellar stroke
- Multiple sclerosis
BPPV is a common cause of peripheral vertigo
- Short spells of vertigo (up to 1 minute) that settle spontaneously
- Occurs when they move their head (ex getting in/out of bed, looking up/turning quickly)
- It can be diagnosed using the Dix-Hallpike manoeuvre
- Treatable using the Epley manoeuvre.
What is Presyncope?
- Feeling as if you are about to faint/complaining of lightheadedness
- Often when standing/seated/upright
- Associated with pallor, relieved by lying
- Suggests cerebral hypoperfusion due to hypotension
- Postural/orthostatic hypotension is common in older patients
- Diagnosed by doing lying and standing BP
What does unsteadiness mean?
A general feeling of unsteadiness or feeling unbalanced that usually comes from a patients legs rather than their head (asking someone “does this feeling come from your head or your legs?” is often useful).
What are some psychogenic causes of dizziness?
- Common
- Fear of falling
- Loss of confidence
- Anxiety/panic attacks/somatisation
- Exacerbates organic dizziness
Which examinations would you do to assess a falls patient?
- Upper and lower limb neurological exam
- Cognition (ex AMT 10, CAM, MMSE, 4AMT)
- Vision
- Vestibular
- CVS
- Musculoskeletal
Which initial investigations should be done for a falls patient?
- ECG - to look for arrythmias/abnormalities
- TFTs/B12/Folate - exclude other causes of peripheral neuropathy
- U&Es
- Bone profile
- FBC
They above look for anaemia, markers of infection and electrolyte abnormalities
Who is involved in the MDT and why?
- Consultant: leads MDT
- Nurse: keeps track of changes in patient
- Physiotherapist: manages mobility and pain
- Podiatrist: neuropathy, difficulty walking, footwear
- Occupational therapist: caters to other aspects of social care
- Pharmacist: checks for drug interactions, safe prescribing, and drug management
How can we create a management plan based off the DAME criteria?
Drugs:
- Stop any antihypertensives, sedatives, etc, unless needed, or reduce dose
Ageing:
- Balance retraining run by physiotherapists
- Check visual acuity and refer to optician
- Check osteoporosis risk
Medical:
- Maintain good diabetic control (slows down rate of diabetic neuropathy)
- Addressing osteoprosis risk reduces rate of fractures
- Cataract surgery improves vision
Environment:
- Environmental assessment for hazards
- Change footwear, lighting in home
- Panic alarm/care-call system with patient
- Adaptations at home
What are the NICE guidelines on assessment of Osteoporosis?
- Assessment of fracture risk be considered in any patient over 50 with a history of falls
- In all women over 65
- In all men over 75
Risk factors that would implicate earlier assessment than specified:
- History of falls
- Previous osteoporotic fragility fracture
- Current or frequent use of oral corticosteroids
- BMI underweight (<18.5)
- Smoker
- Alcohol intake over 14 units/week
Secondary causes of osteoporosis:
- Hyperthyroidism
- Cushing’s
- Diabetes
- Hypogonadism
- Untreated premature menopause
What is the NICE guidance on the management of Osteoporosis?
High risk of fragility fracture:
- Offer DEXA scan
- Then bone-sparing drug treatment if T-score is -2.5 or less
- If T-score is more than -2.5, treat underlying conditions, and repeat DEXA within 2 years
Intermediate risk:
- Arrange a DEXA scan to measure bone mineral density
- Offer drug treatment if T-score is -2.5 of less
Low risk:
- No drug treatment
- Offer lifestyle advice
- Follow up within 5 years
What drug treatments are recommended for patients high risk of osteoporotic fracture?
If bone-sparing treatment recommended:
- Prescribe a biphosphonate (alendronate 10mg OD or 70mg OW/risedronate 5mg OD or 35mg OW)
- If there are no contraindications, with appropriate counselling
- To patients with a T-score of -2.5 or less
If the patient’s calcium intake is adequate (700mg/day)
- Prescribe 10mcg (400IU) of vitamin D without calcium if sun exposure insufficient
If calcium intake inadequate:
- Prescribe 10mcg (400IU) of vitamin D with 1g of calcium daily
- Prescribe 20mcg (800IU) of vitamin D with at least 1g of calcium daily if patient is elderly and housebound, or living in a nursing home
Consider prescribing HRT to women who have the menopause before age 40 (premature)
- Reduced risk of fragility fractures
- Relieves menopausal symptoms
What lifestyle information and advice should be given to patients at risk of fragility fractures?
- Take regular exercise
- Improves muscle strength
- Encourage walking, especially outdoors (vitamin D)
- Strength or weight training of different muscle groups
- A combination of exercise types (ex balance, flexibility, stretching, endurance and strength)
- Eat a balanced diet
- Stop smoking
- Reduce alcohol intake to within recommended limits
- 1-2 units a day with at least 2 alcohol-free days
Provide the patient with information and support:
- National osteoporosis society
- Healthtalkonline
- NHS England
How should you counsel a patient prescribed Biphosphonates?
- Explain that patient likely has osteoporosis, and this increases risk of fracture with future falls
- Explain that biphosphonates can reduce the risk of fractures due to osteoporosis
- Was prescribed due to risk of fracture within the next 10 years
Instructions:
- Ensure no contraindications (swallowing issues, oesophageal disease)
- Cognitive and physical capacity to follow instructions?
- Take with water (always)
- Stay upright/seated for at least half an hour afterwards
- Take on an empty stomach
- 3-5 years
- Consider IV if more appropriate (intervals of 3 months to a year, outpatient setting)
- ICE the patient, understand and agreement
What is the equation to calculate blood pressure?
Cardiac output (C) x Peripheral vascular resistance (PVD) = Blood pressure (BP)
What is the equation to calculate cardiac output?
Heart rate (HR) x Stroke volume (SV) = Cardiac output (CO)
How is blood pressure autoregulation affected by age?
Reduction in baroreceptor sensitivity
- Normally heart rate increases when blood pressure drops due to baroreceptors
- This response is blunted in the elderly
- Worsened due to blood pressure/heart rate lowering drugs
- Hypertension can damage the baroreceptors
- This can lead to systolic hypertension and postural hypotension (bad combination, difficult to treat)
Renin-aldosterone system works less effectively
- Exessive salt waste by kidneys
- Reduces blood volume
- Exacerbated by medications (ex ACE inhibitors, diuretics)
Left ventricular diastolic dysfunction
- Leads to inability to increase stroke volume as effectively
Conduction system disease
- Sinus and atrioventricular nodes age due to:
- Loss of pacemaker cells
- Generalised atrophy
- Amyloid deposits
Why are older bones weaker?
We reach maximum bone density around age 30
As we age, osteoblastic activity lessens, eventually weakening the trabeculae of bone.
How do fractures heal?
- Blood clot forms between broken ends
- Inflammatory mediators flood to area
- Connective tissue (cartilage) forms a bridge between ends of broken bone
- Angiogenesis replaces lost blood vessels
- Osteogenesis then occurs due to osteoblasts
- Once the bridge gas been stabilised, osteoclasts and osteoblasts remodel the callus to create normal bone
Osteoporosis
- Fragility fractures happen due to skeletal ageing
- Requires less trauma to the bone
- More prevalent in women due to menopause
- Vertebral collapse common secondary to osteoporosis
- Trabecular bone is more metabolically active than cortical bone
- Cortical bone is normally 80% of bone mass
- It becomes more porous as you age, increasing fracture risk
- NOF fractures often have poor prognosis and complications due to osteoporosis
Which investigations should be done routinely in elderly patients presenting with falls?
- Blood glucose
- ECG
- Gait assessment
- Lying and standing BP
Which manoeuvre is diagnostic of true vertigo?
Dix-Hallpike manoeuvre
What is the most effective way to minimise falls risk?
Exercise programme
- Reduced risk
- Reduced rate of falls
Other most effective intervention is a home hazard assessment
Other changes such as cataract surgery, vitamin D supplements and falls clinic reviews reduce the RATE of falls but not the risk.
