Geriatrics: Immobility and Falls

Question 1

Define a ‘fall’.

Answer 1

Inadvertently coming to rest on the ground or other lower level without loss of consciousness and other than as a consequence of sudden onset of paralysis, epileptic seizure, excess alcohol intake or overwhelming physical force

Question 2

How does the incidence of fall vary with age?

Answer 2

Incidence increases

• 30% of >65s in the community
• 40% of >80s in the community

Question 3

How serious are fall?

Answer 3

They can be very serious

• There is 1 fall related death every 5 hours in the UK
• 1% of falls result in hip fracture
• Mortality in the elderly who fall is 10x that of the under 65s

Question 4

What are the possible outcomes after a fall?

Answer 4

• Injury (50%): soft tissue, fracture, subdural etc.
• Rhabdomyolysis (Increased CK)
• Loss of confidence/ fear of falling
• Inability to cope
• Dependency/ decrease in QOL
• Carer stress
• Institutionalisation
• Terminal decline

Question 5

Give some examples of risk factors for falls.

Answer 5

• Muscle weakness
• History of falls
• Mobility issues
• > 80 years
• Cognitive impairment
• Visual deficits
• Depression

Question 6

Why do patients fall?

Answer 6

Dependent on 3 things:

• Extrinsic factors
• Intrinsic factors
• Situational factors

Question 7

What intrinsic factors can cause falls?

Answer 7

• Gait and balance problems
• Syncope
• Chronic disease
• Visual problems
• Acute illness
• Cognitive disorder
• Vitamin D deficiency

Question 8

What extrinsic factors can cause falls?

Answer 8

• Inappropriate footwear
• Environmental hazards
• Poor lighting

Question 9

What environmental hazards can cause falls?

Answer 9

• Uneven paving
• Carpets
• Walking aids
• Stairs

Question 10

What situational factors can cause falls?

Answer 10

• Medications
• Alcohol
• Urgency of micturition

Question 11

What types of medications can cause falls?

Answer 11

• Antidepressants
• Antipsychotics
• Anticholinergics/ antimuscarinics
• Benzodiazapines
• Anti-hypertensives
• Diuretics

Question 12

What is postural stability dependent on?

Answer 12

Cerebral perfusion

• Cardiac output
• Vasomotor tone

Posture and balance

• Static
• Dynamic

Question 13

How is balance controlled?

Answer 13

• Sensory input: visual, vestibular and proprioceptive
• Central processing via cerebrum, cerebellum, basal ganglia and brain stem
• Muscular activity

Question 14

What is involved in a gait and balance assessment?

Answer 14

• Sitting to standing ability
• Static standing balance
• Romberg test
• Dynamic standing balance ( functional reach, tandem walking, timed walk)
• Gait
• Tinetti gait and balance scale
• Berg balance scale
• Get and go test

Question 15

How can dizziness be subdivided?

Answer 15

• Vertigo

- Unsteadiness

Question 16

What pathologies can cause vertigo?

Answer 16

• Labrynthitis
• Acute ear infection
• Benign paroxysmal positional vertigo
• Meniere’s disease
• Cerebellar/brainstem pathology

Question 17

What can cause syncope?

Answer 17

• Neurally mediated (reflex)
• Orthostatic hypotension
• Cardiac arrhythmias
• Structured cardiac or cardiopulmonary disease
• Cerebrovascular

Question 18

What reflexes can cause syncope?

Answer 18

• Vasovagal syncope (common faint)
• Carotid sinus hypersensitivity
• Situational syncope

Question 19

When can situational syncope occur?

Answer 19

• Acute haemorrhage
• Cough, sneeze
• Gastrointestinal stimulation (swallow, defaecation, visceral pain)
• Micturition (post-micturition)
• Post-exercise
• Others (e.g. brass instrument playing, weightlifting)

Question 20

When may orthostatic hypotension occur?

Answer 20

Autonomic failure

• Primary autonomic failure syndromes (e.g. pure autonomic failure, multiple system atrophy, Parkinson’s disease with autonomic failure)
• Secondary autonomic failure syndromes (e.g. diabetic neuropathy, amyloid neuropathy)

Volume depletion
-Haemorrhage, diarrhoea, Addison’s disease (relative)

Question 21

What types of cardiac arrhythmias can result in syncope?

Answer 21

• Sinus node dysfunction (including bradycardia/tachycardia syndrome)
• Atrioventricular conduction system disease
• Paroxysmal supraventricular and ventricular tachycardias
• Inherited syndromes (e.g. long QT syndrome, Brugada syndrome)
• Implanted device (pacemaker, ICD) malfunction
• Drug-induced proarrhythmias

Question 22

Give examples of structured cardiac or cardiopulmonary disease which can cause syncope.

Answer 22

• Cardiac valvular disease i.e. aortic stenosis
• Acute myocardial infarction/ischaemia
• Obstructive cardiomyopathy
• Atrial myoxoma
• Acute aortic dissection
• Pericardial disease/tamponade
• Pulmonary embolus/pulmonary hypertension

Question 23

How is syncope assessed?

Answer 23

• History from patient
• Collateral history
• Examination
• 12 lead ECG
• Assess for red flags
• Consider further tests

Question 24

What history do you wish to gather from the patient following syncope?

Answer 24

• Prodromal symptoms
• Loss of consciousness
• What are the last and first things they recall
• Previous episodes
• Injuries
• PMH
• Family history: including sudden death
• Medications

Question 25

What collateral history do you wish to gather following syncope?

Answer 25

- Circumstances of the event - Posture immediately before loss of consciousness - Appearance - Presence or absence of movement during the event (? Limb jerking) - Tongue-biting - Duration of the event (onset to regaining consciousness) - Presence or absence of confusion during the recovery period - Weakness down 1 side during the recovery period

Question 26

What examination do you wish to carry out following a syncope episode?

Answer 26

- Vital signs including lying and standing blood pressure - Focussed neurological and cardiovascular examination - Look for any injuries

Question 27

Give 3 examples of rhythms which you may see on ECG following an episode of syncope.

Answer 27

- Inappropriate, persistent bradycardia - Long QT syndrome (corrected QT >450ms) and short QT (corrected QT <350ms) intervals - Abnormal T wave insertion

Question 28

What red flags are there for syncope?

Answer 28

- An ECG abnormality - Heart failure - Onset with exertion - Family history of sudden cardiac death (<40 years) and/or inherited cardiac condition - New or unexplained breathlessness - A heart murmur

Question 29

What further test may you carry out for a patient >60 years with unexplained syncope?

Answer 29

Carotid sinus massage

Question 30

What further test may you carry out for a patient <60 years with unexplained syncope?

Answer 30

Holter

Question 31

When may you think syncope is a seizure?

Answer 31

If there is 1 or more of the following features: - A bitten tongue - Head turning to 1 side during episode - No memory of abnormal behaviour that was witnessed before or during the episode by someone else - Unusual posturing - Prolonged simultaneous limb-jerking - Confusion after the event - Prodromal deja vu or jamais vus

Question 32

What features make seizure and unlikely cause of syncope?

Answer 32

- Prodromal symptoms that on other occasions have been abolished by sitting or lying down - Sweating before the episode - Precipitated by prolonged standing - Pallor during the episode