Falls Flashcards
Key facts to ascertain in a falls history?
Circumstances of event, mechanism and contract
What was the patient doing when they fell
How did the fall happen
How did they feel before they fell
Was there any dizziness or light-headed feeling?
Was there a loss of conciousness (good question - remember hitting the ground?)
Any cardiac symptoms? (pallor, palpitations)
Are they weak anywhere
Has this happened before
Any near misses before?
What medication do they take (sedatives, cardiac medications, anticholinergics, hypoglycemics, opioids)
How do they normally mobilise?
What should examination of a patient who has had a fall focus on?
Functional assessment of mobility: how do they mobilize, with what and how is their gait
CVS examination (include ECG and lying standing BP (immediate, 3 and 5 mins))
Neurological examination
MSK examination - assess joints
What falls risk assesmement tools may be used?
Falls Risk Assessment Tool (FRAT) - Part 1 - falls risk status, Part 2 – risk factor checklist, Part 3 – action plan
The Berg Balance scale
Mobility Interaction Fall chart
Osteoporosis risk factors?
Older age - over 65 (female) over 75 (male)
Female (particularly post menopausal, as oestrogen is protective)
Reduced mobility and activity
BMI <18.5 kg/m2
Rheumatoid arthritis
Alcohol
Smoking
Long term corticosteroids (equivalent of more than 7.5mg of prednisolone per day for more than 3 months)
Other medications such as:
SSRIs
PPIs
Anti-epileptics
Anti-oestrogens
When might a patient over 75 be automatically commenced on osteoporosis treatment?
When they have fractured a large bone with minimal trauma
What condition should all falls patients be assessed for risk of?
Osteoperosis
What are osteoporosis and osteopenia?
Osteoporosis is a condition where there is a reduction in the density of the bones.
Osteopenia refers to a less severe reduction in bone density than osteoporosis.
Reduced bone density makes bone less strong and more prone to fractures.
Why are post-menopausal women at higher risk of osteoporosis?
Oestrogen is protective against osteoporosis. Unless they are on HRT postmenopausal women have less oestrogen. They also tend to be are older and often have other risk factors for osteoporosis.
Which cells increase bone synthesis?
osteoBLASTS
Which cells increase bone resorption?
osteoCLASTS
What is the FRAX score?
The FRAX tool gives a prediction of the risk of a fragility fracture over the next 10 years. This is usually the first step in assessing someone’s risk of osteoporosis.
It involves inputting information such as their age, BMI, co-morbidities, smoking, alcohol and family history. You can enter a result for bone mineral density (from a DEXA scan) for a more accurate result but it can also be performed without the bone mineral density.
It gives results as a percentage 10-year probability of a:
Major osteoporotic fracture
Hip fracture
How is bone mineral density measured and where is the reading key for classification and management of osteoporosis?
Bone mineral density (BMD) is measured using a DEXA scan, which stands for dual-energy xray absorptiometry.
DEXA scans are brief xray scans that measure how much radiation is absorbed by the bones, indicating how dense the bone is.
The bone mineral density (BMD) can be measured at any location on the skeleton, but the reading at the hip is key for the classification and management of osteoporosis.
How can BMD be represented, what do the scores mean and which is most clinically important?
T score - most clincally important.
Number of standard deviations below mean BMD for a healthy young adult.
Z score
Number of standard deviations below mean BMD for the patient’s age.
What T score (at the hip) indicates normal BMD?
More than -1
What T score (at the hip) indicates osteopenia (less severe reduction in bone density than osteoporosis)?
-1 to -2.5
What T score (at the hip) indicates osteoperosis?
Less than -2.5
What indicates severe osteoporosis in terms of T score and clinical picture?
Less than -2.5 AND a fracture
Which patients should have a FRAX score calculated?
Women aged > 65
Men > 75
Younger patients with risk factors such as a previous fragility fracture, history of falls, low BMI, long term steroids, endocrine disorders and rheumatoid arthritis.
What are the possible outcomes of a FRAX score without BMD measurement?
Low risk – reassure
Intermediate risk – offer DEXA scan and recalculate the risk with the results
High risk – offer treatment
What are the possible outcomes of a FRAX score with BMD measurement?
Treat
Lifestyle advice and reassure
Management of osteopetrosis?
Lifestyle changes
Optimize falls risk factors
Pharmacology: bisphosphonates + vitamin D and calcium
If bisphosphonates are contraindicated, not tolerated or ineffective: Denosumab, strontium ranelate, raloxifene or HRT may be considered
What lifestyle changes are advised in patients with osteoperosis?
Activity and exercise
Maintain a healthy weight
Adequate calcium intake
Adequate vitamin D
Avoiding falls
Stop smoking
Reduce alcohol consumption
Vitamin D and Calcium role in treatment of osteoporosis?
NICE recommend calcium supplementation with vitamin D in patients at risk of fragility fractures with an inadequate intake of calcium.
An example of this would be Calcichew-D3, which contains 1000mg of calcium and 800 units of vitamin D (colecalciferol).
Patients with an adequate calcium intake but lacking sun exposure should have vitamin D supplementation.
What are bisphosphonates, with examples?
Firstline treatment of osteoperosis
They work by interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone.
Alendronate 70mg once weekly (oral)
Risedronate 35 mg once weekly (oral)
Zoledronic acid 5 mg once yearly (intravenous)
What are the important side effects of bisphosphonates?
Reflux and oesophageal erosions. Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this.
Atypical fractures (e.g. atypical femoral fractures)
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating - why?
Prevent reflux and oesophageal erosions
Other options if bisphosphonates are contraindicated, not tolerated or not effective in the management of osteoporosis?
Denosumab is a monoclonal antibody that works by blocking the activity of osteoclasts.
Strontium ranelate is a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction.
Raloxifene is used as secondary prevention only. It is a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus.
Hormone replacement therapy should be considered in women that go through menopause early.
Management of low risk osteoporosis patients?
Low-risk patients not being put on treatment should be given lifestyle advice and followed up within 5 years for a repeat assessment.
How should patients taking bisphosphonates to manage osteoporosis be followed up?
Patients on bisphosphonates should have a repeat FRAX and DEXA scan after 3-5 years
A ‘treatment holiday’ should be considered if their BMD has improved and they have not suffered any fragility fractures. (This involves a break from treatment of 18 months to 3 years before repeating the assessment.)
What might put someone at risks of falls?
Frailty
Polypharmacy
Gait and balance
Co-morbid conditions
Previous falls
Pain – e.g. lower limb or foot
Cognitive impairment – reduction in verbal ability, processing speed and immediate memory
Urinary incontinence – rushing to the toilet at night
What should a falls risk assessment be based around?
1) History and examination
2) Drug review – involve the patient’s GP and/or pharmacist here
3) Specific review of medical risk factors:
Vision Syncope Cardiovascular Cerebrovascular Diabetes
4) Functional and mobility assessment
5) Psychological effects of the fall
May reduce mobility to decrease risk of fall but this may cause muscle weakness and joint stiffness
It is therefore important to encourage or develop techniques to assist with coping with anxiety.
Tests to assess a patient’s balance?
Timed Up and Go (TUG) test
180-degree turn
A systems enquiry may identify other relevant information that may relate to falls, what might this include?
General - weight loss, fatigue (constitutional symptoms)
CVS - chest pain, palpitations
Respiratory - SOB, cough
Neuro - LOC, seizures, sensory or motor disturbance
Genitourinary - dysuria, urgency, incontinence
MSK - joint pain, muscle weakness
Particularly relevant PMH in a falls history?
General - Diabetes, visual/hearing impairment, anaemia
CVS - Cardiovascular disease, arrythmias
Respiratory - COPD
Neuro - Parkinsons, epilepsy, stroke, dementia, peripheral neuropathy
Genitourinary - incontinence, recurrent UTI
GI - diverticulitis, chronic diahrea, alcoholic liver disease
MSK - arthritis, chronic pain, fractures
Important social history in a patient presenting after a fall?
Alcohol intake
Support at home – friends/family and carers
Mobility – use of mobility aids and when (e.g. zimmer frame downstairs only)
Common medications that increase falls risk?
Beta-blockers (bradycardia)
Diabetic medications (hypoglycaemia)
Antihypertensives (hypotension)
Benzodiazepines (sedation)
Antibiotics (intercurrent infection)
Clinical examination of a patient presenting after a fall?
General: Alert and orientated, able to perform timed up and go test
- CVS
Pulse: may have irregularities such as AF or bradycardia
Blood pressure – hypotension
Bruits over carotid arteries (e.g. aortic stenosis, carotid stenosis)
Murmurs: aortic stenosis/regurgitation, mitral stenosis - Resp
Inspection: increased work of breathing
Auscultation: coarse crackles (e.g. pneumonia)
Percussion: dullness (e.g. pleural effusion) - Neuro
Cranial nerve examination: stroke or visual impairment
Power: weakness (e.g. stroke, disuse atrophy)
Tone: increased in stroke
Reflexes: absent (e.g. diabetic neuropathy), hyperreflexia (e.g. upper motor neuron pathology)
Sensation: may be reduced secondary to upper or lower motor neuron pathology
Co-ordination: may be impaired (e.g. chronic alcohol misuse leading to cerebellar degeneration) - GI
Abdominal tenderness
Organomegaly - MSK
Check for injuries associated with falls and examine carefully the point of contact with the floor - ENT
Is there any evidence of ear wax?
Are the tympanic membranes intact?
What bedside investigations might you perform on a patient presenting after a fall and why?
Vital signs (may suggest sepsis or reveal a bradycardia)
Lying standing blood pressure (orthostatic hypotension)
Urine dipstick (infection, Rhabdomyolysis)
ECG (bradycardia, arrythmias, prolonged QT)
Cognitive screening such as AMT (cognitivie impairment)
Blood glucose (hypoglycemia)
What blood test investigations might you perform on a patient presenting after a fall and why?
FBC (anemia, infection)
U&Es (rhabdomyolysis, electrolyte imbalances, dehydration)
Liver function (chronic alcohol use)
Bone profile (calcium over supplementation, calcium abnormalities in malignancy)
What imaging might you perform on a patient presenting after a fall and why?
CXR (pneumonia)
CT head (acute or chronic subdural bleed, stroke)
ECHO (valvular heart disease such as aortic stenosis)
X rays of injured limbs
What specialist investigations might you perform on a patient presenting after a fall and why?
Tilt table test (orthostatic hypotension)
Dix-Hallpike test (BPPV)
Cardiac monitoring e.g. 48 hr tape (If no symptoms during monitoring episode in hospital)
Potential causes of a fall: general
Mechanical: bad footwear, poor flooring, visual impairment
Polypharmacy
Syncopal vs non-syncopal transient LOC
How is SDH diagnosed and what is seen?
In most cases CT scan is sufficient to make the diagnosis and decide on patient management.
CT scan appearance:
The CT scan appearance varies depending on the clot age.
In the hyperacute phase (<1 hour) the clot may appear as a relatively isodense lesion, with underlying cerebral oedema. Note that patients with a SDH rarely present in the hyper-acute phase.
In the acute phase (<3 days) the classic appearance is of a crescent-shaped homogeneously hyperdense extra-axial collection over the affected hemisphere.
In the sub-acute phase (3 days to 3 weeks) there is organisation of the clot, and the density of the clot falls. The haematoma will therefore appear more isodense compared to the adjacent cortex, making identification more difficult. Contrast-enhanced CT or MRI can aid identification. There may be associated mass effect causing midline shift and sulcal effacement.
In the chronic phase (>3 weeks) the haematoma becomes hypodense relative to the adjacent cortex.
Note that 15% of SDH are bilateral in adults, and 80% are bilateral in infants - remember to check both sides of the scan!
Falls evaluation algorithm
