2. Falls Flashcards
(41 cards)
Define ‘fall’.
An unexpected event in which the patients comes to rest on the ground, floor or lower level.
What are some consequences of falls?
- hip fracture
- head trauma
- death
- psychosocial impacts (fear of falling, resulting in restriction of functional capacity)
Note only half of older people who fall can get up unaided, leading to ‘long lies’ which can result in the development of pressure ulcers, rhabdomyolysis and renal failure.
Give some intrinsic risk factors for falls in older adults.
- female gender
- advancing age
- Co-morbid conditions (e.g. Parkinson’s disease, stroke, osteoarthritis)
- cognitive impairment
- visual impairment
- nutritional deficiencies
Give some extrinsic causes of falls in older adults.
- home trip hazards
- bifocal lenses
- medications
- alcohol
- inappropriate footwear
Key questions in a falls history.
Did you lose consciousness?
Have you fallen over more than once?
Did you lose consciousness throughout the fall?
Note a collateral history should be obtained if available.
https://geekymedics.com/fall-history-taking-osce-guide/
What is a FRAT score?
A questionnaire that determines the risk of a patient having recurrent falls.
What is the importance of conduction a medication review after a patient has had a fall?
A review of medication and their potential contribution to falls should be completed, as many older patients take many drugs that may directly cause falls, or interact to increase falls risk.
https://academic-oup-com.ezproxy4.lib.le.ac.uk/view-large/369101031
How should a patient be examined following a fall?
- neurological examination
- test visual acuity (e.g. Snellen chart)
- cardiovascular examination
- lying and standing blood pressure
- review of footwear and walking aids
- review of home environment
What is the protocol for the measurement of lying and standing blood pressure?
Patients rest in the supine position for at least five minutes. Blood pressure is checked while supine and the patient then stands. Blood pressures are repeated at 1 minute, 3 minutes, and 5 minute intervals while standing using a standard sphygmomanometer.
Orthostatic hypotension is defined as a symptomatic systolic BP drop of ≥20mmHg, or diastolic BP drop of ≥10mmHg, within three minutes of standing.
What investigations should be ordered as part of the work-up in a falls patient?
Routine blood investigations may identify contribution of intercurrent illness (e.g. infection) to the presentation.
Vitamin D levels should be measured.
ECG or echocardiography if cardiac arrhythmias / valvular lesions are suspected.
What is head-up tilt testing used to test for?
Syncope as a cause of falls.
Positive tilt test is a drop in systolic blood pressure >60%, associated with symptoms of imminent syncope.
What is a syncopal fall?
The sudden loss of consciousness, causing a person to fall down.
What are the causes of syncopal falls?
- orthostatic hypotension
- carotid sinus syndrome (CSS)
- vasovagal syncope
- cardiac syncope
- postural orthostatic tachycardia syndrome
What are the causes of orthostatic hypotension?
Drug induced (antihypertensives, diuretics etc).
Primary autonomic failure (e.g. Parkinson’s disease, Lewy Body Dementia)
Secondary autonomic failure (e.g. diabetes mellitus, spinal cord injury)
Volume depletion (ie. haemorrhage, dehydration).
How is orthostatic hypotension diagnosed and investigated?
Lying and standing BP with symptomatic drop sBP ≥20mmHg or dBP ≥10mmHg.
Head-up tilt testing
What is carotid sinus syndrome?
A reflex syncope from alterations in autonomic tone due to baroreceptor hypersensitivity.
How can carotid sinus syndrome be diagnosed?
Carotid sinus massage in the resting position, causing significant BP drop or sinus pause.
Give some contraindications to carotid sinus massage.
Stroke within three months.
Presence of unevaluated carotid bruit.
Note prevalence of TIA or stroke following carotid sinus massage is 1 in 1000. All patients should therefore have a valid consent process for the procedure.
Give some non-syncopal causes of falls.
- trips / slips
- poor visual acuity
- abnormal gait (ie. Parkinson’s, osteoarthritis)
- vertigo
How should a patient’s gait and balance be assessed to quantify their falls risk.
Timed Up and Go Test (TUG)
Turn 180° test
Outline how to perform and interpret the Timed Up and Go Test (TUG).
Score of ≥12 seconds = high risk of falls.
Outline how to perform the Turn 180° test.
Ask the patient to stand up and step around until they are facing the opposite direction.
If the patient takes >4 steps, further assessment should be considered.
When should a multifactoral falls risk assessment be used?
Assess patients who:
- have multiple falls
- present for medical attention following a fall
- perform poorly on TUG and Turn 180° test
What is a multifactoral falls risk assessment?
Specialist falls service assesses:
- history of falls
- gait, balance, mobility
- osteoporosis risk
- visual impairment
- cognitive, neurological and cardiovascular problems
- urinary incontinence
- home hazards
- polypharmacy
Aims to identify the CAUSE of falls, to allow appropriate intervention to reduce risk of future falls.
