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Integrated Care [9] > [8] Falls > Flashcards

[8] Falls Flashcards

1
Q

What is syncope?

A

The medical term for fainting or passing out

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2
Q

What causes syncope?

A

A temporary drop in the amount of blood that flows to the brain

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3
Q

What is syncope characterised by?

A
  • Fast onset
  • Short duration
  • Spontaneous recovery
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4
Q

What symptoms might be present before the loss of consciousness with syncope?

A
  • Light-headedness
  • Sweating
  • Pale skin
  • Blurred vision
  • Nausea or vomiting
  • Feeling warm
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5
Q

What are the important systems involved in balance?

A
  • Vision
  • Proprioception, or joint position sense
  • Vestibular system
  • Brain
  • Effector mechanisms
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6
Q

How is vision involved in balance?

A

Required for spatial orientation

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7
Q

Give 4 things that affect vision?

A
  • Cataracts
  • Age-related macular degeneration
  • Diabetic retinopathy
  • Bifocal lenses
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8
Q

How is proprioception involved in balance?

A

Helps with orientation when eyes are shut or vision is impaired

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9
Q

Give 3 things that affect proprioception

A
  • Sensory neuropathy
  • Joint replacements
  • Ageing
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10
Q

How is vestibular system involved in balance?

A

Helps with orientation in 3D

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11
Q

How does the vestibular system help with orientation in 3D?

A

By use of 3 semi-circular canals at 90 degrees to each other

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12
Q

What does the vestibular system respond to?

A

Responds rapidly to head movements

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13
Q

Give 3 things that affect the vestibular system

A
  • Previous middle ear infections
  • Meniere’s disease
  • Ototoxic drugs
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14
Q

How does the brain help with balance?

A

Helps to integrated and co-ordinate the sensory input, and tells the body what to do in order to counteract any challenge to upright posture

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15
Q

Give 3 things that affect the brain

A
  • Cerebrovascular disease
  • Dementia
  • Low blood pressure
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16
Q

What effector mechanism in particular affects balance?

A

Quadriceps muscle

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17
Q

How are effector mechanisms involved in balance?

A

They are the main mechanism the body uses to re-balance

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18
Q

Give 3 things that affect effector mechanisms

A
  • Proximal myopathy
  • Any neurological disease
  • Disuse atrophy
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19
Q

Give 2 causes of proximal myopathy

A
  • Steroid exposure

- Vitamin D deficiency

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20
Q

What is it important to check in a person who has fallen?

A

Postural cardiovascular system reflexes

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21
Q

Why is it important to check the postural cardiovascular system reflexes in someone who has fallen?

A

Because in someone who is vulnerable, a reduction in brain perfusion on standing can give rise to disequilibrium and so a fall

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22
Q

What investigations to check postural cardiovascular reflexes should all patients have following a fall?

A
  • ECG

- Postural BP

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23
Q

What further investigation to check postural cardiovascular reflexes might some patients require?

A

Detailed assessment using tilt table

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24
Q

What is the baroreflex?

A

A homeostatic mechanism that helps to maintain BP at nearly constant levels

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25
Q

How does the baroreflex work?

A

It provides a rapid negative feedback loop, in which an elevated BP reflexively causes the HR to decrease and therefore the BP to decrease

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26
Q

What are baroreceptors found?

A

In the aortic arch and carotid sinus

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27
Q

What is the importance of baroreceptors being found in the carotid sinus?

A

Carotid sinus massage will cause a slowing of the pulse and a dramatic fall in BP

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28
Q

What is the main risk factor for falling?

A

History of falling, particularly in last 12 months

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29
Q

What are the other risk factors for falls?

A
  • Age <80
  • Female gender
  • Low weight
  • Dependancy in ADL
  • Medical problems
  • Medication and polypharmacy
  • Inappropriate footwear
  • Environmental factors
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30
Q

What medical problems increase the risk of falls?

A
  • Orthostatic hypotension
  • Diabetes mellitus
  • Confusion and cognitive impairment
  • Disturbance in vision
  • Gait disorders
  • Urinary incontinence
  • Depression
  • Muscle weakness
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31
Q

In addition to the risk factors for falls, what other risk factors should be looked at in falls?

A

Risk factors for fracture of proximal femur

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32
Q

What are the risk factors for fractures of proximal femur?

A
  • Weak bones

- Poor self protection

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33
Q

What can cause weak bones?

A
  • Osteoporosis
  • Osteomalacia
  • Paget’s disease of bone
  • Mets to bone
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34
Q

What can cause poor self-protection?

A
  • Lack of protective SC fat
  • Neurological problems preventing reflex breaking or cushioning of fall
  • Falls associated with LoC
  • Motor and sensory problems
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35
Q

What can the causes of falls be divided into?

A
  • Environmental factors
  • Poor power and balance
  • Neurological problems
  • Alcohol
  • Syncope
  • Seizures
  • Drop attacks
  • Visual disturbance
  • Medication
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36
Q

Give 3 environmental factors that can cause falls

A
  • Loose rugs/mats
  • Electricity leads
  • Poor lighting
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37
Q

Give 5 neurological problems that can cause falls

A
  • Strokes
  • Parkinson’s disease
  • Neuropathy, e.g. caused by diabetes
  • Proximal myopathy
  • Cognitive impairment
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38
Q

How can alcohol cause falls?

A
  • Acute intoxication

- Consequences of chronic alcoholism

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39
Q

What consequences of chronic alcoholism can cause falls?

A
  • Polyneuropathy
  • Wernicke’s encephalopathy
  • Korsakoff’s psychosis
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40
Q

What are drop attacks?

A

When the cause of fall is unknown, the event is unexpected, and there is no loss of consciousness

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41
Q

What are the categories of drugs that contribute to falls?

A
  • Drugs of sedation
  • Drugs causing hypotension
  • Drugs causing reduced visual acuity/blurred vision
  • Drugs causing muscle weakness
  • Drugs causing ataxia
42
Q

Why are drugs of sedation an important contributor to falls?

A

Because elderly patients are susceptible to CNS side effects of drugs, including excessive sedation, increased body sway, and slowing of reaction time

43
Q

Give 6 drugs of sedation

A
  • Benzodiazepines
  • TCAs
  • Anti-psychotics
  • Barbiturates
  • Sedating anti-histamines
  • Analgesic opiates
44
Q

Give 2 examples of benzodiazepines

A
  • Diazepam

- Lorazepam

45
Q

Give 2 examples of TCAs

A
  • Amitriptyline

- Trazodone

46
Q

Give 2 examples of anti-psychotics

A
  • Promazine

- Haloperidol

47
Q

Give an example of barbiturates

A
  • Barbiturates
48
Q

Give 2 examples of sedating anti-histamines

A
  • Chlorphenamine

- Hydroxyzine

49
Q

Give 2 examples of analgesic opiates

A
  • Codeine

- Morphine

50
Q

Why are drugs causing hypotension an important contributor to falls?

A

Orthostatic blood pressure control is already impaired in the elderly, and they are more likely to suffer drug-induced postural hypotension, which can lead to light-headedness and falls

51
Q

Give 11 drugs causing hypotension

A
  • Diuretics
  • Beta-blockers
  • ACE inhibitors
  • Alpha blockers
  • Calcium channel blockers
  • Vasodilators
  • Urinary anti-muscarinics
  • Phenothiazines
  • TCAs
  • Anti-Parkinsonian drugs
  • ACh inhibitors
52
Q

Give 2 examples of diuretics

A
  • Furosemide

- Bendoflumethiazide

53
Q

Give 2 examples of beta-blockers

A
  • Atenolol

- Propanolol

54
Q

Give an example of ACE inhibitors

A

Valsartan

55
Q

Give 2 examples of alpha blockers

A
  • Doxazoasin

- Prazosin

56
Q

Give 3 examples of alpha blockers

A
  • Nifedipine
  • Amlodipine
  • Verapamil
57
Q

Give 2 examples of vasodilators

A
  • Hydralazine

- Nitrates

58
Q

Give 2 examples of urinary anti-muscarinics

A
  • Oxybutunin

- Tolterodine

59
Q

Give 2 examples of phenothiazine

A
  • Promazine

- Chlorpromazine

60
Q

Give an example of an anti-Parkinsonian drug

A

LevoDOPA

61
Q

Give 2 examples of ACh inhibitors

A
  • Donepezil

- Rivastigmine

62
Q

Give 2 examples of drugs causing reduced visual acuity/blurred vision

A
  • Pilocarpine eyedrops

- Anti-cholinergics

63
Q

Give an example of an anti-cholinergic

A

Procyclidine

64
Q

Give 2 examples of drugs causing muscle weakness

A
  • Baclofen

- Dantrolene

65
Q

Give 2 examples of drugs causing ataxia

A
  • Carbamazepine

- Phenytoin

66
Q

What is the role of polypharmacy in falls?

A

A study has shown there is a 14% increase in falls with each additional medication beyond a 4-medication regime

67
Q

What should the examination include in falls?

A
  • Functional
  • Cardiovascular
  • Neurological and locomotor
  • Mental state
  • Eyes
68
Q

What should be included in a functional examination in falls?

A

Timed up and go test

69
Q

What happens in a timed up and go test?

A

You should ask the patient to stand from chair, walk, turn around, walk back, and sit back down

70
Q

What should be included in the cardiovascular examination in falls?

A
  • Pulse
  • Lying and standing BP
  • Auscultation of heart
71
Q

What postural drop is significant?

A

More than 20mmHg systolic

72
Q

What should you look for in the neurological examination in falls?

A

Signs of;

  • Stroke
  • Peripheral neuropathy
  • Parkinson’s disease
  • Vestibular disease
  • Myelopathy
  • Cerebellar degeneration
  • Cognitive impairment
73
Q

What might be helpful when assessing the mental state of a patient with falls?

A

MMSE

74
Q

What should the examination of the eyes include if there is suggestion of poor eyesight?

A

Should at least include reading of the Snellen chart

75
Q

What routine investigations should be done in a falls patient?

A
  • FBC
  • Vitamin D
  • B12 and folate
  • U&Es
  • ECG
  • Glucose
  • Calcium and phosphate
  • TFTs
76
Q

What will further investigations in falls patients be directed by?

A

Suspected cause

77
Q

What further investigations may be done in falls patients?

A
  • 24 hour ECG
  • Echocardiogram
  • Head-up tilt table testing
78
Q

What are the potential consequences of falls?

A
  • Trauma
  • Long lie
  • Psychological
  • Social
79
Q

What trauma might result from falls?

A
  • Soft tissue injury
  • Fragility fractures
  • Joint dislocation
  • Subdural haemorrhage
80
Q

What might result from long lie after falls?

A
  • Hypothermia
  • Pressure related injury
  • Dehydration and AKI
81
Q

What are the potential psychological consequences of falls?

A

Ongoing concern about falling and limitation of performance of daily activities

82
Q

What problems are the psychological consequences of falls associated with?

A
  • Activity limitation
  • Participation restriction
  • Low quality of life
  • Anxiety and depression
83
Q

What are the social consequences of falls?

A
  • Social isolation
  • Carer strain
  • Institutionalism
84
Q

Why might falls lead to social isolation?

A

Due to avoidance of activities, often associated with fear of falling

85
Q

What is the link between falls and institutionalism?

A

The likelihood of older people requiring admission to care home increase with number and severity of falls recorded

86
Q

What is essential in the assessment and management of falls?

A

An integrated approach

87
Q

Who should be offered a multi-factorial falls risk assessment?

A

Older people who;

  • Present for medical attention because of a fall
  • Report recurrent falls in the past year
  • Demonstrate abnormalities in gait/balance
88
Q

Who should perform the multi-factorial falls risk assessment?

A

A HCP with appropriate skills and experience, normally in the setting of a specialist falls service

89
Q

What might a multi-factorial falls risk assessment involve?

A

Assessment of;

  • Falls history
  • Gait, balance, and mobility, and muscle weakness
  • Older persons perceived functional ability and fear relating to falling
  • Visual impairment
  • Cognitive impairment and neurological examination
  • Urinary incontinence
  • Home hazards
  • Cardiovascular examination and medications review
90
Q

What is included in the general approach to minimising falls?

A
  • Strength and balance training
  • Environmental assessment
  • Medical review
91
Q

What does strength and balance training following a fall involve?

A

A physiotherapist making an assessment of an individual and then prescribing a tailored course of therapy aimed at improving strength and balance

92
Q

What might therapy to improve strength and balance after a fall involve?

A

Variety of activities, including CVS training, strength training, and balance training

93
Q

How long does therapy to improve strength and balance after a fall take?

A

Usually lasts many weeks, with at least 50 hours required

94
Q

Who leads the environmental assessment after a fall?

A

Occupational therapist

95
Q

What is involved in the environmental assessment after a fall?

A

Assessment of individual and their environment to identify ay potential hazards, by visiting the individual in their home

96
Q

What might the outcome of the environmental assessment after a fall be?

A
  • Suggests improvements to environment

- Provide assistive equipment

97
Q

What assistive equipment might be provided after a fall?

A
  • Bath aids, e.g. bath boards and seats, electrical bath lifts
  • Toilet lifts or commodes
  • Aids to help with dressing
  • Grab rails
98
Q

What is the medical review aimed at assessing?

A
  • Diagnose medical reason for falls
  • Optimise management of conditions contributing to falls
  • Bone health assessment
  • Medication review
99
Q

What interventions into falls have NICE recommended as being effective?

A
  • Strength and balance training
  • Home hazard intervention and follow up
  • Medication review
  • Cardiac pacing where indicated
100
Q

What is primary prevention for falls aimed at?

A

Preventing falls in people who have not fallen

101
Q

What might primary prevention for falls include

A
  • Increasing exercise and physical activity
  • Reviewing medication
  • Changing adverse environmental factors
  • Improving management of medical conditions

Integrated Care [9] (14 decks)

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