Falls

Question 1

What causes a fall?

Answer 1

Intrinsic = vision, cognition, CVS, infection, neuropathy, myopathy, surgery, arthritis, seizures, dementia

Extrinsic = medications, incorrect/no walking aids, environment (accommodation, floor covering, lighting, furniture, pets, weather), glasses, footwear, hearing aids, other people, activity at the time, medication

Question 2

What medications put a pt at increased risk of falls?

Answer 2

Diuretics = BP drop, electrolyte imbalance

Abx = diarrhoea, rush to toilet

Parkinson’ s

Anaesthetics = confusions, regional block

Anti-HTN

Anti-histamine

Laxative = diarrhoea

Insulin overdose = low glucose

Gliclazide

Rate limiters = beta blockers

SSRI = postural hypotension

Stain = myopathy, myalgia

Alpha blockers = tamsulosin, vasodilation

Side effect of confusion

Pain relief

Anti-anxiety - diazepam

Question 3

What questions should be asking when Hx a falls pt?

Answer 3

When, where, witness?

Injury?

Other symptoms - postural dizziness (BP prob), positional dizziness (turned, vestibular problem), palpitations

Previous falls?

Ask about stairs - rails, floor covering

Footwear - examine feet as well

Glasses - near/distance vision, distort visual fields (recommend single vision lenses)

What their normal situation is (holistic view)

Explore any fear

Why presenting to A+E?

Question 4

How should a fall be investigated?

Answer 4

Examination = CVS, resp, CN, upper/lower limbs, vestibular, abdo, AMTS/CAM, vision, knee exam, feet/footwear, get-up-and-go, home hazards

Bloods = FBC, glucose, U+Es, LFTs, bone profile, TFT, b12/folate, HbA1C, vit D (myopathy)

ECG = arrhythmia, MI

Urine dip = (don’t dip if >65 due to asymptomatic bacteriuria) - MSU

Postural BP (manual sphig) = lay down for 5, stand BP, then stand for 1 and 3 min BP

24hr ECG

ECHO = murmur

CT head = looking for bleed (particularly if on anti-coag)

Bone health + fracture risk assessment = FRAX tool

Question 5

How should a fall be managed?

Answer 5

Medication review = do they need all meds, are they taking them correctly

Treat a reversible cause

Bone health and fracture risk management

MDT review

Refer to falls clinic if >2/year

Physiotherapy = walking aids, strength and balance training, fall prevention programme

Occupational therapy = environmental adaptations, functional assessments

Postural hypo = fludocortisone

Question 6

How is orthostatic hypotension treated?

Answer 6

Med reduction/withdrawal = antihypertensive, alpha blockers, antidepressants

Adequate salt/water intake

Fludrocortisone (salt and water retention)

Question 7

What are the risk factors for osteoporosis?

Answer 7

• Women
• Age
• FH
• Early menopause
• Vit D, calcium def
• Malnutrition
• Smoking
• Low body weight
• Caucasian

Question 8

What medications are used to treat osteoporosis?

Answer 8

Colecalciferol with calcium

Bisphosphonates (alendronate, risedronate, zoledeonate)

Parathyroid hormones

Calcitonin
HRT

Question 9

Define orthostatic hypertension, the Sx seen and how is it recorded

Answer 9

drop by more than 20mm/Hg in systolic, or 10mm/Hg in diastolic BP

Sx = dizziness, syncope, palpitations

Ix = BP lying down after 1 min, stand up and check BP straight away and again at 3 min, if drop at 3 min then repeat at 4 + 5 min

Mx = fludrocortisone (SE: fluid retention, hypoK)

*** comonly seen in PD

Question 10

What key are should be assessed in a falls assessment?

Answer 10

Good Hx + exam

Look for injuries

ECG

Lyign and standing BP

Med review

Gait/functional assessment (timed up and go, turn 180 degree test)

Bone health review = FRAX score (if high do DEXA)
- RF = long term steroids, previous fragility fractures, PPIs, low BMI, smoking, RA, tamoxifen, phenotoin, valproate, T1DM

Fear of falling/loss of confidence

Exercise programme