Elderly - falls and immobility

Question 1

What are the main causes of falls?

Answer 1

MSK causes
Drugs
Neurological
Sensory
CVS
Generally unwell
Incontinence

Question 2

What MSK causes lead to falls?

Answer 2

Arthritis of weight bearing joints
Sarocopenia
Deformities of feet

Question 3

What are neurological causes of falls?

Answer 3

Stroke - old or new
Parkinsonism
Dementia
Delirium
Ataxia

Question 4

What are sensory causes of falls?

Answer 4

Visual impairment

Inattention

Question 5

What are CVS causes of falls?

Answer 5

Postural hypotension
Arrythmia
Heart failure
Aortic stenosis

Question 6

Why does incontinence lead to falls?

Answer 6

Rushing to the toilet

Question 7

What drugs cause falls?

Answer 7

Anti-hypertensives
Sedatives
Alcohol
Beta blockers
Anticholinergics
Opioids

Question 8

Why do drugs cause falls?

Answer 8

Decrease blood pressure
Decrease heart rate
Decrease awareness
Increase urine output
Increase sedation
Increase hallucinations
Increase dizziness
Increase QTc interval

Question 9

How are patients likely to be after a fall in the falls clinic?

Answer 9

Likely to be well with a difficult and multifactorial fall

Question 10

How are patients likely to be in A&E after a fall?

Answer 10

More likely to be acutely unwell

Question 11

How are inpatients who have fallen in hospital likely to be?

Answer 11

Very likely to be acutely unwell, significant injury possible

Question 12

What roles does the nurse have in the falls clinic?

Answer 12

Eye test
ECG
Lying and standing BP
Incontinence questionaire

Question 13

What is the role of the physiotherapist in the fall clinic?

Answer 13

Full assessment of gait and balance

Question 14

What is the role of the doctor in the falls clinic?

Answer 14

Thorough history and examination

Consider bone health and osteoporosis screening

Question 15

What details should be found in the history of a fall?

Answer 15

If they remember the fall - syncope or cognition
Clear history of the trip
Palpitations preceding fall?
On turning? - postural instability
Any ‘near misses?’ - unsteady on standing
Syncope on exertion?

Question 16

What should be asked about in systematic enquiry?

Answer 16

Memory
Urinary symptoms - might not tell you if you dont ask
Has walking changed recently?

Question 17

What should be found in drug history other than the common causes?

Answer 17

Antihistamines

Question 18

What neurological signs should be examined?

Answer 18

Cranial nerves except olfactory
Check for neglect
Cerebellar signs
Bradykinesia, rigidity

Question 19

What non-neurological signs should be examined?

Answer 19

Pulse
BP
Heart sounds
Kyphosis
Abdominal examination

Question 20

What should be examined in the legs?

Answer 20

Feet - footwear and toenails
Sensation, vibration sense, proprioception
Co-ordination
Romberg's test
Gait

Question 21

What pathology would cause ataxic gait?

Answer 21

Cerebellar damage

Question 22

What pathology would cause arthralgic gait?

Answer 22

Arthritis

Question 23

What pathology would cause hemiplegic gait?

Answer 23

Stroke

Question 24

What pathology would cause gait with shuffling small steps?

Answer 24

Parkinsonism

Question 25

What pathology would cause high stepping gait?

Answer 25

Peripheral neuropathy

Question 26

What are typical features of falls patients in A&E?

Answer 26

``` Tired Injured In pain Unable to stand due to injury - gait is difficult to assess Systemically unwell Will need MDT assessment later ```

Question 27

What should be found in the history in A&E?

Answer 27

``` ABCDE assessment How did they fall - trip? Any other falls Assess cognition Incontinence? Syncope? Features of seizure? Drunk? Talk to relatives ```

Question 28

What should be done in examination in A&E?

Answer 28

Neuro exam Look at legs and try to assess gait Full set of obs

Question 29

What investigations should be done in A&E?

Answer 29

ECG Bloods - B12, Folate, CK, TFTs Check for delirium using 4AT Consider CT head

Question 30

What needs to be considered about a patient going home after a fall?

Answer 30

Can they go to the toilet on their own? Can they get themselves food and drink between carer visits Can they walk in A&E? Could they summon help if they fell?

Question 31

What immediate assessments are done for serious injuries?

Answer 31

``` Head injury and extradural haematoma Seizure C-spine injury Abdo injury Flail chest Pelvic injury Limb fracture ```

Question 32

What would indicate immediate CT head?

Answer 32

``` GCS<13 Still confused after 2 hours Focal neurology Signs of skull fracture Seizure Vomiting Anti-coagulation ```

Question 33

When should a joint be X-rayed?

Answer 33

If pain on moving joint | No deformity but pain on weight bearing

Question 34

What can cause falls in inpatients?

Answer 34

``` Postural hypotension New medication Low blood glucose Getting more ill Delirium De-conditioning ```

Question 35

What could lead to a patient lying for a long time after a fall?

Answer 35

Call bell out of reach

Question 36

What do the nurses do after an inpatient falls?

Answer 36

Repeat risk assessment Datix Call family Try and prevent further fall