Falls Flashcards
What are the 3 components of normal gait?
Normal gait involves:
- The neurological system
- Basal ganglia and cortical basal ganglia loop
- The musculoskeletal system
- Which must have appropriate tone and strength
- Effective processing of the senses such as sight, sound, and sensation
- Fine touch and proprioception
Give examples of neuropsychiatric risk factors for falling
- Visual impairment e.g. diplopia, loss of peripheral vision or blurred vision
- Peripheral neuropathy
- Vestibular dysfunction e.g. BPPV
- Gait and balance disturbance
- Fear of falling itself can increase the risk of falls
- Cognitive or mood impairment e.g. dementia, depression, or delirium
- Seizure disorder
- Subdural haematoma
- Stroke or transient ischaemic attack
What can cause a possible gait or underlying balance disturbance?
Possible history of lumbar disc disease, peripheral neuropathy, arthritis or prior injury/fracture; specific abnormalities in gait or movement (shuffling gait, tremors, bradykinesia) may suggest underlying disorder such as Parkinson’s disease.
Give examples of cardiovascular risk factors for falling
- Syncope
- Orthostatic hypotension
- Carotid sinus syndrome
- Post-prandial hypotension
Give examples of musculoskeletal risk factors for falling
- Joint buckling, instability or poor mechanical mobility
- Deconditioning
Give examples of environmental risk factors for falling
- Medications
- Polypharmacy
- Substance abuse
- Environmental hazards
What medications may increase the risk of falling?
Benzodiazepines, antidepressants, and anxiolytics; others associated with an increased risk of orthostatic hypotension include alpha-blockers, antihypertensives, diuretics, beta-blockers, bromocriptine, levodopa, non-steroidal anti-inflammatory drugs, marijuana, opioids and sedatives, hypnotics, sildenafil, tricyclic antidepressants, highly anticholinergic medications such as diphenhydramine and vasodilators.
What is the risk of polypharmacy in contributing to falls?
Use of 5 or more medications increases the risk of falls by 30% in community-dwelling people, and by at least a factor of 4 in nursing-home patients
Give examples of environmental hazards that may contribute to falling
Loose rugs or tiles, poor lighting, uneven floors, presence of clutter; recent use of a walking stick or frame, or living alone: these factors are of increased importance with age.
What are the red flag for falling?
- Any history of sudden change in alertness or level of consciousness
- Possible causes include cerebrovascular (transient ischaemic attack, stroke, seizure), cardiovascular (hypotension, bradycardia or tachycardia), medication adverse effects (especially newly prescribed) or infection
- New head trauma
- Concurrent use of anticoagulation or antiplatelet therapy raises concern for a subdural haematoma
- Pain suggesting a potential fracture
- Persistent pain, inability to bear weight, or any obvious anatomical abnormality should prompt a quick evaluation for fracture, along with appropriate orthopaedic consultation
Briefly describe the history taking for a patient presenting with a fall
- Circumstances surrounding a fall should be elicited:
- Location
- Activity at the time of the fall (e.g. fall while standing, while walking down steps, while walking on uneven surfaces)
- Injury related to the fall (e.g. head trauma, bruise, fracture)
- Associated symptoms concurrent with a fall should be assessed, including:
- Any change in level, or loss, of consciousness
- Cardiovascular symptoms such as chest pain, palpitations, dizziness, vertigo or lightheadedness
- Symptoms related to a change in position (e.g. supine to sitting or sitting to standing)
- Pain or neurological symptoms (e.g. headache, weakness/tingling/numbness or acute change in mental status)
Medicines should be reviewed (with particular reference to psychotropic medications and opioids.
A history of comorbidities such as diabetes, Parkinson’s disease or osteoporosis should be elicited.
Briefly describe the examination of a patient presenting with a fall
The focus is on:
- Factors contributing to a fall
- Identification of any fall-related injury (e.g. a fracture or subdural haematoma from head trauma)
- Fall risk factors that can be reduced/modified/corrected to prevent future falls
Evaluation and examination may include:
- Cardiovascular examination
- Musculoskeletal examination
- Neurological examination
- Visual examination
- Gait examination
What testing and imaging may be performed to investigation falls?
- Blood tests
- X-rays
- CT or MRI of the brain
- ECG
- Echocardiogram
- An electroencephalogram
- Testing of vision, hearing or vestibular function
- Orthostatic challenge
What blood tests are used to investigate a fall?
Blood tests such as full blood count, serum B12, blood glucose (including glycated haemoglobin [HbA1c] to assess level of control in diabetic patients), electrolytes and thyroid-stimulating hormone are useful in evaluation of peripheral neuropathy or a change in mental status.
Give examples of medications that cause postural hypotension
- Nitrates
- Diuretics
- Anticholinergic medications
- Antidepressants
- Beta-blockers
- L-Dopa
- ACE inhibitors
