Falls Flashcards
(42 cards)
1
Q
What questions would you ask regarding when did you fall ?
A
- What time of day ?
- What were they doing at the time ? (Looking upwards - vertebrobasilar insufficiency, getting up from the bed - postural hypotension)
2
Q
What questions would you ask regarding where did you fall ?
A
- In the house or outside?
3
Q
What questions would you ask regarding what happened before/ during/ after the fall ?
A
- Before: any warning, was there any dizziness/ chest pain/ palpitations
- During: was there any incontinence or tongue biting ? Was there any loss of consciousness? Was the patient pale/flushed? Did the patient injure themselves? What part of the body had the first contact with the floor?
- After: what happened after the fall ? Was the patient able to get themselves up off the floor? How long did it take them ? Was the patients able to resume normal activity afterwards? Was there any confusion after the event ? Was there any weakness or speech difficulty after the event ?
4
Q
What questions should be asked regarding why?
A
- Why did you think you may have fallen
5
Q
What questions should be asked regarding how?
A
- how many times have you fallen over the last 6 months
6
Q
What questions would you ask for a general systems review?
A
- Fatigue
- Weight loss
7
Q
What questions would you ask for a CVS systems review?
A
- Chest pain
- Palpitations
8
Q
What questions would you ask for a Respiratory systems review?
A
- SOB
- Cough
9
Q
What questions would you ask for a Neurological systems review?
A
- Loss of consciousness
- Seizures
- Motor/ sensory disturbances
10
Q
What question would you ask for a GI systems review?
A
- Abdominal pain
- Diarrhoea
- Constipation
11
Q
What questions would you ask for a Urology systems review?
A
- Incontinence
- Urgency
- Dysuria
12
Q
What questions would you ask for a MSK systems review?
A
- Joint pain
- Muscle weakness
13
Q
What is significant in the Past Medical History for Falls?
A
- Visual/ Hearing impairment
- Diabetes
- Anaemia
- CVS disease
- Arrhythmias
- COPD
- Parkinson’s disease
- Peripheral neuropathy
- Stroke
- Dementia
- Recurrent UTI
- Incontinence
- Diverticulitis
- Chronic diarrhoea
- Alcoholic liver disease
- Arthritis
- Chronic pain
- Fractures
14
Q
What is important to establish from the social history for falls?
A
- Alcohol intake
- support at home = friends/ family and carers
- mobility - use of mobility aids
15
Q
What should you assess during clinical examination of a falls patient?
A
- Is the Patient orientated/ alert? Can the patient perform the timed up and go test? (getting up walking 3 meters and returning?
- Pulse/ BP? Bruits- carotids? Murmurs?
- Increased work of breathing? Coarse crackles (pneumonia)? Dullness on percussion (pleural effusion)
- Cranial nerve examination
- Power weakness (stroke)? Tone changes (stroke)? Reflexes (reduced = diabetic neuropathy, increased = UMN lesions)? Sensation reduced (UMN/LMN lesions)? Co-ordination impaired (Chronic alcohol misuse or cerebellar degeneration)?
- Abdominal tenderness? Organomegaly?
- Injuries associated with falls?
- Ear wax? tympanic membranes intact?
16
Q
What Investigations would you do for Falls?
A
- Bedside: BP/HR/RR/Spo2/Temp
- Lying and Standing BP (orthostatic hypotension)
- Urine dipstick: infection, rhabdomyolysis
- ECG: Bradycardia, Arrhythmias
- Cognitive Screening: AMT - Cognitive Impairment
- Blood Glucose: Hypoglycaemia
- Bloods: FBC
- U+E: Dehydration, electrolyte abnormalities, rhabdomyolysis
- LFTs: Chronic Alcohol Use
- Bone Profile: Calcium abnormalities in malignancy, over-supplementation of Calcium
- Imaging: CXR, CT head (stroke, bleeds), ECHO (valvular heart disease - Aortic stenosis)
- Specialist - Tilt Table Test (Orthostatic hypotension), Dix-Hallpike test (BPPV), Cardiac Monitioring (48 hour tape)
16
Q
What Investigations would you do for Falls?
A
- Bedside: BP/HR/RR/Spo2/Temp
- Lying and Standing BP (orthostatic hypotension)
- Urine dipstick: infection, rhabdomyolysis
- ECG: Bradycardia, Arrhythmias
- Cognitive Screening: AMT - Cognitive Impairment
- Blood Glucose: Hypoglycaemia
- Bloods: FBC
- U+E: Dehydration, electrolyte abnormalities, rhabdomyolysis
- LFTs: Chronic Alcohol Use
- Bone Profile: Calcium abnormalities in malignancy, over-supplementation of Calcium
- Imaging: CXR, CT head (stroke, bleeds), ECHO (valvular heart disease - Aortic stenosis)
- Specialist - Tilt Table Test (Orthostatic hypotension), Dix-Hallpike test (BPPV), Cardiac Monitioring (48 hour tape)
17
Q
What are some of the Differential Diagnosis for falls?
A
- General: Mechanical (poor footwear/ visual impairments, Polypharmacy)
- CVS: Arrhythmias, orthostatic hypotension, bradycardia, valvular heart disease
- Neurological: Stroke, Peripheral Neuropathy
- Genitourinary: Incontinence, UTI
- Endocrine: Hypoglycaemia
- MSK: Arthritis, Disuse Atrophy
- ENT: BPPV, Ear wax
18
Q
What is the Management for Gait Issues with falls?
A
- Physiotherapy
19
Q
What is the managment for Visual Problems with Falls?
A
- Eye tests
- Ensures glasses are worn
20
Q
What is the managment for Hearing Difficulties with Falls?
A
- Remove Earwax
- Hearing Assessment
21
Q
What is the managment for Medication Reviews with Falls?
A
- Cut down any unnecessary medications
22
Q
What is the managment for Alcohol intake regarding Falls?
A
- Alcohol cessation advice
- Alcohol service referral
23
Q
What is the managment for Cognitive Impairment for Falls?
A
- Psychiatric team
24
What is the managment for Postural Hypotension for Falls?
- Review Medication
- Improve Hydration
25
What is the managment for Continence in Falls?
- Treat/ rule out infections
- Continence assessment
26
What is the managment for Footwear in Falls?
- Ensure good fitting footwear
27
What is the managment for Environmental Hazards in Falls?
- Turn on Lights
- Take up Rugs
28
What is the managment options for Falls?
1. Gait
2. Visual Problems
3. Hearing Difficulties
4. Medications Review
5. Alcohol Intake
6. Cognitive Impairment
7. Postural Hypotension
8. Continence
9. Footwear
10. Environmental Hazards
29
What are the three Fall Risk Assessment Tools?
- FRAT (falls risk assessment tool)
- Timed Up and Go test ( Time the person getting up from a chair without using their arms walking 3 metres, turning around, returning to their chair and sitting down)
- Time 180 test ( Ask the person to stand up and step around until they are facing the opposite direction)
30
What are the three Fall Risk Assessment Tools?
- FRAT (falls risk assessment tool)
- Timed Up and Go test ( Time the person getting up from a chair without using their arms walking 3 metres, turning around, returning to their chair and sitting down)
- Time 180 test ( Ask the person to stand up and step around until they are facing the opposite direction)
31
What is Osteoporosis?
- Osteoporosis is a condition where there is a reduction in the density of the bones
32
What are the risk factors of Osteoporosis?
- Older Age
- Female
- Reduced Mobility and Activity
- Low BMI
- RA
- Alcohol and Smoking
- Long term corticosteroids
- Other Medications: SSRI, PPIs, Anti-epileptics and Anti-oestrogens
- Post-menopausal women
- Oestrogen is protective against osteoporosis
33
What is the FRAX tool?
- Frax tool gives a prediction of the risk fo fragility fracture over the next 10 years.
- Looks at age, BMI, co-morbidities, smoking, alcohol and family history
- It gives results as a percentage 10-year probability of a: Major osteoporotic fracture and hip fracture
34
What is Bone Mineral Density?
- BMD is measured using a DEXA scan ( Dual-energy xray absorptiometry)
- Gives you a T score
- This forms the basis for the WHO classification of the level of osteoporosis
35
What is the WHO classification Score?
- More than -1 = Normal
- -1 to -2.5 = Osteopenia
- Less than -2.5 = Osteoporosis
- Less than -2.5 plus a fracture = severe osteoporosis
36
How would you go about assessing for osteoporosis?
Perform a Frax assessment on:
1. Women aged >65
2. Men aged >75
3. Younger Patients with risk factors such as previous fragility fractures, history of falls, low BMI, long term steroids, endocrine disorders and RA
After Frax assessment perform a BMD:
- low risk = reassure
- intermediate risk = offer DEXA scan and recalculate the risk with the results
- high risk = offer treatment
Frax outcome with BMD:
1. Treat
2. Lifestyle advice and Reassure
37
What is the Managment for Osteoporosis?
- Activity and Exercise
- Maintain a Healthy weight
- Adequate calcium + Vit D intake ( Calchichew- D3 = 1000mg of calcium and 800 units of Vit D)
- Avoiding Falls
- Stop Smoking
- Reduce Alcohol Consumption
38
What are some examples of Bisphosphonates?
- Alendronate 70mg
- Risedronate 35mg
- Zoledronic Acid 5mg
39
What are some of the side effects of Bisphosphonates?
1. Reflux and oesophageal erosions - taken on empty stomach sitting upright for 30 minutes before moving or eating
2. Atypical fractures
3. Osteonecrosis of the jaw
4. Osteonecrosis of the external auditory canal
40
What are some other medical options if bisphosphonates are contraindicated?
- Denosumab = monoclonal antibody which works by blocking the activity of the osteoclasts
- Strontium Ranelate = stimulate osteoblasts and blocks osteoclasts, but increases the risk of DVT, PE and MI
- Raloxifene = used as secondary prevention only. It is a SERM that stimulates oetrogen receptors on the bone but blocks them in the breast and uterus
- HRT = considered in women who go through menopause early
41
What is the Follow Up for Patients who have Osteoporosis?
- Low risk patients only given lifestyle advice should be followed up within 5 years
- Patients on Bisphosphonates should have a repeat FRAX and DEXA scan after 3-5 years and a treatment holiday should be considered if there BMD has improved
