Falls

Question 1

What is a fall?

Answer 1

An unexpected event in which the participant comes to rest on the ground, floor or lower level

Question 2

What are some complications of falls?

Answer 2

Fracture (Esp. hip)
Functional decline
Social isolation
Loss of confidence
Morbidity and mortality

Question 3

What is the most commonly reported cause of falls?

Answer 3

Dizziness

Question 4

What are the 3 main categories of physiological factors that contribute to increased falls risk in the elderly?

Answer 4

Motor co-ordination
Biomechanics
Sensory inputs and organisation

Question 5

Motor co-ordination changes in ageing causing falls

Answer 5

Decreased motor planning (Reaction times)
Decreased attention
Decreased co-ordination
Decreased peripheral sensation

Question 6

Biomechanics changes in ageing causing falls

Answer 6

Decreased skeletal integrity
Decreased joint stability and flexibility
Decreased muscle strength (Sarcopenia)

Question 7

Sensory changes in ageing causing falls

Answer 7

Smaller pupils and lens thickening cause decreased vision
Decreased vestibular function causing postural sway
Decreased proprioception

Question 8

What are some medical conditions that can increase risk of falling?

Answer 8

Diabetes (Peripheral neuropathy + Retinopathy)
Arthritis, Parkinson’s, Stroke -> Altered gate
Incontinence -> Rushing, mobilising at night

Question 9

What are some environmental factors that increase fall risk?

Answer 9

• Medications
• Rugs, furniture, stairs, inadequate lighting
• Inappropriate footwear
• Inappropriate use of walking aids

Question 10

How does cataracts surgery affect falls risk?

Answer 10

It greatly reduces fall risk

Question 11

How do new prescription glasses affect falls risk?

Answer 11

Increase fall risk due to quick change in sight

Question 12

How does fear of falling increase falls risk?

Answer 12

Leads to a cautious gait with a decrease in walking speed and step length, therefore decreasing walking stability

Question 13

What are some drug types that can increase fall risk?

Answer 13

Diuretics
Anti-hypertensives
Sedatives
Anti-cholinergics
Hypoglycaemic agents
Anti-psychotics

Question 14

How do anti-psychotics affect falls risk?

Answer 14

Psychotropic drugs almost doubles fall risk and so should be stopped in old age if possible

Question 15

What are some anti-depressants and anti-psychotics that can cause orthostatic hypotension?

Answer 15

Venlafaxine
Duloxetine
Risperidone
Haloperidol

Question 16

What BP in older people is associated with falls risk?

Answer 16

< 120 mmHg systolic

Question 17

What is the BP target in those over 80?

Answer 17

< 150/90

Question 18

What is the BP target in those under 80?

Answer 18

< 140/90

Question 19

What anti-hypertensives should be continued in old age?

Answer 19

ACEi and ß-Blockers

Question 20

What anti-hypertensives should be stopped in old age?

Answer 20

Nitrates
Ca2+ channel blockers
Vasodilators
Alpha blockers

Question 21

What are some causes of orthostatic hypotension?

Answer 21

Baroreflex dysfunction - Ageing, vascular
Medication
Environmental factors - Volume depletion, bed rest
Diabetes
Amyloidosis
Parkinson’s
Lewy-body dementia

Question 22

How is orthostatic hypotension managed?

Answer 22

Stop culprit drugs
Encourage patients to avoid sudden changes in movement
Water loading
Increase dietary salt
Compression stockings
Keep legs elevated when sitting
Calf-muscle exercises
Medication

Question 23

What are some medications used in orthostatic hypotension (Last resort)?

Answer 23

Fludricortisone
Midodrine

Question 24

What is a risk of long term phenytoin use?

Answer 24

Permanent cerebellar damage and unsteadiness

Question 25

What are some common causes of falls?

Answer 25

Medications Orthostatic hypotension Carotid sinus syndrome Syncope Stroke Tripping

Question 26

What is carotid sinus syndrome?

Answer 26

A condition of abnormal activation of the carotid sinus, leading to symptoms secondary to cerebral hypo perfusion

Question 27

What is the carotid sinus (+ function)

Answer 27

The carotid sinus is an area of dilatation in the internal carotid artery which contains a number of baroreceptors When pressure increases, the carotid sinus causes the resultant peripheral vasodilation and reduction in heart rate

Question 28

What are the 4 main steps in assessing a falling patient?

Answer 28

Patient + collateral history Examination Investigation Further tests

Question 29

What are some important history points in a falling patient?

Answer 29

- Where? - Events before, during and after the fall - Loss of consciousness? - Injuries? - Could they get up? - How long did they lie? - Previous falls? - Walking aids? - Systemic enquiry - Medical history - Drug history

Question 30

What are some examinations in a falling patient?

Answer 30

- General observation - Evidence of concurrent illness - Injuries - Head, vertebrae, humerus, hips, pelvis - Cardio - Murmur or arrhythmia, postural BP - Neurological exam - Stroke, visual field, peripheral neuropathy, gait - 4-AT/AMTS/MoCA - If vertigo → Dix-Hallpike manoeuvre and HINTS

Question 31

What are some investigations required in a falling patient?

Answer 31

- ECG ± Telemetry - Blood sugar - Postural BP - Lying → Standing 0, 1 and 3 minutes - Timed up and go - Echocardiogram (If required) - Head CT (Consider)

Question 32

What are some further tests in assessing a falling patient?

Answer 32

- Ambulatory ECG - Carotid sinus massage - Tilt-table

Question 33

What are the main management steps for falls?

Answer 33

- Strength and balance training (3x per week for at least 12 weeks) - Home hazard assessment and intervention - Vision assessment and referral - Medication review and modification/withdrawal

Question 34

What is involved in carotid sinus massage?

Answer 34

- Connect to cardiac monitor and BP cuff - Lie patient flat and start rhythm strip printout - Apply pressure for 5 seconds to carotid sinus while a friend hits ‘mark’ to signify start of CSM - Check blood pressure - Maximal drop at 15 seconds - Repeat for other side when HR returns to normal

Question 35

What are some contraindications for carotid sinus massage?

Answer 35

MI or CVA last 3 months, Hx of VT, carotid artery stenosis

Question 36

What are some risks of carotid sinus massage?

Answer 36

0.1% risk of transient visual loss 0.01% risk of completed stroke

Question 37

What are the 3 positive findings on carotid sinus massage?

Answer 37

- Cardio-inhibitory CSS - Pause in HR > 3 seconds - Vasodepressory CSS - Drop in systolic BP of 50mmHg - Mixed CSS - Simultaneous combination of both