Falls Flashcards
Implications of falls?
Immobilisation after a falls is associated with: • Hypothermia • Dehydration • Pressure sores • Rhabdomyolysis • Venous thromboembolism • Bronchopneumonia • Muscular de-conditioning
Fear of falling - a history of falls increases risk; leads to social isolation, loss of confidence and functional decline
Occurrence of falls?
More common in women and residents of long-term care
Often hospital inpatients
Patients with cognitive impairment
Causes of falls?
MULTI-FACTORIAL - there is ALWAYS more than 1 reason:
• Person (intrinsic) factors - includes physiology of ageing and pathology that is commonly assoc. with ageing
• Environment (extrinsic) factors
• Activity
Why does physiology of ageing (intrinsic factor) increase the risk of falls?
Vision - smaller pupils, lens thickening
Central processing and recognition - decreased reaction time
Decreased cardiorespiratory fitness
Sarcopenia - loss of muscle mass and function
Decreased peripheral sensation and proprioception contributes to increased postural sway
Common age-related pathologies?
The following all increase falls risk: • CV disease and syncope • Cognitive impairment • Neurological • Vestibular disease • Vision problems • MSK/gait
Common description of syncope as a cause of falls?
“I just go down”; they often assume they must have tripped
Suspicious if there are significant facial injury or a Hx of pre-syncope before the fall
20% of unexplained falls are due to syncope
Common conditions underlying syncope?
Arrhythmias
Orthostatic hypotension
Neurogenic (vasovagal) - simple faint
Carotid sinus hypersensitivity
Valvular heart disease (aortic stenosis)
Define orthostatic hypotension?
After 3 minutes of standing:
• A fall in systolic BP of >20 mmHg
OR
• A fall in diastolic BP of >10 mmHg
Risk factors for orthostatic hypotension?
Mediated by the ANS so there is an increased risk with:
• Diabetes
• Hypertension and anti-hypertensive drugs
• Parkinson’s disease (due to the disease itself and the drugs used to treat it, e.g:
Levodopa)
• Polypharmacy
How does cognitive impairment
2x more likely to fall if cognitively impaired, as it affects:
• Judgement
• Visual-spatial perception
• Orientation
Key neurological disorders that cause falls?
Cervical myelopathy patients have a high-stepping gait and Romberg’s test is +ve
Peripheral neuropathy causes altered sensation; patients have a wide-based gait
Lumbar stenosis causes pain and paraesthesia in legs
Cerebellar ataxia can occur in those with chronic alcohol withdrawal or if they have had a previous stroke; patients have a wide-based gait and cerebellar signs
Parkinson’s disease is characterised by shuffling gait, tremor, rigidity and bradykinesia; common cause of orthostatic hypotension as well
Stroke
Describe Romberg’s test
Patient stands with feet together; doctor stand behind and asks them to close their eyes
Check how unsteady they are
Symptoms of vestibular disease?
Vertigo and imbalance; clarify what a patient means by “dizzy”, as many do not describe true vertigo
Common vestibular disease? Examination and treatment?
BPPV - confirm with Dix-Hallpike manoeuvre and treated with Epley manoeuvre
Examples of how vision can increase the risk of falls?
Age-specific changes
Consider cataract surgery to decrease the risk of falls
Bifocal/varifocal lens pose a high risk, as they alter depth perception
How common are gait disturbances as a part of falls?
2/3rds of falls will have this, often resulting from specific disease:
• Stroke
• Arthritis
• Parkinson’s disease
Environmental (extrinsic) factors that increase the risk of falls?
- Medications
- Alcohol
- Environmental hazards, e.g: clutter, rugs, poor lighting, no hand rails, stairs (consider environment modification)
- Inappropriate clothing/footwear
- Inappropriate walking aids
Why is medication a risk factor for falls?
Common contributor and, if a patient has polypharmacy consisting of ≥4, this is an INDEPENDENT FALLS RISK FACTOR
Common drugs that increase the risk falls?
Two main classes are:
• Benzodiazepines (‘pams’)
• Neuroleptics (‘peridols’)
Other common contributors: • Anti-hypertensives • Anti-depressants • Anti-cholinergics • Class 1A anti-arrhythmic drugs
What does a FALLS ASSESSMENT consist of?
History (often a collateral history is also helpful)
Examination:
• Focus on risk factors and cause of falls
• Tools for assessing gait and balance
Establish all RISK FACTORS for the patient
Target Ix
What should a falls history include?
Prevention - screen for falls routinely
• Have you had 2/more falls in the last 12 months?
• Have you presented acutely with a fall?
• Problem with walking/balance?
Full history: • What happened before and after the fall? • Impact/consequences? • Frequency of falls? • Medication list?
Examination of falls patient?
Gait, balance, joints
Nueological and Romberg’s test
CVS - pulse rate/rhythm, murmurs, lying and standing BP (for orthostatic hypotension)
Visual acuity (Snellen chart)
Feet and footwear
Incontinence assessment
How to measure a lying and standing BP?
1st reading taken after lying for at least 5 minutes
2nd reading taken after standing in the 1st minute
3rd reading taken after standing for 3 minutes
Assessment tools to check the risk of fools?
Timed Up and Go test (TUG) - patient stands from a chair and the time is switched on, walk 3 metres, turn around and walk back to sit in the chair.
>12 seconds is abnormal
Burg balance test
Tinetti score
