Falls Flashcards
What should you ask during a falls history?
Before:
- Time, date, place
- Pattern to falls?
- ICE on reasons for falling
- Lightheadedness
- Vertigo
- Palpitations
During: - Loss of consciousness - Jerking - Seizures After - Post-ictal - Incontinence - Able to get up? - Injuries? - Did they get help? - Complications (ex long lie, fractures, head injury)
Causes:
- Medication history
- Vision
- Cognition
- Osteoporosis risk factors
What are some causes for falls that come under DAME?
Drugs
- Polypharmacy
- Antihypertensives
- Opioids
- Psychotropics
- Anticholinergics
Age:
- Vision changes
- Cognitive decline
- Gait abnormalities
- Osteoarthritis
Medical:
- Hypotension
- Arrhythmias
- Neurological disease (ex Parkinson’s, strokes, neuropathy)
- Cataracts
Environmental:
- Walking aids
- Footwear
- Home hazards
What is Vertigo?
- Sensation of the room spinning around
- Suggests problem in the vestibulo-labyrinthine system, anywhere between the ear (peripheral vertigo) and the central vestibular pathways (central vertigo)
Peripheral causes
- Benign paroxysmal positional vertigo (BPPV) (common)
- Meniere’s disease
- Vestibular neuritis
- Acoustic neuroma
Central causes
- Migraine
- Brainstem ischaemia
- Cerebellar stroke
- Multiple sclerosis
BPPV is a common cause of peripheral vertigo
- Short spells of vertigo (up to 1 minute) that settle spontaneously
- Occurs when they move their head (ex getting in/out of bed, looking up/turning quickly)
- It can be diagnosed using the Dix-Hallpike manoeuvre
- Treatable using the Epley manoeuvre.
What is Presyncope?
- Feeling as if you are about to faint/complaining of lightheadedness
- Often when standing/seated/upright
- Associated with pallor, relieved by lying
- Suggests cerebral hypoperfusion due to hypotension
- Postural/orthostatic hypotension is common in older patients
- Diagnosed by doing lying and standing BP
What does unsteadiness mean?
A general feeling of unsteadiness or feeling unbalanced that usually comes from a patients legs rather than their head (asking someone “does this feeling come from your head or your legs?” is often useful).
What are some psychogenic causes of dizziness?
- Common
- Fear of falling
- Loss of confidence
- Anxiety/panic attacks/somatisation
- Exacerbates organic dizziness
Which examinations would you do to assess a falls patient?
- Upper and lower limb neurological exam
- Cognition (ex AMT 10, CAM, MMSE, 4AMT)
- Vision
- Vestibular
- CVS
- Musculoskeletal
Which initial investigations should be done for a falls patient?
- ECG - to look for arrythmias/abnormalities
- TFTs/B12/Folate - exclude other causes of peripheral neuropathy
- U&Es
- Bone profile
- FBC
They above look for anaemia, markers of infection and electrolyte abnormalities
Who is involved in the MDT and why?
- Consultant: leads MDT
- Nurse: keeps track of changes in patient
- Physiotherapist: manages mobility and pain
- Podiatrist: neuropathy, difficulty walking, footwear
- Occupational therapist: caters to other aspects of social care
- Pharmacist: checks for drug interactions, safe prescribing, and drug management
How can we create a management plan based off the DAME criteria?
Drugs:
- Stop any antihypertensives, sedatives, etc, unless needed, or reduce dose
Ageing:
- Balance retraining run by physiotherapists
- Check visual acuity and refer to optician
- Check osteoporosis risk
Medical:
- Maintain good diabetic control (slows down rate of diabetic neuropathy)
- Addressing osteoprosis risk reduces rate of fractures
- Cataract surgery improves vision
Environment:
- Environmental assessment for hazards
- Change footwear, lighting in home
- Panic alarm/care-call system with patient
- Adaptations at home
What are the NICE guidelines on assessment of Osteoporosis?
- Assessment of fracture risk be considered in any patient over 50 with a history of falls
- In all women over 65
- In all men over 75
Risk factors that would implicate earlier assessment than specified:
- History of falls
- Previous osteoporotic fragility fracture
- Current or frequent use of oral corticosteroids
- BMI underweight (<18.5)
- Smoker
- Alcohol intake over 14 units/week
Secondary causes of osteoporosis:
- Hyperthyroidism
- Cushing’s
- Diabetes
- Hypogonadism
- Untreated premature menopause
What is the NICE guidance on the management of Osteoporosis?
High risk of fragility fracture:
- Offer DEXA scan
- Then bone-sparing drug treatment if T-score is -2.5 or less
- If T-score is more than -2.5, treat underlying conditions, and repeat DEXA within 2 years
Intermediate risk:
- Arrange a DEXA scan to measure bone mineral density
- Offer drug treatment if T-score is -2.5 of less
Low risk:
- No drug treatment
- Offer lifestyle advice
- Follow up within 5 years
What drug treatments are recommended for patients high risk of osteoporotic fracture?
If bone-sparing treatment recommended:
- Prescribe a biphosphonate (alendronate 10mg OD or 70mg OW/risedronate 5mg OD or 35mg OW)
- If there are no contraindications, with appropriate counselling
- To patients with a T-score of -2.5 or less
If the patient’s calcium intake is adequate (700mg/day)
- Prescribe 10mcg (400IU) of vitamin D without calcium if sun exposure insufficient
If calcium intake inadequate:
- Prescribe 10mcg (400IU) of vitamin D with 1g of calcium daily
- Prescribe 20mcg (800IU) of vitamin D with at least 1g of calcium daily if patient is elderly and housebound, or living in a nursing home
Consider prescribing HRT to women who have the menopause before age 40 (premature)
- Reduced risk of fragility fractures
- Relieves menopausal symptoms
What lifestyle information and advice should be given to patients at risk of fragility fractures?
- Take regular exercise
- Improves muscle strength
- Encourage walking, especially outdoors (vitamin D)
- Strength or weight training of different muscle groups
- A combination of exercise types (ex balance, flexibility, stretching, endurance and strength)
- Eat a balanced diet
- Stop smoking
- Reduce alcohol intake to within recommended limits
- 1-2 units a day with at least 2 alcohol-free days
Provide the patient with information and support:
- National osteoporosis society
- Healthtalkonline
- NHS England
How should you counsel a patient prescribed Biphosphonates?
- Explain that patient likely has osteoporosis, and this increases risk of fracture with future falls
- Explain that biphosphonates can reduce the risk of fractures due to osteoporosis
- Was prescribed due to risk of fracture within the next 10 years
Instructions:
- Ensure no contraindications (swallowing issues, oesophageal disease)
- Cognitive and physical capacity to follow instructions?
- Take with water (always)
- Stay upright/seated for at least half an hour afterwards
- Take on an empty stomach
- 3-5 years
- Consider IV if more appropriate (intervals of 3 months to a year, outpatient setting)
- ICE the patient, understand and agreement
