Falls Flashcards
(27 cards)
How is postural hypotension investigated?
A reduction in brain perfusion on standing can give rise to a disequilibrium and so a fall
Baroreflex- homeostatic mechanism that helps to maintain blood pressures at a nearly constant levels, provides a rapid negative feedback loop, which in an elevated BP reflexively causes the HR to decrease therefore BP decrease, baroreceptors found in aortic arch and carotid sinus
All patients presenting after a fall should have an ECG and postural BP checked as standard some patients may need more detailed assessment using a TILT table
Carotid sinus massage is commenced for 5 seconds using a longitudinal massage over the point of maximal carotid pulsation- this is followed by slowing of the pulse and a dramatic fall in BP
What is the definition of a fall?
An event which results in a person coming to rest inadvertently on the ground or floor or other lower level
Unintentionally coming to rest on the ground, floor or other lower level; excluding coming to rest against furniture, wall or other structure
What is the epidemiology of falls?
Every 5hrs in the UK an older person dies as a direct result of a fall
Twice as many women aged 75+ die from falls as men of the same age
Up to the age of 64 twice as many men as women die in falls
Following a hip fracture, 1 in 3 become totally dependent and 1 in 2 become partly dependent
50% of people aged 80+ fall at least once a year
The 1 year mortality in people with fractured neck of femur is 20-35%
1% of falls result in hip fracture
50% of those who fall will fall again in the next 12 months
Which disorders can affect balance?
Vision: Cataracts Age-related macular degeneration Diabetic retinopathy Bifocal lenses Proprioception: Sensory neuropathy Joint replacements Ageing Vestibular system: Previous middle ear infections Meniere’s disease Ototoxic drugs Brain: Cerebrovascular disease Dementia- affects judgement Low blood pressure- reduces cerebral blood flow Effector mechanisms: Proximal myopathy eg. steroid exposure, vitamin D deficiency Any neurological disease Disuse atrophy
Which drugs can be used to help prevent falls?
Fludrocortison is used in people with unexplained, persistently low BP to increase the circulating volume and thus raise BP
Calcium and vitamin D are used to improve muscle strength on people who are vitamin D deplete, there is evidence to suggest that vitamin D improves the function of stretch receptors and so reduce falls
What are the drugs of sedation?
Benzodiazepines Tricyclic antidepressants Anti-psychotics Barbiturates Anti-convulsants Sedating anti-histamines Analgesic opiates
Which drugs cause hypotension?
Diuretics Beta-blockers ACE inhibitors Angiotensin II blockers Alpha blockers Calcium channel blockers Vasodilators Urinary anti-muscarinics Phenothiazine TCAs Anti-parkinsonian drugs Acetylocholinesterase inhibitors
Which drugs cause reduced visual acuity/blurred vision?
Eyedrops
Anti-cholinergics
Which drugs cause muscle weakness?
Baclofen, dantrolene
Which drugs cause ataxia?
Carbamazepine, phenytoin
What are the intrinsic risk factors for falls?
Diabetes Parkinson’s Disease Thyrotoxicosis Cataracts Osteoarthritis Metastatic prostate cancer
What are the extrinsic risk factors for falls?
Highly polished wooden floors Poorly fitting slippers Walking stick Poor lighting conditions Diazepam 10mg nocte Rugs
What are the other risk factors for falls?
Female gender- ratio 1.5 Visual deficit- ratio 1.5-3.0 Medication- mainly benzodiazepams, anti-depressants and anti-psychotics – ratio 1.5 Assistive device- relative risk 2.6 Cognitive impairment- ratio 2.0-4.0 Muscle weakness- ratio 3.0 Osteoarthritis- relative risk 2.0 Home hazards- relative risk 3.6 Testosterone deficiency- relative risk 1.8
What are the risk increasing conditions for falls?
Dementia Delirium Lower urinary tract symptoms in men Stroke Urinary incontinence in neurological disease Urinary incontinence in women
What are the consequences of falls?
Fear of fall- activity limitation, participation restriction, low quality of life, anxiety and depression
Social isolation
Injuries and fractures
Carer strain- stress
Institutionalisation- the likelihood of an older people requiring admission to a care home increases with both the number and severity of falls recorded
What are the physical consequences of falls?
Trauma Soft tissue injury Fragility fractures- mortality and morbidity Joint dislocations Subdural haemorrhage 'Long lie' Hypothermia Pressure related injury- sores Dehydration and AKI Infection- pneumonia
What is the multifactorial assessment for falls?
Identification of falls history
Assessment of gait, balance and mobility, and muscle weakness
Assessment of osteoporosis risk
Assessment of the older person’s perceived functional ability and fear relating to falling
Assessment of visual impairment
Assessment of cognitive impairment and neurological examination
Assessment of urinary incontinence
Assessment of home hazards
Cardiovascular examination and medication review
What is carotid sinus massage?
Exaggerated response to carotid sinus baroreceptor stimulation- results in dizziness or syncope with transient diminished cerebral perfusion although baroreceptor function usually diminishes with age, some people experience hypersensitive carotid baroreflexes
Indications- unexplained falls or presyncope
What are the contraindications for carotid sinus massage?
MI/TIA/stroke <3 months Previous adverse reaction to CSM Relative contraindications: VF/VT Carotid bruits
What is the general approach to minimising the risk of falls?
Strength and balance training
Environmental assessment
Medical review
What is strength and balance training?
Involves a physiotherapist making an assessment of an individual and then prescribing a tailored course of therapy aimed at improving strength and balance, therapy might involve a variety of activities, such as CVS training, strength training and balance training
This usually lasts many weeks – at least 50hrs is required
What is an environmental assessment?
Always be led by an occupational therapist OT will assess the individual and the environment to identify any potential hazards but visiting the individual at their home and suggest improvements to be made if necessary and may provide some assistive equipment
Raised toilet seat/commode
Grab rails
Bath boards and seats
What is the medical assessment for falls?
Diagnose medical reasons for falls eg. CVS, neurological, psychiatric, infective or opthlamic
Optimise the management of conditions contributing to falls- co-morbidities
Bone health assessment- evidence of previous fracture, prescribe bone protection and DEXA
Medication review- poly pharmacy increases the risk of fall
What are the components of a successful multifactorial intervention programme?
Strength and balance training
Home hazard assessment and intervention
Vision assessment and referral
Medication review with modification/withdrawal.
