Falls

Question 1

What is mechanical fall?

Answer 1

This term is not used.

This is because all falls are mechanical, it used to be a conclusion of exclusion but is not used.

Question 2

History of fall.

Answer 2

What were they doing?

How did the fall happen?

How did they feel before the fall?

Was there any dizziness or a lightheaded feeling?

How did they feel after the fall?

Did they lose consciousness?

Did they have any cardiac symptoms?

Are they weak anywhere?

Has this happened before?

Have they had any near falls before?

Medication?

How do they normally mobilise?

Question 3

What medications are important to consider in a fall?

Answer 3

Sedatives

Cardiac medications like antiarrhythmics and hypotensives.

Anticholinergics

Hypoglycaemics

Opiates

Question 4

Examination of a fall.

Answer 4

Functional assessment of mobility - How do they mobilise, do they need aid, what is their gait?

CVS examination + ECG and lying and standing BP (immediate, 3 and 5 minutes)

Neurological examination

MSK examination + joint assessment.

Abdominal - constipation and urinary incontinence

Question 5

Intrinsic and optimisable risk factors for falling.

Answer 5

Concurrent illness

Cardiac syncope

Medications

Question 6

Intrinsic and static risk factors of falling.

Answer 6

Weakness from previous stroke

Question 7

Extrisinc and optimisable risk factors for falling.

Answer 7

Trip hazards

Grab rails

Question 8

Extrinsic and static risk factors of falling.

Answer 8

Stairs into the house

Question 9

Give example of risk factors for falls.

Answer 9

Unsteady gait

Leg weakness

Peripheral sensory impairment

Joint instability

Pain

Cerebrovascular disease

Cognitive impairment

Depression

VIsual impairment

Hearing impairment

Medication/polypharmacy

Postural hypotension

Electrolyte imbalances

Anaemia

Urinary incontinence

DM

Brady and tachyarrhythmias

Fear of falling

Vertigo like BPPV

Foot health

Question 10

Investigations of falls.

Answer 10

Bloods - FBC, crea and U&Es, Glucose/HbA1c, Bone profile and Vit D, TFT, B12 etc…

ECG

CXR

Possible CT head if trauma to head

Question 11

How can falls be categorised?

Answer 11

Into syncopal and non-syncopal falls.

Question 12

5 I factors of falls.

Answer 12

Immobility

Instability

Incontinence

Iatrogenesis

Intellectual impairment

Question 13

What is the main cause of falls?

Answer 13

Medications such as;

Vasoactive

Psychoactive

Statins

Steroids

Hypoglycaemic agents

Anti-histamines

Question 14

Define syncope.

Answer 14

A transient loss of consciousness due to inadequate cerebral blood flow.

In lay-term = faint

Question 15

Give types of syncope.

Answer 15

Vasovagal syncope

Postural (orthostatic hypotension)

Postprandial hypotension

Micturition syncope (while passing urine)

Carotid sinus syncope (tight collar, looking upwards, turning head)

Cough syncope

Obstructive - aortic stenosis, myopathy, pulm stenosis, pulm HTN/E, atrial myxoma

Arrhythmias

Question 16

What is the most common syncope?

Answer 16

Vasovagal syncope

Question 17

Explain vasovagal syncope.

Answer 17

Also called neurocardiogenic syncope.

It is a simple faint due to peripheral vasodilation and venous pooling of blood.

This leads to a reduction in the amount of blood returned to heart.

The near-empty heart responds by contracting vigorously, this leads to stimulation of mechanoreceptors in the inferoposterior wall of the left ventricle.

These in turn will trigger reflexs via the CNS to reduce ventricular stretch. This can cause further vasodilation and bradycardia.

This drops blood pressure and therefore the syncope.

Question 18

Prodromal symptoms of vasovagal syncope.

Answer 18

Dizziness

Nausea

Sweating

Tinnitus

Yawning

Sinking feeling

Question 19

Prodromal symptoms of a cardiac-related syncope.

Answer 19

Chest pain

Palpitations

Dyspnoea

Question 20

Prodromal symptoms of a CNS related syncope.

Answer 20

Aura

Headache

Dysarthria

Limb weakness

Question 21

Non-cardiac related causes of syncope.

Answer 21

Dehydration

Intense emotional stress

Anxiety

Fear

Pain

Hunger

Use of alcohol or drugs

CNS - TIA, Stroke, Seizure

Question 22

What is situational syncope?

Answer 22

Situational syncope is a type of vasovagal syncope. It happens only during certain situations that affect the nervous system and lead to syncope. Some of these situations are:

Dehydration

Intense emotional stress

Anxiety

Fear

Pain

Hunger

Use of alcohol or drugs

Hyperventilation (breathing in too much oxygen and getting rid of too much carbon dioxide too quickly)

Coughing forcefully, turning the neck, or wearing a tight collar (carotid sinus hypersensitivity)

Urinating (miturition syncope)

Question 23

How can non-syncopal falls be classified?

Answer 23

Disorders without any loss of consciousness

Disorders with partial or complete loss of consciousness

Question 24

Give causes of nonsyncopal falls without LOC.

Answer 24

Falls/trips

Weakness in legs

Joint instability

Pain

Peripheral neuropathy

Visual impairment

Cataplexy

Drop attacks

Psychogenic pseudo‐syncope

Transient ischaemic attacks (TIA) of carotid origin

Question 25

Give causes of nonsyncopal falls with partial or complete LOC.

Answer 25

Metabolic disorders, including hypoglycaemia, hypoxia, hyperventilation with hypocapnia Epilepsy Intoxications Vertebro‐basilar TIA etc...

Question 26

Causes of loss of consciousness diagram.

Answer 26

Question 27

Treatment of falls.

Answer 27

Treat underlying cause. Medication review. Treat any reversible cause. Consider bone health by FRAX tool MDT review with physio, occy health and referrals

Question 28

Interventions in fall.

Answer 28

Strength and balance training Home hazard intervention Correct vision Modification and withdrawal of medication Integrated management of contributing morbidities Consider barriers to change like fear and patient preference.

Question 29

Consequences of falls.

Answer 29

Fear of subsequent falls Fragility fractures Neck of femur fractures Institutionalisation

Question 30

Explain fear of falling.

Answer 30

Even after a minor fall without any injuries a patient might develop fear of falling. This is characterised by anxiety around mobilising and is associated with an increasing loss of confidence and hesitant gait. This leads to an increased risk of falling, due to hesitant gait, lack of movements due to anxiety leading to sarcopenia and weakness. It can also cause social isolation and depression further increasing the risk of falls and the consequences of falls.

Question 31

What are fragility fractures?

Answer 31

Occur when an injury from a standing height or lower. It ranges from vertebral fractures to wrist, proximal humeral, pubic rami and NOF fractures. They are commonly associated with osteoprosis and needs further investigation.

Question 32

Causes of acute postural hypotension.

Answer 32

Reduced intravascular volume such as; Decreased oral intake Excessive diuresis Diarrhoea Vomiting Haemorrhage

Question 33

Chronic causes of postural hypotension.

Answer 33

Medications - diuretics, b-blockers and other antiarrhymtics, antihypertensives and vasodilators. Autonomic dysfunction associated with DM, Parkinson's, multisystem atrophy. Poor vascular compliance seen in ageing blood vessels due to a reduction in elasticity and increased calcification.

Question 34

Explain measurement of postural BP.

Answer 34

Ensure that patient is able to stand. Use a manual ideally. Lie patient down for 5 minutes. Measure BP. Stand patient up and measure straight away. Wait 3 min and measure again. Wait to a max of 5 min total and do it again.

Question 35

Definitions of signficant drop in BP in postural hypotension.

Answer 35

Classic - reduction of 20/10 mmHg within 3 min of standing Initial - Reduction of 40/20 in first 15 sec. Delayed - No agreed definition but occurring after 3 min

Question 36

Management options in postural hypotension.

Answer 36

Review medications Treat underlying cause Abdominal binders Bolus of water Bed elevation Counter-manoeuvres Drugs like fludrocortisone and midodrine Education Exercise Fluid intake