Lecture 3- Managing falls Flashcards
1
Q
falls reduce
A
Falls reduce quality of life, loss of confidence and impendence and ultimately, mortality
2
Q
Causes of falls
A
Causes of falls
- Trips
- UTI
- Stroke
- Delirium
- Syncope
- etccccccc
3
Q
how to think about a fall
A
who
when
what
how
4
Q
- Who?
A
- How much they remember about the fall
- Did anyone else witness the fall? If so take a collateral history
5
Q
A
6
Q
- When?
A
- When did it occur?
- At night? Vision an issue?
7
Q
- Where?
A
- In the house?
- Which room?
- Any trip hazards?
- Flashing lights from tv? Can cause a seizure in old people
- In the shop?
8
Q
- What?
A
- What where they doing at the time?
- Looking up?
- Just got up from chair/bed?
- Just been to toilet? Post micturition syncope
- Before?
- Any symptoms prior to fall (light headedness/dizziness)
- Chest pain
- Did they trip or slip
- During
- Loss of consciousness
- Incontinence, tongue biting, shaking
- Any injuries? E.g.head injury, broken hip etc
- After
- What happened after?
- Diff they regain consciousness quickly?
- Were they able to get up without help?
- Any confusion or neurological symptoms?
9
Q
- How?
A
- How long were they on the floor for?
- How many times has this happened before?
- How many in last 6 months
- Any serious injuries
10
Q
Essential part to any history-
A
did they pass out before or after fall?
11
Q
What is syncope?
A
- Transient loss of consciousness characterised by fast onset and spontaneous recovery
- Caused by a reduced perfusion in the brain
- Syncope is usually self-limiting- being horizontal will fix low blood pressure
- Beware of people who have been held in an upright position
12
Q
Pre-syncope symptoms?
A
- Symptoms preceding a syncopal episode include
- Light-headedness
- Sweating
- Pallor
- Blurred vision
13
Q
types of syncope
A
reflex syncope
orthostatic (postural) hypotension
cardiac/cardiopulmonary disease
14
Q
reflex syncope
A
- Disorder of the autonomic regulation of postural tone
- Activation of part of medulla leads to decrease in sympathetic output and increase in parasympathetic
- Decreased CO
15
Q
Orthostatic (postural) hypotension
A
- Symptoms occur after standing from a sitting or lying position
- Can cause syncope if drop in blood pressure is severe enough
- Normally defined as a drop of 20mmHg or more
- The problem with standing
16
Q
why can standing up caue hypotension
A
- standing up causes 500-800ml of blood to pool i t he lefs
- reeduction in end diastolic volume
- reduced cardiac stretch, therefore reduce stroke volume and cardiac output
- normally managed by the baroreceptor reflex
- if this fails then cerebral perfusion will drop and syncope occurs
17
Q
baroreceptor reflex
A
- aBP normally regulated within a narrow range
- accomplished by negative feedback system incorporating pressure sensors i.e. baroreceptors that sense aBP
18
Q
where are baroreceptors found
A
carotid sinus
aortic arch
19
Q
carotid sinus
A
- (bifurcation of external and internal carotids)
- Innervated by the sinus nerve of Hering (branch of the glossopharyngeal nerve)
- Glossopharyngeal synapses in the nucleus tractus solitarius (NTS) located in the medulla of the brainstem
20
Q
- Aortic arch
A
- Innervated by the aortic nerve, which combines with the vagus nerve travelling to the NTS (medulla)
- NTS modulates the activity of sympathetic and parasympathetic (vagal) neurones in the medulla, which in turn regulates the autonomic control of the heart and blood vessels
21
Q
If BP rises
A
- the walls of the vessels expand passively
- which increases firing frequency of action potential generated by the receptors
22
Q
If BP falls
A
- decreased stretch of arterial wall
- decrease firing of AP
23
Q
Why does the baroreceptor reflex fail?
A
- Baroreceptors become less sensitive with age
- Also become less sensitive with hypertension
- Medications such as anti-hypertensive can impair this response
- Dehydration
24
Q
Seizures
A
- A generalised tonic-clonic seizure is a cause of loss of consciousness and will cause a fall
- However it is not syncope
- Be are of new epilepsy in the elderly
- 2nd peak in incidence rate is in over 80s
- Seizure can often be subtle
25
**Aortic stenosis**
* Narrowing of aortic valve
* Harder to push blood through aortic valve
* During exercise, when the heart has to work harder, the stenosis can limit CO and therefore fail to adequately perfuse the brain
* If AS with syncope- survival of 2-5 year if untreated
26
**Non-syncopal falls**
* Fall in which the cause is not a syncope
* A fall with loss of consciousness following a head trauma is still a non-syncopal fall
* Trips and slips fall in the category
* Often the fall can be the end result of an intercurrent illness such as an infection
27
**Multifactorial falls**
* Many falls will be a result of more than one thing
* Imagine a pt with OA and Diabetic neuropathy
* Add infection on top of this
28
**Medications which may cause falls**
* Antihypertensives
* hypotension
* Drugs which reduce blood glucose
* Hypoglycaemia
* Medications which effect the brain
* i.e. cause sedation of drowsiness
29
**Is this patient safe to be at home?**
* Need to complete a full history
* Presenting complaint
* History of presenting complaint
* Past medical history
* Family history
* Drug history
* Social history
30
**Drug history**
* Polypharmy
* Any new medications
* Anti-hypertensives/ anti-arrhythmias
* Any drug which may induce drowsiness?
* Analgesia
* Benzodiazepine
* Antidepressants
* Antipsychotics
* Have they had a recent medication review
31
**Social history**
* Who does she live with?
* Does she have any help
* Family close by?
* Any stairs?
* Any walking aids?
* Does she drink alcohol?
* Does she smoke?
32
**Examination after fall- patient guided**
* Only 1% of falls result in a fracture
* Don’t just stick to where the pt say it hurts
* Ideally palpate all bony prominences if patient unsure
* Other injuries can be masked due to pain elsewhere
* **Full neurovascular, cranial nerve, CVS and respiratory exam – at a min**
33
**Investigations**
* LSBP (lying and standing BP)
* ECG
* FBC and U&Es
* CK if long lie (rhabdomyolysis)
34
**Be guided by the symptoms- not all falls require scans**
* X-ray
* Echo
* 24hr tape
* CT
35
**To CT or not to CT**
* Age \>65
* History of bleeding or clotting disorder
* Dangerous mechanism of injury ( a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a heigh of \>1 m or 5 stairs)
* More than 30 minutes retrograde amnesia or events immediately before the head injury
36
**Action after being a fall**
* **Basic advice**
* Drink plenty
* Stand up slowly
* Remove loose carpets/leads
* Sensible slippers
* Good lighting
* OT assessment
* Social work/ PCC assessment
* Do they need more help at home?
* Opticians/audiologists
* **If A and E write a complete GP letter**
* **Needs a medication review**
37
**Common clinical challenges in assessing older people**
* Cant give proper history of falls/ other ailments that may increase likelihood of fall due to poor memory
* Not wanting to lose independence
* Lack of resources to assess older people
* Elderly may not want to move house around to make it safe
38
**Practical solutions to minimise risk of falls**
* Clean up clutter
* Remove tripping hazards
* Install grab bars and handrails
* Avoid loose clothing
* Ensure lighting is right
* Wear shoes
* Make it nonslip
* Live on one level
39
**Rhabdomyolysis**
* Rhabdomyolysis may result from any traumatic or medical injury to the sarcolemma (muscle)
* Release of intracellular ions, myoglobin, CK and urates into the circulation
* Can lead to electrolyte disturbances, disseminated intravascular coagulation (DIC), renal failure and multi-organ failure
* Serum CK levels- 5 times the upper limit of normal
* Common complications of a fall with a ‘long life’- prolonged immobilisation
