Managing Falls

Question 1

What do falls cause?

Answer 1

Reduced QOL
Loss of confidence and independence
Mortality

Question 2

Differentials for cause of falls

Answer 2

There are lots:
Trip
UTI
Stroke
HF
Hypo/hypercalcaemia
Polypharmacy
Ruptured AAA
Epilepsy
Cauda equina
OA
Accidental overdose
Pneumothorax - tension

Question 3

3 types of risk factors for falls

Answer 3

Intrinsic - patient factors
Extrinsic
Environmental

Question 4

Intrinsic risk factors for falls

Answer 4

Demographic - elderly
General health/functioning
Medical conditions
MSK and Neuro
Sensory
Gait and balance
Cognitive/psychological

Question 5

Extrinsic risk factors for falls

Answer 5

Environmental hazards

Risk-taking - eg doing things they are no longer capable of doing

Transfer manoeuvres

Question 6

Environmental risk factors for falls

Answer 6

Poor stairway design
Inadequate lighting
Clutter
Slippery falls
Unsecure mats/rugs
Non-skid surfaces in bathtubs

Question 7

What does a falls assessment involve?

Answer 7

History - presenting complaint, system review, PMH, medications, social

Examination

Investigations

Question 8

What is involved with history taking of presenting falls complaint?

Answer 8

Who - did anyone else witness fall? If yes, take collateral history too

When - when did fall occur? Night? What were they doing at the time? looking up? toilet? getting up?

Where - Inside? outside? Trip hazards? Flashing lights?

What - Before, during and after

How - how many times have they had a fall in last 6 months?

Question 9

Expand the ‘What’ section of before during and after a fall when taking a history for a fall

Answer 9

Before - symptoms prior to fall? chest pain? did they trip/fall?

During - loss of conciousness? incontinence, tongue biting, shaking? Injuries?

After - regain consciousness quickly? able to get up without help? any confusion or neurological symptoms?

Question 10

What systems are involved in the ‘systems review’ section of a history taking following a fall?

Answer 10

CVS
Resp
Neurological
Genitourinary
Gastrointestinal
Musculoskeletal

Question 11

Questions to ask for CVS

Answer 11

Chest pain?
Palpitations?
Dizzy?
Clammy?

Question 12

Questions to ask for resp

Answer 12

Cough? - dry, wet? colour of mucus?
Haemoptysis?
Dyspnoea?
Wheeze?
COPD/asthma?

Question 13

Questions to ask for neurological

Answer 13

Slurred speech?
Weakness/numbness?
Headaches?
Photphobia?
Neck pain?

Question 14

Questions to ask for genitourinary?

Answer 14

Discharge?
Dysuria?
Frequency?
Nocturia?
Colour of urine - blood? frothy?

Question 15

Questions to ask fro GI

Answer 15

Vomiting?
Diarrhea?
Constipated?
Abdominal pain?

Question 16

Questions to ask for MSK

Answer 16

Pain anywhere?
Full range motion?
Swelling/erythema over joints?

Question 17

What are the two types of fall?

Answer 17

Syncope - transient loss of consciousness die to reduced cerebral blood flow

Non-syncope - with or without loss of consciousness, not due to cerebral hypoperfusion

Question 18

4 types of syncope fall and a few causes within these groups

Answer 18

Neurocardiogenic aka vasovagal - carotid sinus, situational eg cough, defaecation, swallow

Orthostatic hypotension - drug induced, ANS failure, dehydration

Cardiac arrhythmias - bradycardia (AV block) tachycardia (ventricular tachycardia/supraventricular)

Structural cardio-pulmonary - aortic stenosis, pulmonary hypertension

Question 19

How is BP controlled?

Answer 19

Baroreceptor reflex - fall in BP causes decreased firing, rise in BP causes increased firing to medulla

If high BP - inhibits sympathetic activity and increases vagal activity

If low BP - increases sympathetic activity and lowers vagal (increase HR, FOC, vasoconstriction, adrenaline released)

RAAS activated if low BP from kidney baroreceptors too

Question 20

Causes of non-syncope falls

Answer 20

Without loss of consciousness:
- fall
- psychogenic
- TIA

With partial/complete loss:
- Epilepsy
- Metabolic - hypoglycaemia, hypoxia, hypocapnia
- Intoxications

Question 21

Specific questions to ask for medications and social history for falls

Answer 21

Anti-hypertensives?

Live alone?
Carer?
Bungalow or stairs?
Walking aid?
Smoker/drinker?

Question 22

Examinations to do on presenting complaint of fall

Answer 22

CVS
Resp
GI
MSK
Neurological

• ALL OF THEM

Question 23

Investigations to do for fall presenting complaint

Answer 23

Bedside - bladder scan, urine dip, lying/standing BP, ECG

Bloods - VBG, blood glucose, FBC, LFT, U&Es, CRP, CREATINE KINASE

Imaging - ECHO, CT, X-ray

Procedures - tilt table, assess syncope

Question 24

What can cause AKI in pts who have recently fallen?

Answer 24

Myoglobin breakdown from rhabdomyolysis (esp if have been on the floor for a long time)

= myoglobin damages kidney (toxic), CK will then be elevated due to muscle breakdown

Question 25

What in a history can suggest Rhabdomyolysis?

Answer 25

Long lie - been lay on floor for a while
Raised CK
Dark urine (tea coloured - lots of myoglobin)

Question 26

What kind of AKI does rhabdomyolysis cause?

Answer 26

Intrinsic

Question 27

What people are involved in the discharge of someone who has had a fall?

Answer 27

Physiotherapist
Occupational therapist - assess home and see if ok
Dietician
GP
Nursing staff
Pharmacist
Discharge team / carers

Question 28

What change in BP suggests orthostatic/postural hypotension?

Answer 28

Change of 20mmHg from sitting to standing suggests