Factors that are important when taking a history about a fall
• Did anyone else witness the fall? - If yes - take a collateral history
• When did the fall occur? If at night, is vision an issue?
• What were they doing at the time?
- Were they looking up?
- Just got up from a chair/bed?
- Just been to the toilet ?
• In the house?
• At the shops?
• If at home,
- Which room?
- Any trip hazards?
- Flashing lights from TV?
• What? – Before, During, After
- Any symptoms prior to the fall (light headedness/dizziness)
- Chest pain
- Did they trip or slip?
- Loss of consciousness (beware of this in unwitnessed falls as the patient probably won't know)
- Incontinence, tongue biting, shaking
- Any injuries?
- What happened after?
- Did they regain consciousness quickly?
- Were they able to get up without help? If not then they may be unsafe to return home.
- Any confusion or neurological symptoms?
• How long where they on the floor for?
• How many times has the patient fallen over before?
• How many in the last 6 months?
• Any serious injuries?
Most Important part of any fall historyis to establish the presence or absence of loss of conciousness leading to the fall
• A transient loss of consciousness characterised by fast onset and spontaneous recovery
• Caused by a reduced perfusion pressure 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
What can cause a fall?
Many different causes so thorough history is important.
What is pre-syncope?
• Symptoms preceding a syncopal episode, includes:
• Blurred vision
Not everyone who has these will have a fall but if someone is experiencing these regularly, then they are at much higher risk of having a fall
Seizure as a cause of falls and how it’s different to syncope
• A generalised tonic-clonic seizure is a cause of loss of consciousness and will cause a fall however it is not a syncope. Both will have a loss of conciousness and cause a fall put a seizure spontaneous recovery.
• Be aware of new epilepsy in the elderly as incidence increases in old age
• Seizures can often be subtle
Categories of syncope
• A few broad categories:
• Reflex Syncope
• Orthostatic Hypotension
• Cardiac/Cardiopulmonary Disease
What is reflex syncope?
• Disorder of the autonomic regulation of postural tone
• Activation of part of medulla leads to decrease in sympathetic output and increase in parasympathetic
• Fall in CO (reduced HR) and BP leads to reduced cerebral perfusion
• Vasovagal- ‘simple faint’- from prolonged standing, stress, sight of blood, pain
• Situational syncope e.g coughing, straining, lifting heavy weight
• Carotid sinus massage
What is orthostatic hypotension?
• 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, with pre-syncopal symptoms on standing
• Standing up causes 500-800ml of blood to pool in the legs
• Reduction in end diastolic volume
• Reduced cardiac stretch, therefore reduced stroke volume and cardiac output
• Normally managed by the baroreceptor reflex
• If this fails then cerebral perfusion will drop and syncope occurs
Describe the baroreceptor reflex
Baroreceptors present in the arch of the aorta and carotid body, undergo a slight stretch under higher pressure causing a decrease in baroreceptor activity and this signal is taken by the glossopharyngeal nerve (CN IX) to the brain and causes deactivation of our sympathetic chain and activation of the vagus nerve (CN X) which goes to the sinoatrial node and causes heart rate to fall so cardiac output falls and then blood pressure falls. The oppsoite occurs during low blood pressure. The symapthetic chain causes an increase in heart rate and an incresed force of contraction.
Why can the baroreceptor reflex fail?
• Baroreceptors become less sensitive with age
• Also become less sensitive with prolonged hypertension
• Medications, such as anti-hypertensives can impair this response, or venous return
• Dehydration - causes lower blood volume
• Syncope caused by a cardiac disease or abnormality
• Can be an electrical (rhythm), structural or coronary cause
• Aortic Stenosis
• Hypertrophic Obstructive Cardiomyopathy
Features of Cardiac Syncope:
• Exertional syncope
• Family history of cardiac disease or sudden cardiac death
• Preceding chest pain or palpitations
• Past medical history of heart disease
• Abnormal ECG
How can aortic stenosis cause syncope?
• Narrowing of the aortic valve
• Harder to push blood through the aortic valve
• If heart has to work harder, e.g during exercise, it can fail to adequately perfuse brain
• If AS with syncope then patients have a mean survival of 2-5 years untreated
What are non-syncopal falls?
• A fall in which the cause is not a syncope
• A fall with a loss of conciousness following a head trauma is still a non-syncopal fall
• Trips and slips fall in this category
• Often the fall can be the end result of an intercurrent illness, such as an infection
Are falls normallydue to one cause
• Many falls will be as a result of more than one thing
E.g. A patient with osteoarthritis and diabetic neuropathy. Add in an infection on top of this.
Risk factors pile up and act together.
When is it okay to send a patient home after a fall?
• Main question: Is this patient safe to be at home?
• As with any patient, you take a complete history:
• Presenting Complaint
• History of Presenting Complaint
• Past Medical History
• Family History
• Drug History:
- Any new medications?
- Anti-hypertensives/anti-arrythmials - Long-term?
- Any drug which may induce drowsiness? - E.g. new analgesia, benzodiazepines, antidepressants, antipsychotics etc
- Have they had a recent medication review?
• Social History:
- Who does she live with?
- Does she have any help at home?
- Family close by?
- Any stairs?
- Any walking aids - Or other helpful household aids?
- Does she drink alcohol?
- Does she smoke cigarettes?
Depending on the patient's history and the type of fall they've had you can use this to piece together the likelihood of them falling again upon returning home. Social and rug history will be more important here.
What to do when a patient has a walking aid or may need one after a fall?
Many different types, patient could using wrong one so refer to occupational therapy
How do you examine a patient after a fall?
Full examination – Patient-guided after a fall
• Only 1% of falls result in a fracture
• Don’t just stick to where the patient says 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 examination at an absolute minimum Investigation:
• LSBP • ECG • FBC and U and Es • Creatine Kinase if long lie
( • X-ray • Echo • 24hr tape • CT )
To be guided by symptoms – not a one size fits all
Rhabdomyolysis in the context of fall?
• Rhabdomyolysis may result from any traumatic or medical injury to the sarcolemma causing a 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 complication of a fall with a “long lie” – prolonged immobilisation
To CT or not to CT…? after a fall
Is there any immediate reason to CT?
- GCS lower than 13 on assesment or less then 15 2 hourse after injury
- Possible skull fracture
- post trauma seizure
- Focal neurolgical deficit
- More than one episode of vomiting since the head injury
What to do on discharge after a patient has had 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 increased help at home?
• Opticians/Audiologists if needed
• If in A+E – write a complete GP letter
• Needs a medications review
How does the respiratory system change during aging?
Lung and chest wall compliance decrease with advancing age. Total lung capacity (TLC), Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 second (FEV1) and Vital Capacity are all reduced as people age.
These changes occur as a result of reduction in elastic support of the airways and leads to increased collapsibility of alveoli and terminal conducting airways.
• Atelectasis, pulmonary emboli and pneumonia are common post-operative complications in the elderly.
• These complications are increased in smokers, patients with chronic chest disease and those undergoing abdominal or thoracic surgery.
• With advancing age, loss of elastic tissue around the oropharynx can lead to collapse of the upper airway. Sleep or sedative states may result in partial or complete obstruction of the airway
• A progressive increase in the number of episodes of arterial desaturation during sleep occurs with advancing age.
Ageing and the Pharmacokinetics
Elderly patients have an increased sensitivity to CNS depressant drugs and so drug doses need to be modified accordingly. Patients have reduced hepatic and renal function leading to slower metabolism and elimination of drugs.
How does skin change with aging?
Elderly patients tend to have thin skin and fragile subcutaneous blood vessels and therefore patients tend to bruise easily. Achieving and securing venous access can be difficult panopto and picture
Ageing and the Cardiovascular system
• Large and medium sized vessels become less elastic and therefore become less compliant with age. • This results in raised systemic vascular resistance and hypertension, which in turn may lead to left ventricular strain and left ventricular hypertrophy • Cardiac conducting cells decrease in number making heart block, ectopic beats, arrhythmias and atrial fibrillation more prevalent. • Since atrial contraction contributes approximately one third of the volume towards normal ventricular filling, patients with atrial fibrillation suffer a reduction in cardiac output of about 30%. Cardiac output falls by 3% per decade which is due to reduced stroke volume and ventricular contractility. The reduction in cardiac output with age increases the arm-brain circulation time for drugs and means intravenous anaesthesia is achieved more slowly and with reduced doses of anaesthetic agent.
How does aging and its effect on the cardiovascular system affect pharmacology?
Reduced cardiac output results in delayed onset of intravenous anaesthesia. Reduced total body water and increased adipose tissue leads to an altered volume of distribution of some drugs. Plasma proteins are reduced resulting in decreased protein binding and increased free drug availability.
Ageing and the Renal System
•Glomerular filtration rate is thought to decrease by 1% per year over the age of 20 years due to a progressive loss of renal cortical glomeruli. •A reduction in renal perfusion secondary to reduced cardiac output and atheromatous vascular disease leads to a decline in renal function. • In addition diabetes mellitus is increasingly common, as is the use of nephrotoxic drugs such as non-steroidal anti-inflammatory drugs (NSAID’s) and angiotensin converting enzyme inhibitors (ACE inhibitors). • Prostatism in males can lead to obstructive nephropathy and dehydration is common in the elderly especially during illness
CNS changes with age
• Cerebrovascular disease is common in the elderly secondary to diffuse atherosclerosis and hypertension. • Neuronal density is reduced by 30% by the age of 80 years.
Endocrine and Metabolic Effects of Ageing
•The basal metabolic rate falls by 1% per year after the age of 30. Fall in metabolic activity and reduced muscle mass may cause impaired thermoregulatory control
Polypharmacy and age
•Many patients take multiple medications on a regular basis and the effects of these medications on the individual’s physiology must be taken into account.
Lifestyle Factors and age
•Non-specific presentations are due to… •Homeostatic failure because of… •Multiple pathology and, sometimes •Differential challenge panopto