Week 1 - Falls Flashcards
1
Q
What does the mnemonic DAME stand for in grouping the causes of a fall?
A
D - drugs
A - Age-related
M - Medical causes
E - Environmental
2
Q
Give some examples of drugs that may cause a fall (DAME)
A
D - Drugs
- Polypharmacy i.e. drug interactions or compounded effects
- Antihypertensives → hypotention
- Sedatives → ↓ awareness
- Opiods → depressant/dizziness
- Psychotropics
3
Q
Give examples of age-related causes of falls (DAME)
A
A - Ageing
- Vision changes
- Cognitive decline
- Gait abnormalities
- Osteoarthritis
- Sarcopenia / reduced proximal muscle strength
4
Q
Give examples of medical causes of falls (DAME)
A
M - Medical causes
- Cardiac e.g. hypotension, arrhythmias → syncope
- Neuro e.g. PD, strokes, neuropathy, cateracts e.g. ↓ sensation to feet → trip
5
Q
Give examples of Environmental causes of falls (DAME)
A
E - Environmental
- Walking aids
- Footwear
- Home hazards
- Fear of falling
6
Q
How do you structure a history of a fall?
A
- Before - what caused the fall? symptoms?
- During - was it syncope or seizure? did they # something? LOC + for how long?
- After - how did they get help? complications e.g. #, head injury, long lie, skin break?
7
Q
What could “dizzy” mean?
A
- Pre-syncopal symptoms - light-headed, pale, about to faint, relieved by lying - postural hypotension
- Unsteady
- in the legs
- in the head
- Vertigo - room spinning
- Psychogenic - associatied with and exacerbates organic dizziness. Fear of falling, ↓ confidence, anxiety, somatisation
8
Q
What is Vertigo?
A
Vertigo = the false sense that the body or environment is moving in any direction
- Often described as “sensation of room spinning”
- Is suggestive of a problem with vestibulo-labyrinthine system
- i.e. anywhere between the ear (peripheral vertigo)
- and the central vestibular pathways (central vertigo)
9
Q
Name 4 causes of peripheral vertigo
A
- Benign Paroxysmal Vertigo
- Meniere’s disease
- Acute vestibular neuronitis
10
Q
What medications can be given buccal/IM in severe nausea and vomiting and orally in less severe?
A
→ To rapidly relieve severe nausea and vomiting administer buccal prochlorperazine or a deep IM injection of the same or cyclizine.
→ A short course of prochlorperazine or cyclizine can help alleviate symptoms over days.
11
Q
What is the most common cause of central vertigo?
A
Vestibular migraine
12
Q
Name 4 causes of central vertigo
A
- Vestibular migraine
- Posterior circulation stroke
- Cerebellar or brainstem tumour
- MS
13
Q
What is Zopiclone?
A
Is a non-benzodiazepine hyponotic used to treat insomnia
14
Q
What are 4 features of acoustic neuroma?
A
Acoustic neuroma
- Hearing loss
- Tinnitus
- Absent corneal reflex
- Associated with neurofibromatosis type 2
15
Q
what details might suggest their dizziness is a presyncopal sensation?
A
- Feeling like “about to faint” or “light-headed”
- Often occurs when patient is; standing, seated or upright
- Associated with pallor - relieved by lying down
- Suggests cerebral hypoperfusion due to hypotension
16
Q
What is a common cause of presyncopal symptoms, especially in the elderly?
A
Orthostatic (postural) hypotension
- When BP ↓ as a result of standing from seated/lying position
- Diagnosed by doing a lying standing BP
17
Q
How is a lying + standing BP performed?
A
- Acquire assistance (needed for standing BP)
- Ask patient to lie down for > 5 mins
- Measure BP
- Ask patient to stand (assist if needed)
- Measure BP (within 1st minute of standing)
- Measure BP again after pt has been stood for 3 mins
- Repeat BP is it is still falling
18
Q
What qualifies at a +ve result on a lying + standing BP test?
A
Positive result = :
- A drop in systolic BP of ≥ 20 mmHg (with or without symptoms)
- A drop to < 90 mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
- A drop in diastolic BP of 10 mmHg with symptoms (although clinically less significant than a drop in systolic BP)
19
Q
What features might the patient have if there was a psychogenic cause for dizziness?
A
- Psychogenic causes of ‘dizziness’ are common!
- Fear of falling
- Loss of confidence in movement
- Anxiety / panic attacks / somatisation (psychological stress manifested as physical symptoms)
- Psychogenic causes of dizziness are often associated with + exacerbate organic causes
20
Q
What is an AMT-10 test? What is involved?
A
Abbreviated Mental Test (10 questions - correct/incorrect)
- Age
- Time (nearest hour)
- Current year
- Patient’s home address
- What jobs do these people do? (show pictures e.g. postman + cook)
- Date of birth
- Year WW1 started?
- Current Primeminister
- Count backwards from 20 to 1
- Ask to recall address given at start “42 west street”
21
Q
What highly effective intervention is offered to falls patients?
A
strength and balance (re)training
- ↓ risk of further falls
- ↓ fear of falling
- Show pts how to get up off the floor if they do fall
22
Q
What 4 interventions have a lot of evidence behind them for falls?
A
- Strength + balance training
- Home hazard assessment and intervention
- Vision assessment and referral
- Medication review with modification/withdrawal
23
Q
When, according to NICE guidelines, should the following be assessed for fracture risk?
- Pt with history of falls
- Women
- Men
A
should be assessed for fracture risk:
- Patients > 50 yrs + history of falls or any risk factors e.g. low BMI
- Women > 65 yrs
- Men > 75 yrs
24
Q
What are some secondary causes of osteoporosis?
A
- Hypogonadism in either sex, including untreated premature menopause (menopause before 40 years of age), treatment with aromatase inhibitors (such as exemastane) or gonadotrophin-releasing hormone agonists (such as goserelin).
- Endocrine conditions:
- diabetes mellitus,
- Cushing’s disease,
- hyperthyroidism,
- hyperparathyroidism,
- hyperprolactinaemia
- Conditions associated with malabsorption including
- inflammatory bowel disease,
- coeliac disease,
- chronic pancreatitis.
- Rheumatoid arthritis and other inflammatory arthropathies.
- Haematological conditions such as multiple myeloma and haemoglobinopathies.
- Chronic obstructive pulmonary disease.
- Chronic liver failure.
- Chronic kidney disease.
- Immobility.
25
When might the FRAX tool tell you to do a DEXA scan?
* If your # risk is \> 10% in 10 years
* If you are over 50 years old and have a history of fragility #s
* If you are \< 40years with a major risk factor:
* premature / untreated menopause
* previous fragility fracture
* long term oral corticosteroids
26
What is the FRAX calculator for?
To assess future **fracture risk**
It gives **10-year probability** of:
1. **Hip** fracture
2. **Osteoporotic** fracture (spine, forearm, hip or shoulder)
27
FRAX not only calculates risk of a fracture as a % but classifies the patient as: low risk, intermediate risk and high risk. For each what is the next course of action?
* **Low** risk (green) - **lifestyle advice** and reassure
* **Intermediate** risk (yellow) - **Measure BMD** (bone mineral density)
* **High** risk (red) - **treat**
28
What are the 9 major risk factors for osteoporosis (these are used by FRAX tool)?
1. Age
2. Female
3. Previous #
4. Hx of parental hip #
5. Hx of glucocorticoid use
6. RA
7. Low BMI
8. Alcohol excess
9. Smoking (current)
29
What other risk factors for osteoporosis are there besides those accounted for in FRAX?
* Sedentary lifestyle
* Caucasians and Asians
* Premature menopause
* Endocrine disorders:
* Hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus
* Multiple myeloma
* Lymphoma
* GI disorders:
* IBD, malabsorption (e.g. Coeliac's), gastrectomy, liver disease
* CKD
* Osteogenesis imperfecta
30
Which 7 medications worsen osteoporosis?
1. **Glucocorticoids** (main one)
2. **SSRIs** e.g. Citalopram, Fluoxetine, Sertraline
3. **Antiepileptics** e.g. Clonazepam, Carbamazepine
4. **PPIs**
5. **Glitazones** e.g. pioglitazone
6. **Heparin** therapy (long term)
7. **Aromatase inhibitors** e.g. anastrozole - used in treatment of post-menopausal breast cancer and gynecomastia in men
31
A DEXA scan is used to measure BMD (bone mineral density) - your results include T-scores and Z-scores, what are each of these?
* **T-score** = BMD is compared to a **healthy 30-year old adult**
* **Z-score** = BMD is compared to someone the **same age**, **gender** and **ethnicicity** (often misleading as everyones BMD reduces with age, so might not deviate far from the norm, but put a pt at risk of osteoporotic fractures)
32
For the following DEXA T-scores what does each represent?
1. \< -1.0
2. -1.0 to -2.5
3. -2.5 or less
1. Normal = \< -1.0
2. Osteopenia = -1.0 to -2.5
3. Osteoporosis = -2.5 or less
33
What is the first line management for osteoporosis?
* **Alendronic acid** (bisposphonate) - ↓ bone turnover --\> ↓ bone resorption = ↓ blood [Ca2+}
* 10 mg PO OD OR 70mg PO once weekly
* ~ 25% of pts can't tolerate Alendronic acid - GI side effects
* aka alendronate
* **Vitamin D + calcium supplementation**
34
What is second line treatment for Osteoporosis?
If Alendronic acid can't be tolerated then (both bisphosphonates):
* **Risedronate**
* **Etidronate**
If bisphosphonates aren't tolerated then:
* Strontium ranelate
* Raloxifene
35
Whichinvestigations should be done **routinely** in older people who present with falls?
1. **Glucose**
2. **ECG**
3. **Gait**
4. Lying + standing **BP**
36
When might you need to wait before starting bisphosphonates?
If the pt is severely deficient in Vit D then these stores need to be repleted first
37
What is the loading regimen for vitamin D?
20'000 units twice a week for 6 weeks
38
What is the maintenance calcium and vitamin D regimen?
**10-20 micrograms** of vitamin D and **1000mg** of calcium **daily**
39
what should everyone with a TLOC have according to NICE?
12-lead ECG
40
What special instructions need to be given to a patient for taking bisphosphonates?
* Take on **empty stomach**
* Remain **upright** for **30 mins** (after taking)
* Likely to take it for **3-5 years**
Taking bisphosphonates in this way reduces the risks of developing side effects i.e. reflux, indigestions, oesophageal and gastric ulcers
