Makindo Medical Notes.com

Related Subjects: |Osteoporosis

After a fall patients may regress and become more housebound and worried about falling outside.

About

• A fall is defined as an event that causes a person to, unintentionally, rest on the ground or other lower level.
• A long lie is a fall that is defined as an event that causes a person to, unintentionally, rest on the ground or other lower level for at least one hour.
• Usually seen in elderly and causes are multifactorial

The most important history in a patient with falls is whether it was preceded by a loss or impairment of consciousness. If so get a witness account. Check L/S BP, look for murmur of aortic stenosis, check ECG for heart block, review BP control, review hypoglycaemic meds.

Incidence

• Inpatient falls are a growing problem with over 200,000 falls in hospitals each year
• 40% of those over the age of 80 fall each year
• Falls cause 90% of hip fractures in this age group
• Some 3-5% of falls result in fracture
• Falls are an independent risk factor for nursing home placement.

Risks

• Muscle weakness
• History of falls
• Abnormal gait or balance
• Use of walking aid
• Visual impairment
• Arthritis
• Impaired ADLs
• Depression
• Cognitive impairment
• Age over 80
• Psychotropic medication

Causes

• Transient loss of consciousness (See article)
• Hypotension, Stroke
• Weakness and Sarcopenia
• Dyspraxia and Cerebrovascular disease
• Cerebellar degeneration
• Low BM usually diabetic
• Drugs - sedation, Alcohol
• Infections - Urine/chest
• Severe aortic stenosis, MI
• Arrhythmias, Seizures, Accidental
• Parkinson's, Vascular dementia

Check list

It will also help reduce postural hypotension, defined as a drop in BP of > 20 mmHg systolic or > 10 mmHg diastolic pressure on standing from supine

Assessment

• NEWS and are the cardiovascular/neurology stable
• Preceding symptoms.
• Ask about syncope, dizziness, instability
• Cardiac or neurological causes
• Stroke, Infection, Vertigo, TIA
• Old disability e.g stroke or small vessel disease
• Poor vision, Pets, Clutter
• Has this happened before
• Previous tests and assessments

Contributing factors: Gravity +

• Acute illness of any cause
• Frailty, Dementia, Sarcopenia
• Cardiac disease and drugs and hypotension
• Stroke, Neuropathy, Dyspraxia, Cerebellar disease, PD
• Alcohol, sedation, Anticonvulsants
• Poor lighting, lack of walking aid
• Simple trips , pets, loose rugs, obstructions
• Poor vision, not wearing glasses, distractions, lack of care
• Arthritis and pain, Delirium
• Rushing: phones, doorbell, urge incontinence/diuretic

Quick On call check list

Immediately Pre Fall Assessment

• Look for any pre-syncopal symptoms e.g. feeling dizzy, light-headed, palpitations
• What were they doing? Standing from sitting or lying (postural hypotension?)
• Getting off toilet, or standing urinating (micturition syncope)
• After a large meal ( Vasovagal)
• When already up and walking (arrhythmia?)
• Turning head/looking up their head (carotid sinus hypersensitivity?)
• Take a close history so you can play the event back in your mind
• Get a witness report if any loss of consciousness even to ringing people
• If they fell do they remember falling and hitting floor
• Was it a simple trip
• Did they manage to protect themselves e.g. # wrists from arm outstretched to protect. A black eye and head injury suggests less self-protection and may have had LOC before fall
• If LOC then for how long
• Any incontinence or tongue biting
• Any limb jerking or urinary/faecal incontinence to imply seizure
• Could they get back up and if not why not
• Were they able to mobilise independently following the fall?
• Do they have any pain - have they a fracture
• Were they well-oriented following the fall?

Pre morbid health

• Assess frailty if frail
• Walking: do they use aids e.g stick, frame, furniture walk
• Do they have careline and could they use it

Examination

• If unwell assess patient using ABCDE approach
• If any new neurology and head injury urgent CT head
• If any bone pain then X-Ray for possible fractures, dislocation
• Identify causes especially if (pre) syncope before hand
• Cardiovascular: Pulse, AF, Low BP or postural drop, Murmurs
• Respiratory: COPD or Bronchiectasis and cough. SOBOE. Frail. Steroids
• Abdominal: constipation, urinary retention, prostatism
• Neurological: seeing gait is most useful. If not power, tone, vision, cerebellar signs, neuropathy, cognition
• Cognition: AMTS or MMSE. Use CAM if suggestion of delirium
• Trauma: Any head injury or fractures. Look for tenderness or deformity

Other factors

• Treated Diabetes Mellitus: was it a hypo or neuropathy
• Hypertension: Do you need to reduce them, any recent increase
• Epilepsy: any history of seizures?
• Previous falls: aetiology. Always seek the worst and go into details
• Hearty disease: palpitations/ECG/ Need telemetry and echo
• Neurological disease: old stroke, Parkinsonism, dementia, SVD
• Poor vision: Glaucoma, ARMD, Cataract, Hemianopia
• Cognitive impairment: Dementia, Dyspraxia
• Bone Health: steroids, old #, Osteoporosis, Paget's Disease

Drug history relevant to falls

• Postural hypotension: Alpha-receptor blockers in male patients with prostatism g. tamsulosin, ACEI, ARB, CCB, Diuretics
• Analgesia: e.g. codeine
• Sedatives: antihistamines, benzodiazepines
• Diuretics: urge incontinence
• Anticoagulants: increased risk of bleed (SDH/Traumatic ICH) get CT head if worried
• Psychotropic Drugs SSRIs, benzodiazepines, all increase the risk of falls

Investigations

• FBC, U&E, ESR, CK if long lie
• ECG and 24 hr tape if syncope(presyncope)
• Echo if suspected aortic stenosis or structural heart disease

Acute Management

• Issues are the fall and harm caused. This may require CT head or X-Rays looking for broken bones.
• Pelvic X-rays can occasionally miss a hip fracture and if pain persists then CT or MRI is indicated.
• Chest x-ray: may show infection or rib fractures
• Patients should not go under the elderly team until a fracture that might require surgery has been excluded.
• Next issues are why the fall and how to prevent a recurrence and this demands detective work and critical thinking.
• One major issue is the fall itself causes a huge loss of confidence and patients become very withdrawn and anxious and resist mobilisation.
• It must all be assessed in the context of the living environment. There are many strategies and ways to minimise falls and their effect.
• One major worry is falling downstairs and a chairlift or moving bed downstairs might help. Patients may have cognitive impairment and varying degrees of insight.
• Review medications eg. sedatives, psychoactive drugs (such as benzodiazepines), stop drugs that can cause postural hypotension
• Ask about alcohol.

Assessment

• History of falls.
• Gait, balance and mobility, and muscle weakness.
• Osteoporosis risk.
• Perceived impaired functional ability and fear relating to falling.
• Visual impairment.
• Cognitive, neurological, and cardiovascular problems.
• Urinary incontinence.
• Home hazards.
• Polypharmacy (the use of multiple drugs)

Rare but useful Interventions

• Pacemaker if symptomatic bradycardia
• Aortic valve replacement if severe AS
• Anticonvulsants if Seizure
• Stopping meds if Drug induced hypotension or unsteadiness
• Avoiding drugs or patches that cause sedation
• Cataract surgery for poor vision
• Exercise for limb strength
• Calcium and vitamin D supplementation: may help
• Home: environment assessment and modification
• Anti-slip and well-fitting shoes

Later interventions commonly offered by specialist falls services

• Strength and balance training: helps older community-dwelling people with a history of recurrent falls or balance and gait deficit.
• Home hazard assessment and intervention should be offered to older people who have received treatment in hospital following a fall.
• Vision assessment and referral.
• Medication review and discontinued if possible.
• Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.

Environmental modifications

• The only way to stop falls risk is to not allow patients to walk but this reduces quality and probably length of life
• Falling is bad but falling downstairs is very high risks and is an issue to address with downstairs living or stairlift
• Once we cannot change the patient we need to change their world around them
• May need additional support at home. A package of care may help with ADLS and check patient is all right
• In extreme cases placement is preferred to ensure safety, either RH or NH based on level of dependence
• Occupational therapy and community home visits can be helpful in frail patients who might have cluttered houses with uneven floors
• Good lighting and using lights when going to toilet overnight. Using a bedside commode to save having to walk to distant bathroom.
• Consider a microenvironment "Studio" with downstairs living in one room with easy access to commode and handrails. If needed a stair lift to go upstairs.
• Some may need a hospital bed and hoist of high level of care and very immobile
• Pendant alarms if patient has cognition to use one and to wear it at all times. A mobile phone can be useful. Some have put internet cameras for family to observe.
• Newer models have in-built impact sensors that are set-off as a fall happens
• Falls clinic and exercise and balance classes can help some