Medicine 5th year, 2nd lecture (Dr. Asso Fariadoon Ali Amin)


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The lecture has been given on May 7th, 2011 by Dr. Asso Fariadoon Ali Amin.

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Medicine 5th year, 2nd lecture (Dr. Asso Fariadoon Ali Amin)

  1. 1. Investigation & Management of Falls & Syncope<br />Dr Asso Fariadoon Ali Amin MRCP(UK)<br />GIM/ Care of Elderly physician<br />
  2. 2. Falls in the Elderly<br /><ul><li>Falls are common presentation to a GP surgery, accident and emergency, orthopaedic and medical admission units.
  3. 3. Mechanical or accidental falls refer to a fall secondary to slipping or tripping over something. Mechanical falls among Elderly above the age of 65 admitted to hospital are uncommon and recurrent falls should never be considered accidental. Older people often fall as a result of medical condition , many of which can be treated.
  4. 4. Definition:- of fall is unintentionally coming to rest on the ground or some lower level and other than a consequences of sustaining a violent blow, loss of consciousness, or sudden onset of paralysis as in stroke or epilepsy.
  5. 5. Very common in elderly, 1/3 of elderly above the age of 65 living in their own homes fall each year. ½ of these falls occurs during doing normal daily activity with no environmental factors. The incidence of fall is higher among those living in institutions , around half of care home residents who are mobile falls each year. </li></li></ul><li>Consequences of Falls <br /><ul><li>Injury:- 40-60% of falls lead to injury, 40-50% are minor injuries, 5-6% are major (excluding fracture) and 5% fracture.
  6. 6. Hospital admission:- admission due to falls are six times higher in older people above the age of 65.
  7. 7. Psychological:-
  8. 8. 1/3 of those age over 60 years develop a fear of falling
  9. 9. loss of confidence
  10. 10. Post fall anxiety
  11. 11. self imposed functional limitation
  12. 12. Social isolation
  13. 13. Depression.
  14. 14. Disability
  15. 15. Long Lie:- defined as remaining on the floor for more than 1 hour. Which can result in:-
  16. 16. Pressure sore
  17. 17. Hypothermia
  18. 18. Orthostatic pneumonia
  19. 19. Rhabdomyolysis
  20. 20. Dehydration
  21. 21. Increase mortality , 50% of those remain on the floor for 1 or more hour are dead within 6 months- 1 year.
  22. 22. Institutionalisation </li></li></ul><li>Categories of fall<br />Falls due to acute illness:- <br /><ul><li>Infection:- mainly bronchopneumonia or UTI
  23. 23. Vascular:- Myocardial infarction or Cererbrovascular accident
  24. 24. Metabolic:- hypoglycaemia, hyponatremia </li></ul>Single fall which may be accidental<br />Recurrent falls <br />
  25. 25. Risk factors for falls<br /><ul><li>Social and demographic factors:-
  26. 26. Advanced age
  27. 27. Living alone
  28. 28. Previous falls
  29. 29. Limited activity of daily living
  30. 30. Age related changes
  31. 31. reduced ability to discriminate edges. ( e.g. Stairs) ,
  32. 32. reduced peripheral sensation,
  33. 33. slower reaction time
  34. 34. muscle weakness
  35. 35. Poor gait and balance
  36. 36. Medical problem:- e.g. Parkinson's disease, cognitive impairment, CVA, Poor vision ( cataract and glaucoma) , foot problems, arthritis, peripheral neuropathy, incontinence
  37. 37. Medication:- antihypertensive, antipsychotic, sedative, opiates, diuretic, hypoglycaemic specially long acting oral drugs and insulin
  38. 38. Environmental :- Ill fitting footwear or wearing bifocal spectacles </li></li></ul><li>NSF – identifying those at risk<br />Intrinsic Risk Factors<br /><ul><li>Balance, gait or mobility problems
  39. 39. Taking four or more medications – especially sedating drugs, anti-hypertensives, anti-depressants, diuretics, anti-anginals, Digoxin
  40. 40. Visual impairment
  41. 41. Impaired cognition or depression
  42. 42. Postural hypotension, Carotid Sinus Hypersensitivity, Vasovagal tendency
  43. 43. Fear of falling</li></ul>Extrinsic Risk Factors<br /><ul><li>Poor lighting –particularly on the stairs
  44. 44. Steep Stairs
  45. 45. Loose carpets & rugs
  46. 46. Slippery floors
  47. 47. Badly fitting footwear or clothing
  48. 48. Lack of grab rails or raised seating
  49. 49. Inaccessible lights or windows</li></li></ul><li>
  50. 50. Assessment of Acute fall<br />History of the fall in details , review of system, and medication review.<br />Examination of :-<br /><ul><li>the injuries
  51. 51. Vital signs including respiratory rate
  52. 52. Conjunctivae for severe anaemia
  53. 53. Chest, abdomen, CVS, neurological examination
  54. 54. Blood pressure lying and standing
  55. 55. Cognitive function
  56. 56. Functional assessment – get up and go test. </li></ul>Test- investigation:- <br /><ul><li>FBC, Urea and Electrolyte, CRP, glucose, CXR, ECG.</li></li></ul><li>Acute Fall<br />yes<br />Can mobilise <br />Admit to treat and consider MFA<br />no<br />Yes<br />OP<br />
  57. 57. NSF – who should be referred to a specialist falls service?<br />Those who have had a previous or new fragility fracture<br />Those who attend A&E having fallen<br />Those who have called out an ambulance having fallen<br />Those who have two or more intrinsic risk factors in the context of a fall<br />Those who have frequent unexplained falls<br />Those who fall in a care home<br />Those who live in unsafe housing<br />Those who are very afraid of falling<br />
  58. 58. Single and Recurrent fall assessment<br /><ul><li>History taking (splatt)
  59. 59. Symptoms:- dizziness, vertigo, chest pain, palpitation, speech problem
  60. 60. Previous fall:- is this the first fall secondary to acute illness or recurrent secondary to mobility problem or cognitive function.
  61. 61. Location:- outdoor or indoor ( outdoor has a better prognosis than the ones at home)
  62. 62. Activity:- walking, hanging out washing, standing on a chair, standing from sitting
  63. 63. Time:- after meal, early in the morning.
  64. 64. Trauma:- sustained?
  65. 65. Medication review
  66. 66. Cognitive function assessment ( AMT)
  67. 67. Functional assessment ( get up and go test)
  68. 68. Vision assessment ( cataract-acuity, visual field)
  69. 69. Hearing
  70. 70. CVS examination
  71. 71. Blood Pressure Lying and standing *
  72. 72. Investigation:- FBC, Urea and electrolyte, LFT, TFT, CRP, Urine , ECG,
  73. 73. Further test:- CXR, ECHO, 12 Hour ECG, Holter , Tilt Test, CT-scan brain. </li></li></ul><li>Drugs associated with falls<br />Works either directly or may lead to systemic hypotension and cerebral hypo perfusion. Poly pharmacy is an independent risk factor.<br /><ul><li>Benzodiazepines
  74. 74. Tricyclic antideprresant
  75. 75. Skeletal muscle relaxant like baclofen
  76. 76. Opiate
  77. 77. Diuretic
  78. 78. Antihypertensives specilly ACE I and alpha blockers
  79. 79. Hypoglycaemic </li></li></ul><li>Syncope and pre-syncope<br />Syncope:- sudden, transient loss of consciousness, due to reduced cerebral perfusion. The patient is unresponsive with loss of control.<br />Pre-syncope:- feeling of light-headiness tat would lead to syncope, if corrective measures were not taken ( usually sitting, lying or hanging) <br /><ul><li>It is a major cause of morbidity in elderly population occurs in ½ of institutionalized patients. Account for 5% of hospital admission.
  80. 80. Causes:- </li></ul>Vasovagal :- vagal stimulation for example in fears and bad news<br />Postural hypotension:- main causes dehydration, septicaemia, medication, autonomic in Diabetes and addison’s disease.<br />Carotid sinus hypersensitivity <br />Cardiovascular :- arrythmia and outlet obstruction e.g. Aortic stenosis. <br />Neurology:- TIA and stroke. <br />
  81. 81. ORTHOSTATIC HYPOTENSION<br /> Common condition<br /> Most marked after meal, high temperature, exercise, and at night.<br />Reduction in systolic BP of 20mmHg on standing<br />Reduction in systolic BP to less than 90mmHg on standing<br />Reduction in diastolic BP of 10mmHg<br /> with symptoms<br />
  82. 82. ORTHOSTATIC HYPOTENSIONCauses<br /><ul><li>Drugs
  83. 83. Dehydration
  84. 84. Septicemia
  85. 85. Prolonged hypertension
  86. 86. Autonomic failure (pure, diabetic, parkinsons)
  87. 87. Adrenal insufficiency </li></li></ul><li>ORTHOSTATIC HYPOTENSION - THERAPY<br />Lifestyle measures<br />Stop offending drugs<br />Compression hosiery<br />Sympathomimetic vasoconstrictors - Midodrine, 2.5 mg tds (max 40mg daily) CI in IHD<br /> Caffeine with meal or NSAID <br /> Head up-tilt to bed<br /> Erythropoietin or octreotide <br />Volume expansion - Fludrocortisone, DDAVP<br />
  88. 88. VASOVAGAL SYNCOPE -MECHANISM<br />Upright posture, downward displacement of blood & venous pooling leading to:<br /><ul><li>Decreased ventricular filling & cardiac mechanoreceptor activation leading to:
  89. 89. Increased brainstem input & reduced sympathetic outflow & increased vagal tone
  90. 90. Resulting in vasodilatation & bradycardia syncope</li></li></ul><li>CAROTID SINUS HYPERSENSITIVITY<br /> 2% in healthy individual, and 35% of fallers above the age of 80 years. <br /> Mechanism <br /> Typical triggers are:- neck turning( looking up or around), tight collars, straining, meal, prolonged standing. <br /> How to perform CSM<br />
  91. 91. CAROTID SINUS HYPERSENSITIVITY<br />Carotid sinus massage for 5 seconds:<br />Cardio inhibitory: 3 second or more period of asystole<br />Vasodepressor: a 50mmHg fall in systolic blood pressure<br />Mixed response<br />
  92. 92. CSH - THERAPY<br />Cardio-inhibitory: permanent pacing<br />Vasodepressor: very difficult to treat, consider those therapies used for orthostatic hypotension<br />
  93. 93. Dizziness<br />Full history ?dizziness, ?vertigo, Pre-syncope, mixed, unsteadiness, malaise or generalised weakness <br /> Causes <br /><ul><li> Acute lybranthitis
  94. 94. Menieres disease
  95. 95. BPV
  96. 96. Causes of syncope and pre-syncope
  97. 97. Post Circulation infarction
  98. 98. Vertebrobasilar insufficiency
  99. 99. Anxiety and depression
  100. 100. Multifactorial </li></li></ul><li>PATIENT ASSESSMENT FOR SYNCOPE<br />HISTORY<br />Situation in which syncope occurred<br />Posture at time<br />Preceding symptoms<br />Actual loss of consciousness<br />Subsequent symptoms<br />Eye witness account<br />Co-morbidity<br />Drug history<br />
  101. 101. EXAMINATION<br />Heart rate / rhythm<br />Postural BP<br />Carotid bruits<br />Carotid sinus massage<br />Presence of murmurs<br />Neurology: evidence of stroke, cerebellar signs, Parkinson’s Disease<br />
  102. 102. INVESTIGATIONS<br />Baseline bloods : anaemia, renal dysfunction, diabetes<br />12 lead ECG<br />Holter monitoring<br />Tilt testing : 80’ head up tilt for 45 minutes +/- GTN provocation. <br />CSM supine & 80’ head up tilt<br />
  103. 103. Tilt Table Testing<br />Advise patient to avoid caffeine, large meals & alcohol prior to test<br />Omit cardiac drugs prior to test<br />Consent for the procedure<br />Lie flat on tilt table for 15 minutes<br />CSM Supine<br />Tilt for 30 minutes <br />If no events – carry out CSM when tilted<br />If no events – administer 2 puffs GTN sublingually & monitor for a further 15-20 minutes depending on response<br />
  104. 104. Life Example <br />66 lady from India, diabetic on metformin, presented with history of recurrent falls in the last 6 months. She also complained of generally feeling weak, tired, lost 7kg in the last 3 months with nausea and vomiting in the morning . O/E Bp Lying 130/80 Standing 100/60<br />76 years old , history of recurrent fall, with history<br />Of hypertension on amlodipine, and osteoarthritis of<br />Both knees. Last fall happened while searching for <br /> a book in his library . O/E BP L/S normal , bilateral<br />Knee swelling, X-ray neck severe OA (previous film) <br />
  105. 105. Life Examples <br /> 74 man , hypertensive on amlodipine ,and amiloride, and lisinopril also has history of bilateral knee OA with left sided TKR. Recently visited a surgeon for symptoms of BPH , started on Doxazocin 4mg . Presented with feeling light headed , dizzy, and followed by blackout and then fall. <br /> 77 old man , history of parkinson disease , presented with recurrent falls associated with feeling dizzy on standing up ,BP (L) 140/90 (S) 110/70 <br />
  106. 106. The End<br />