Staying upright
• Muscles and joints• Eyes:
– Acuity– Contrast – Depth perception– Field- range of vision
• Ears– Semicircular canals in 3 planes– Utricle and saccule
Staying upright
• Proprioception– Receptors in skin and joints
• Vasoactive responses– Blood pressure and heart rate correct for
changes in position against gravity
• Neural processing– Needed to put it all together
Healthy ageing
• Reduced muscle strength and power
• Reduced reaction times
• Reduced proprioception
• Changes in vision
• Reduced bone strength
• Reduced neural processing power
Falls in individuals
Identify those at greatest risk
• Previous history of falling
• High number of risk factors
• Fear of falling
• Functional tests
Effects of illness
• Stroke:
• Parkinson's disease• Arthritis
• Diabetes
• Weakness, balance , sensation
• Neural processing
• Strength power and proprioception
• Sensory loss, muscle weakness
Effects of illness
• Cardiac problems
• Dementia
• Bladder problems
Changes in blood pressure and heart rhythm
Reduced processing
need to move fast
Falls risk factors
• Visual problems• History of eye disease: may cause difficulty with
contrast and depth even if acuity ok
• Bifocal glasses
• Cognitive impairment • Evidence of delirium in hospital
• Inability to walk and talk at same time is subtle clue to loss of processing
Medications
• Psychotropics
• Analgesics
• Anticonvulsants
• Antihypertensive
• Antimuscarinics/ anticholinergics
• Diuretics
FRAT Falls risk assessment tool
• Any history of fall in the last year
• On > 4 medications
• History of Parkinson's disease or stroke
• Self reported problems with gait and balance
• Unable to rise from chair at knee height without use of arms
Functional tests of falls risk
• Sit to stand 5
• Six meter walk test
• 180 degree turn test
• Stalk test
Functional test of falls
• Tinetti gait and balance score– Assesses falls risk as high , medium or low
• Elderly mobility score– Assesses likelihood of independence with
functional daily tasks
Syncope and postural hypotension
• Neurocardiogenic syncope
• Carotid sinus syndrome
• Orthostatic hypotension
Orthostatic hypotension
• Neurogenic– Primary autonomic failure
– Secondary autonomic failure
• Non- neurogenic– Reduced intravascular volume
– Vasodilatation
– Cardiac impairment
– Drugs
– hypertension
• Evidence of loss of consciousness causing fall
• No recollection of cause
• Fall with injury particularly facial
• Symptoms of faint
• Confusion after event
Syncope and seizures
Epilepsy/ syncopeVasovagal Cardiac Epilepsy
Trigger Common Rare Rare
Prodrome Almost always Uncommon/ brief Common/ aura
Onset Gradual Sudden Sudden usually
Duration 1-30 secs Variable 1-3 mins
Colour Pale Pale Cyanosed
Jerks Brief Brief Common
Lat tongue bite Rare Occasional Common
Breathing Quiet Quiet apnoeic
Injury Rare Occasional Common
Recovery Sleepy- mins – hours
Rapid Slow-often with confusion
Syncope investigations
• Ambulatory ECG
• R wave recordings
• Head up tilt test + carotid sinus massage– Two or more episodes of blackout– One blackout with injury
Falls interventions
• There have been effective falls interventions using single and multiple components
• Reduced falls order of 20- 40 %
• Single interventions are effective if targeted to people where high proportion of falls risk is attributable to risk factor and is modifiable
Modifiable single risk factors
• Reductions in psychotropic drugs ( Campbell 1999)
• Treatment of syncope ( Kenny 2001)
• Reductions of home hazards ( Cummings 1999)
• Cataract surgery ( Foss 2006)
Gait and balance training
• Targeted gait and balance training is part of successful multi-factorial and single interventions
• Exception is for patients with dementia
Medical falls clinic
• Examination for new or undiagnosed medical problems
• Investigation of blackouts and postural hypotension
• Review of medications especially sedatives or multiple cardiac medicines
• Screen for osteoporosis• Recommendation for exercise/ rehabilitation if
frail or high fear of falling
Treatment of syncope
• Cardiac pacing- cardioinhibitory and mixed carotid sinus syndromes
• Midodrine –hypotensive carotid sinus syndrome
Orthostatic hypotension- general measures
• Hot weather• Post prandial• Drugs• Leg crossing• Diurnal• Raised intrathoracic
pressure
• Increase fluid intake• Increase caffeine• Isotonic exercises• Bed head raise
Orthostatic hypotension-medications
• Anaemia- erythropoietin
• Parkinson's disease- domperidone
• Fludrocortisone
• Midodrine
Exercise
• One to one or group
• Targeted to individual
• Strength and balance
• Progressive
• Prolongued intervention
Health promotion in falls
• Reasons people don’t exercise:
• Health problems• Associations with
frailty• Increased pain• Other priorities
• Reasons people do:• Feeling better• Less dizzy• Able to do more• Looking good!
Summary:
• Maintaining upright posture and mobility involves complex processes
• Therefore there maybe many contributors to falls risk including illness but also general ageing and lack of conditioning
• Assessment of new onset problems or deteriorating mobility is worthwhile
Summary
• Interventions to reverse weakness and balance problems take time and effort and are not possible for all
• If a person is unable or unwilling to engage in rehabilitation and exercise then reducing the risk of falls with assisstive devices and environmental checks and aids is the best option
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