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FALLS
Falls and unsteadiness are very common in
older people. Around 30% of those aged 65
and over fall each year, this figure rising to
over 40% in those aged over 80 years.
Although only 10-15% of falls result in
serious injury, they are the principal cause of
fractured neck of femur in this age group.
Falls also lead to loss of confidence and
fear, and are frequently the 'final straw' that
makes an older person decide to move to
institutional care
.
• The approach to the patient varies
according to the underlying cause of falls,
as follows
• Accidental trip
• Those who have simply tripped may not
require detailed assessment unless they
are doing so frequently or have sustained
an injury
• Blackouts
• A proportion of older people who 'fall' have in
fact had a syncopal episode. It is important to
ask about loss of consciousness and, if this is a
possibility, to perform appropriate investigations
.Recent research suggests that in small
numbers of patients, carotid sinus syndrome
may be the cause of otherwise unexplained falls.
A wide variety of cardiovascular disorders can
cause an abrupt fall in cerebral perfusion that
may manifest as recurrent or isolated episodes
of syncope (sudden loss of consciousness) and
presyncope (lightheadedness and nearcollapse).
• Differential diagnosis Diagnosis may be difficult
but the probable mechanism of the patient's
symptoms can usually be determined by careful
analysis of the history. For example, a history of
vertigo is suggestive of a labyrinthine or central
vestibular disorder. Whenever possible, an
accurate description of the attack should be
obtained from the patient and a witness.
Particular attention should be paid to possible
precipitants or triggers such as medication,
exercise and alcohol, the duration of the
unconscious period and the recovery phase.
In cardiac syncope, defined as due to arrhythmia or
structural heart disease, onset is usually sudden and
recovery is usually rapid. In contrast, patients with
vasovagal syncope often feel nauseated and unwell
for several minutes before and after the episode.
Patients with seizures do not exhibit pallor, may have
abnormal movements and usually take more than 5
minutes to recover and are often confused on
recovery.
A careful history, clinical examination and simple .
tests will often reveal the cause of recurrent
syncope. The pattern and description of the patient's
symptoms should indicate the probable mechanism
and will therefore determine subsequent
investigations.
.
• Arrhythmia
• Lightheadedness may occur in association with a wide variety of
arrhythmias, but blackouts (Stokes-Adams attacks )are usually due
to profound bradycardia or malignant ventricular tachyarrhythmias.
Ambulatory ECG recordings may help to establish the diagnosis but
are of limited value unless the patient experiences typical symptoms
while the recorder is in place. Since minor rhythm disturbances are
quite common in the healthy population, a close temporal
relationship must be demonstrated between the patient's symptoms
and a recorded arrhythmia before arriving at a diagnosis.
• Patient-activated ECG recorders are useful diagnostic aids for
patients with recurrent dizziness but are clearly of no value in
assessing sudden episodes of collapse.
• In patients with presyncope or syncope in whom these
investigations fail to establish a cause, an implantable 'loop
recorder' can be placed beneath the skin of the upper chest under
local anaesthetia. This device continuously records an ECG and will
store arrhythmic events in its digital memory, which can be later
accessed using a telemetry device
Structural heart disease
• Severe aortic stenosis,
• hypertrophic obstructive cardiomyopathy
and
• severe coronary artery disease
can cause lightheadedness or syncope on
exertion. This is usually mediated by
profound hypotension due to the
combination of a reduction in cardiac
output and a drop in peripheral vascular
resistance, but may also be the
consequence of an arrhythmia
Carotid sinus syndrome
Hypersensitivity of the carotid baroreceptors can cause
recurrent episodes of altered consciousness by promoting
inappropriate bradycardia and vasodilatation. The diagnosis
can be established by monitoring the ECG and blood
pressure during carotid sinus massage; however, this
should not be attempted in patients with suspected or
proven carotid vascular disease as it may cause TIA.
A positive cardio-inhibitory response is defined as a sinus
pause of 3 seconds or more; a positive vasodepressor
response is defined as a fall in systolic blood pressure of
more than 50 mmHg. Carotid sinus massage will produce
positive findings in about 10% of elderly subjects but fewer
than 25% of these individuals will report spontaneous
syncope. Symptoms should not therefore be attributed to
the hypersensitive carotid sinus syndrome unless they are
reproduced by carotid sinus massage. Dual-chamber
pacing may relieve symptoms that are due to bradycardia
• Vasovagal syncope
• This is usually triggered by a reduction in
venous return due to prolonged standing,
excessive heat or a large meal. It is mediated by
the Bezold-Jarisch reflex, which is characterised
by initial sympathetic activation that then leads
to vigorous contraction of the relatively
underfilled ventricles. This stimulates ventricular
mechanoreceptors and in turn produces
parasympathetic (vagal) activation and
sympathetic withdrawal causing bradycardia,
vasodilatation or both. Head-up tilt testing, which
involves lying the patient on a table that is then
tilted to an angle of 70° for up to 45 minutes
while the ECG and blood pressure are
monitored, can be used to confirm the diagnosis.
• A positive test is characterised by profound bradycardia
(cardio-inhibitory response) and/or hypotension
(vasodepressor response) that is associated with typical
symptoms. Treatment is often unnecessary but in severe
cases β-blockers (which inhibit the initial sympathetic
activation) or disopyramide (a vagolytic agent) may be
helpful. A dual-chamber pacemaker can be useful if
symptoms are predominantly due to bradycardia.
Finally, the subgroup of patients with a urinary sodium
excretion of less than 170 mmol/24 hours may respond
to salt loading.
Some variants of vasovagal syncope occur in the presence
of identifiable triggers (e.g. cough syncope, micturition
syncope) and are known collectively as situational
syncope
Postural hypotension
Symptomatic postural hypotension is caused by a failure of
the normal compensatory mechanisms. Relative
hypovolaemia (often due to excessive diuretic therapy),
sympathetic degeneration (diabetes mellitus, Parkinson's
disease, ageing) and drug therapy (vasodilators,
antidepressants) can all cause or aggravate the problem.
Treatment is often ineffective; however, withdrawing
unnecessary medication while advising the patient to wear
graduated elastic stockings and get up slowly may be helpful.
Treatment with fludrocortisone, in an attempt to expand blood
volume through sodium and water retention, may also be of
value .
Acute illness
Falling is one of the classical atypical presentations of acute illness in the
frail.
The reduced reserves in older people's integrative neurological function
mean that they are less able to maintain their balance when challenged
by an acute illness. Suspicion should be especially high when falls have
occurred suddenly over a period of a few days.
Common underlying illnesses include infection, stroke, metabolic
disturbance and heart failure. Thorough examination and investigation are
required to identify these
It is also important to establish whether any drug has been started
recently, as this may precipitate falls. Once an underlying acute illness
has been treated, falls may no longer be a problem.
INVESTIGATIONS TO IDENTIFY ACUTE ILLNESS
Full blood count Urea and electrolytes, liver function tests, calcium and
glucose
Chest X-ray( Electrocardiogram (ECG )
Urinalysis for leucocytes and nitrites; if positive, urine culture
C-reactive protein: useful marker for occult infection
Blood cultures if pyrexial
• Multiple risk factors
• Many patients, especially those with recurrent
falls, are frail with multiple medical problems and
chronic disabilities. Their tendency to fall is
associated with risk factors that have been well
established from prospective studies)
• .The annual risk of falling increases linearly with
the number of risk factors present, from 8% with
no risk factors to 78% in those with four or more.
Obviously, such patients may present with a fall
resulting from an acute illness or syncope as
above, but they will remain at risk of further falls
even when the acute illness has resolved
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RISK FACTOR FOR FALLS
Muscle weakness
History of falls
Gait or balance abnormality
Use of a walking aid
Visual impairment
Arthritis
Impaired activities of daily living
Depression
Cognitive impairment
Age over 80 years
Drugs
– Polypharmacy (four or more drugs )
– Digoxin
– Diuretics
– Drugs associated with sedation: benzodiazepines,
phenothiazines, antidepressants
– Type I anti-arrhythmics
PREVENTION OF FALLS IN OLDER PEOPLE‘
• Effective interventions to prevent falls in
elderly people include
• multidisciplinary, multifactorial interventions,
muscle strength and balance training,
• home hazard assessment and modification,
withdrawal of psychotropic medication,
cardiac pacing in fallers with carotid sinus
syndrome. It has been shown that an
effective way of preventing further falls in
this group is multiple risk factor intervention.
• The most effective way is balance and exercise
training by physiotherapists. An assessment of
the patients' home environment for hazards must
be delivered by an occupational therapist, who
can also provide personal alarms so that
patients can summon help, should they fall
again. Rationalising medication may help to
reduce sedation, although manyolder patients
are reluctant to stop their hypnotic. It will also
help reduce postural hypotension, defined as a
drop in blood pressure of >20 mmHg systolic or
>10 mmHg diastolic pressure on standing from
supine
• The cause of any disability such as loss of strength or gait
disturbance should be established, as specific treatment may
improve it. For example, a patient's quadriceps muscles may be
weak due to osteoarthritis of the hip, which will improve with
adequate analgesia and physiotherapy. Gait disturbance due to
Parkinson's disease will improve with appropriate drug treatment
and physiotherapy. Simple interventions such as providing new
• glasses or chiropody can have a surprising impact on function .
• Bone protection
• Osteoporosis prophylaxis should be considered in all older patients
who have recurrent falls, particularly if they have already sustained a
fracture.)
• In female patients in institutional care, calcium and vitamin D have
been shown to reduce fracture rates, and may also reduce falls due
to improvements in muscle function. Devices known as hip
protectors have also been shown to reduce the risk of hip fracture in
those in institutional care, but are poorly tolerated. They consist of
polypropylene pads fixed in special underwear to keep them
positioned over the greater trochanters. Should patients fall on their
hip, the pads disperse the force of the fall away from bone to soft
tissues.
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• MULTIFACTORIAL INTERVENTIONS TO PREVENT
FALLS
• Balance and exercise training
• Rationalisation of medication, especially sedative drugs
• Correction of visual impairment
• Home environmental hazard assessment and safety
education
• Treatment of cardiovascular disorders, including carotid
sinus syndrome and postural hypotension
• MANAGEMENT OF POSTURAL HYPOTENSION
• Correct dehydration ,Tilt up the head of the bed, Support
stockings (older patients may struggle to get these on),
Non-steroidal anti-inflammatory drugs (increase
circulating volume due to salt and water retention; gastric
side-effects limit use)
• Fludrocortisone (causes salt and water retention but
poorly tolerated due to cardiac failure)
ACUTE CONFUSION
This is also known as delirium, and is seen much
more commonly than dementia. Unlike dementia,
there is a disturbance of arousal that accompanies
the global impairment of mental function. This
usually takes the form of drowsiness with
disorientation, perceptual disturbances and
muddled thinking. Patients typically fluctuate,
confusion being worse at night, and there may be
associated emotional disturbance (e.g. anxiety,
irritability or depression) or psychomotor changes
(e.g. agitation, restlessness or retardation).
IN OLD AGE Increased risk: in the context of
relatively minor systemic disturbances.
• Predisposing factors:
– -dementia: conversely, an acute confusional state may herald
the onset of dementia
– -malnutrition
– -visual and/or auditory impairments
– -infections: chest or urinary tract infections are the most common
causes of confusion in old age, and a low threshold of suspicion
is essential. Typical symptoms including pyrexia may not be
present, so if there is no other obvious cause, it may be
appropriate to treat with antibiotics 'blind' once cultures have
been taken
– -surgery: very common after emergency surgery, and only
slightly less so after elective surgery
– -drugs: because of polypharmacy and changes in the response
to and elimination of drugs in old age.
CAUSES OF ACUTE CONFUSIONAL STATE
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Acute decompensation of dementia
Hashimoto's encephalopathy
Altitude sickness
Migraine
The diagnosis of an acute confusional state
involves careful history-taking. Patients are
usually disorientated, often in both time and
place, and therefore their account may not be
helpful. As with dementia, it is vital to take a
history from a witness (either a relative or a
carer). Examination may yield other clues to
the cause (e.g. pyrexia, or focal chest or
neurological signs). It is important to
distinguish confusion from a fluent aphasia,
since patients with this speech disorder may
appear confused. Often, however, the cause
is not immediately obvious, and a wide
screen of tests must be performed including:-
Almost any acute illness may present with confusion
in old age, and the most common are infection and
stroke. The recent addition of a drug is a further
common precipitant. Predisposing factors include
visual or hearing impairment, alcohol misuse and
poor nutrition .After the telephone test, any acute
illness should be sought and treated.
Computed tomography (CT) of the brain is required
in:- :
those with focal neurological signs
those with head injury
those who fail to improve despite treatment of
identified acute illness
• Management
• The management of acute confusional states
involves identifying the cause and correcting it if
possible.
• Confused patients should be nursed in a well-lit
room. During the period of confusion,
• sedative drugs are best avoided, as they may
exacerbate the confusion, although occasionally
drugs such as haloperidol (1-10 mg 8-hourly)
may be required.
• In delirium tremens (alcohol withdrawal), the
treatment is a tapered course of diazepam with
high-dose intravenous thiamin
• If confused patients become so agitated that
their behaviour puts them or others at risk,
sedation may be required. Initially, small doses
of haloperidol (0.5 mg) or lorazepam (0.5 mg)
are the safest drugs to use. Not all patients
present with agitation; some become apathetic
and withdrawn, and care must be taken to
ensure their adequate hydration and nutrition.
Acute confusion in old age can be slow to
resolve and may not do so completely. It is a
marker for the possible subsequent
development of dementia .
Urinary incontinence
is defined as the involuntary loss of urine,
sufficiently severe to cause a social or hygiene
problem. It occurs in all age groups but becomes
more prevalent in old age, affecting about 15% of
women and 10% of men aged over 65 years. It may
lead to skin damage if severe and is very socially
restricting. While age-dependent changes in the
lower urinary tract predispose older people to
incontinence, it is not an inevitable consequence of
ageing and always requires investigation. Urinary
incontinence is frequently precipitated by acute
illness in old age and is commonly multifactorial
.
• Clinical assessment and investigations
• The pattern of micturition is important in defining the
incontinence, and patients should be encouraged to
keep a voiding diary, including the estimated volume
voided, frequency of voiding, precipitating factors and
associated features, e.g. urgency .
• Examination includes an assessment of cognitive
function and mobility, and of
• perineal sensation and anal sphincter tone since the
innervation is from the same sacral nerve roots that
supply the bladder and urethral sphincter.
• A general neurological assessment is required to detect
disorders such as multiple sclerosis that may affect the
nervous supply of the bladder, and the lumbar spine
should be inspected for features of spina bifida occulta.
• Rectal examination is needed to assess the
prostate in men and to exclude faecal impaction
as a cause of incontinence.
• Genital examination should identify phimosis
and paraphimosis in men, and vaginal mucosal
atrophy, cystoceles or rectoceles in women. .
• Urinalysis and culture should be performed in all
patients.
• An assessment of post-micturition volume
should be made, either by post-micturition
ultrasound or catheterisation. Urine flow rates
and full urodynamic assessment may also be
helpful in selected cases
Incontinence syndromes
Stress incontinence
In stress incontinence leakage occurs because
passive bladder pressure exceeds the urethral
pressure, due to either poor pelvic floor support or
a weak urethral sphincter. Most often there is an
element of both. This is very common in women
and most often seen following childbirth. It is rare in
men and then usually follows surgery to the
prostate. Urine leaks when abdominal pressure
rises, e.g. when coughing or sneezing. In women,
perineal inspection may reveal leakage of urine
when the patient coughs, and sometimes also a
prolapse. Females in particular respond well to
physiotherapy but if incontinence is persistent and
troublesome, surgical treatment is indicated .