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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 • • • • • • • • • • • 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. • • 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 p a g e 1 1 8 7 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 .