(eg carers) Range of interventions Increasing range of movement \200 Active or passive exercises \200 Use after stroke or prolonged bed rest to increase joint mobility and prevent pain and contractures Increasing strength of muscles \200 Usually general strengthening to improve stamina \200 Can be targeted at speci \201 c areas of weakness and enhanced by the use of resistance and weights Important part of falls prevention Improve coordination \200 Usually after stroke \200 Repeated movements rehearse skills and improve coordination \200 Improve sitting balance Transfers (ie the ability to get from one place (bed) to another (chair)) \200 Strategy d epends on patient ability \200 Totally dependent patients are hoisted \200 Once there i s sitting balance then transfers with assistance of two people and a sliding board can be attempted Once there is standing ability, then standing transfers with one person, then a frame can be worked on PHYSIOTHERAPY 87 Ambulation \200 Exercises aimed at improving independence in mobilizing \200 Realistic goals should be set \200\224 ideally premorbid state should be achieved, but 10m may be adequate for discharge home if this is the distance from chair to kitchen Balance aided by bars then walking aids Heat treatment Using packs, hydrotherapy pools, ult rasound etc. to treat pain and imp-rove joint mobility. Other treatments For example, cold treatments, electrical stimulation for pain relief (eg t ranscutaneous nerve stimulation (TENS) machine). Provision of aids Usually ambulatory aids. 88 CHAPTER 4 Rehabilitation Walking aids These increase stability, leading to improved con \201 dence and function, an d decreased falls. In general, identifying the need for an aid should prompt consideration of: the cause of functional decline (is it reversible?); provi- sion of a physiotherapy ass essment for prescription (correct aid, correct size); education (use of the aid, how to get up after falls); and treatment (strength/balance training). All walking aids without wheels should be \201 tted with rubber ferrules to optimize grip and then checked for wear regularly (Fig. 4.1 ). Stick (or cane (USA)) \200 May be single-ended ( \200\230straight \200\231), double-ended ( \200\230hemi- \200\231 or \200\230bipod \200\231), three-ended ( \200\230tripod \200 \231) or four-ended (delta-, quadrupod).The latter offer modest additional stability compar ed to the straight stick Held in the hand opposite the most impaired leg, thus unweighting the impaired limb The level of hand placement should be at the greater trochanter, permitting 20 \200\22330 of elbow \202 exion \200\224 the most ef \201 cient elbow m uscular function The choice of handle is important, eg Contoured : improve grip, reduce pressure, in permanent users or those with deformities Swan neck : weight is centered over the base of the stick, providing a little more stability Right-angled : more comfortable, but not easily secured when not in use Crook handle : hooked over the arm when not in use Frame \200 A structure of lightweight alloy metal that is self-stabilizing (usually based around four points in contact with the \202 oor), providing unweighting of the lower lim bs and greater stability than a stick Various heights, depths and widths are available \200 Bulky, and dif \201 cult to transp ortation. Some folding versions (often only three legs) are available \200 May be used indoors or out \200 The handgrips should be at wrist level, with the elbows slightly (15 ) \202 exed. Shorter frames are used in patients who fall backwards To use a non-wheeled frame , lift it and move it 10 \200\22330cm in front of the body; then lean forwards a little, taking some weight through the arms before taking two equal steps towards the center of the frame A weighted frame has weights low on the frame structure to provide additional counter-balance against falls A wheeled frame has wheels at the front, permitting faster walking and an improved gait pat tern, but it provides a slightly less stable base. Small-wheeled frames are suitable only f or smooth surfaces \200 A gutter frame has forearm rests, enabling weightbearing through forearms rather than hands alone, providing additional support in the early stages of mobil ization, or when hands/wrists are impaired WALKING AIDS 89 Crutches A full assessment by a therapist is needed before selecting crutches. Crutches may be of the axilla- or elbow- type. Both are available with various features that should be individually prescribed, eg closed elbow cuffs provide added security and enable the user t o let go of the handgrip to open a door without the crutch falling to the \202 oor. Walkers or rollators \200 A frame that has three or four wheels and often hand-operated b rakes (for added stability while static) Three-wheeled versions usually fold, permitting stowage in a car \200 Rollators with addi tional features such as bigger wheels (for uneven ground), a seat or attached basket for sh opping or other house/ garden tasks are larger than most standard frames and are usually us ed outdoors A trolley walker combines walking support with a means of transporting items from room to room. One or two shelves. The lower shelf is recessed at th e back so that it doesn t interfere with walking Early walking aids (EWA) For example post-amputation mobility aid (PAM-aid). Used early (us ually from 7day 7) following amputation, in patients in whom a permanent pros- thesis is pl anned or being considered. 90 CHAPTER 4 Rehabilitation Quadrupod stick Gutter frame Wheeled frame Non-wheeled frame Wheeled trolley (indoors) Three-wheeled rollator (in and outdoors) Fig. 4.1 Different types of walking aid. OCCUPATIONAL THERAPY 91 Occupational therapy Training BSc Occupational Therapy a is 3 \200\2234 years \200\231 full -time course or can be done as a 2-year accelerated postgraduate course. The courses are 2/ 3 academic and 1/3 \201 eld work. After primary training OTs usually subspecialize in one area such as care of the elderly. See (for UK) the British Association of Occupational The rapists and College of Occupational Therapists website, M www.cot.org.uk . Role of the OT College of Occupational Therapy de \201 nition: \200\230OT enables people to achieve health, well-being and life satisfaction through part icipation in occupation (ie daily activities that re \202 ect cultural values, provide str ucture to living and meaning to individuals; these activities meet human needs for self car e, enjoyment and participation in society) \200\231. OTs achieve this by assessing both functional status and the environment then advising how to adapt. Skills versus habits \200 A skill is having the ability to start, carry out, and complete a task effectively (eg making a cup of tea) A habit is those tasks that are actually carried out (eg a person may be able to make a mea l, but does not do so when alone as they do not feel hungry) Components of personal ability Assessed by direct observation during tasks, formal testing, and informa- tion taken from carers, relatives, and other professionals. \200 Cognition \200\224 to understand the task and why it needs doing. May be limited by dementia, poor concentration span, poor problem-solving skills, etc. Assessed wi th cognitive tests such as Middlesex Elderly Assessment of Mental State (MEAMS) Psychology \200\224 wanting to do and complete the task. Limited by depression, apathy, impaired coping skills, etc. \200 Sensorimotor ability \200\224 espe cially in the upper limb 92 CHAPTER 4 Rehabilitation Occupational therapy assessments and interventions Assessments \200 Washing and dressing \200\224 aim to be done in the morning, when the patient would normally be carrying out these tasks Kitchen \200\224 looking at competence and safety for required tasks (depending on circumstances, eg may need to make a meal on a gas stove, or just pour a drin k from a prepared thermos) Access visits \200\224 are done without the patient, to study the layout and potential problems of a patient \200\231s own home Home assessment visits \200 A visit done with the patient, to see them in their own envir onment \200 Can be done by the OT alone, or with another member of the MDT (eg physiotherapist, care manager) May be useful to include intended carers (family or professional) as concerns can be addressed during the visit Can be done in the community while the patient is still at home, from a hospital ward prior to discharge to ensure that it is feasible and that all possible problems and dangers have been minimized, or after discharge as a follow-up Sometimes surprising \200\224 patients may either perform considerably better than expected (as they are in a familiar environment to which they have been adaptin g for years) or considerably worse (especially when a new physical limitation has occurred, such as stroke, as being at home emphasizes how different life will now be) Standard format for assessing all aspects of the property \200 Followed by a report conta ining observations on client performance and a list of recommendations regarding reorganiza tion of furniture (eg bring bed downstairs), equipment provision, and care required Often typed and circulated to all MDT members Interventions Teaching new skills (eg putting on a jumper with an arthritic shoulder) and h abits (eg heating up microwave meal every lunchtime). Looking at how much can be done by th e patient themselves, and how much help is needed (family or professional carers). Assessin g need for equipment and advising about suitability, as well as training carers in its use. Commonly used equipment includes aids to: \200 Access \200\224 ramps, rails, banisters, stairlifts, perching stools (high stools to enable seated access to a kitchen work surface) etc. Transfers \200\224 \200\230banana boards \200\231 (curved boards that the patient slides across from one horizontal surface to another), swivel mats (two circles that twist to allo w easier turning of an immobile patient, usually in a car seat) Mobility \200\224 wheelchairs, scooters etc \200 Bathing and dressing \200\224 bath boa rds, accessible baths and showers, long shoe horns, grab handles (to allow picking things u p without bending), etc. OCCUPATIONAL THERAPY ASSESSMENTS AND INTERVENTIONS 93 Toileting and continence \200\224 seat raises, commodes, non-return urine bottles (for use when lying \202 at), etc. Eating and drinking \200\224 cutlery and cups with easy grip handles, aids to improve safe ty with hot water (kettle holders, full cup alarms), tap turners, etc. Splints \200\224 for wrists (prevent pain) and ankles (foot drop) \200 Sensory aids \200\224 enhanced signals, eg large dials on a clock or altered signals, such as \202 ashing light instead of a bell for the deaf 94 CHAPTER 4 Rehabilitation Doctors in the rehabilitation team Doctors are commonly part of hospital rehabilitation tea ms but may be missing from community rehabilitation teams where a nominated doctor (eg GP o r community geriatrician) can be consulted about speci \201 c issues. When present, doctor s often chair MDT meetings \200\224 this may be partly historical and partly because they are \200\230professional risk takers \200\231 who are more con \201 dent at coaxing a sha red decision from a team, sometimes in very uncertain circumstances. Medical ward rounds are often less frequent than on acute wards (a weekly round would be us ual) and since the patient is usually medically stable, communication with patient and fami ly may predominate over medical management. In a rehabilitation setting the doctor \200\231s main duties to the patient are: Selecting patients and maintaining a waiting list \200 Optimizing and stabilizing medical treatments (eg ensure adequate analgesia) Rationalizing drug therapy (eg stop night sedation) \200 Anticipating and treating compli cations (eg pressure sores, Clostridium dif \201 cile -associated diarrhea (CDAD), DVT) Diagnosing and treating depression \200 Identifying and managing comorbid conditions (eg incontinence, skin tumors) Initiating secondary prevention (eg aspirin for stroke, bisphosphonates following osteoporotic fractures, in \202 uenza vaccination) Organizing secondary referral to other specialists (eg dermatology, orthopedics) Additional duties to the team include: \200 Education \200 Team building \200 Context -setting \200\224 doctors often cross health sector boundaries whereas therapists and nurses can be \201 xed in teams or wards. They should share inform ation about the patients on the waiting list and about those who do not reach the rehabilit ation unit and why. This overview can help the team understand pressure on beds, etc. NURSES IN THE REHABILITATION TEAM 95 Nurses in the rehabilitation team The role of rehabilitation nurses in the recovery of a pa tient is often underestimated. They spend the longest time and often have the most intimate relationship with patients and their relatives. Their wide role encompasses: Rehabilitation helper \200\224 particularly rehearsal of new tasks learned with therapists (eg transfers, dressing). It takes longer and more skill to encourage a patient to wash/dr ess themselves than simply to provide personal care \200\224 this is the fundamental diffe rence between rehabilitation and normal ward nursing Overall performance assessors versus snapshot \200\224 they can detect any differential pe rformance between what a patient \200\230can do \200\231 with the therapist and what he/sh e \200\230does do \200\231 when on their own, when tired or when relatives are visiting Communication and liaison \200\224 \201 rst port of call between members of the team and patient and relatives. Emotive information sometimes more readily revealed in such non-thr eatening discussions Nocturnal assessment \200\224 they are the only professionals able to monitor sleep, nocturnal confusion/wandering, and nocturnal continence/ toileting Continence management \200 Pressure and wound care management \200 Medication administe ring and monitoring self-medication \200 Ward or unit management Some senior specialist n urses have roles that overlap with the doctor, eg in selecting patients for rehabilitation, chairing MDT and family meet- ings, nurse prescribing, etc. This is especially true in som e CHs which can be exclusively run by nurse consultants. 96 CHAPTER 4 Rehabilitation Other members of the rehabilitation team Speech and language therapy Trained to degree leve l (3 \200\2234 years), or postgraduate diploma. See the Royal College of Speech and Languag e Therapists (RCSLT) website, M www.rcslt.org . Assessment and treatment of swallowing disorders forms the bulk of inpatient work. Careful bedside evaluation of the patient is central to this, complemented if necessary by video \202 uoroscopy, the assessment \200\230gold standard \200\231. Useful interventions include patient positioning, changes in the texture or consistency of food/ \202 uid, and carer supervision or prompting with food boluses. A period of \200 \230nil by mouth \200\231 may be necessary until possible recovery of a safer swallow, duri ng which arti \201 cial feeding should be considered. Assessment and treatment of speech disorders forms the remainder of their work, commonly fo llowing stroke, or head/neck surgery. Therapists are experts in communication disorders, an d their assessments are useful in distinguishing between severe dysarthria and dysphasia, f or example. They provide: advice to patient, carers and staff; alternatives to speech, incl uding communication boards, non-verbal strategies, and electronic communicators. Dieticians Trained to degree level (3/4 years) or postgraduate diploma. See the British Die tetic Association website, M www.bda.uk.com . \200 Malnutrition in older people is common , underdiagnosed and undertreated. Prevalence and severity is especially high with (acute or chronic) comorbidit y, and in inpatients Community dwelling older people may have an unvaried diet, depleted in fruit and vegetables ( \200\230tea and toast \200\231) Dieticians are experts in the assessment and treatment of nutritional problems, but other m embers of the MDT must be alert to the possibility of malnutrition, and initiate interventi ons and dietician referral. Screening tools are useful (see b Appendix, \200\230Malnutriti on universal screening tool (MUST) \200\231, p.695) Effective interventions include offering attractive food tailored to the individual, asking the family to bring in food, offering food frequently, and providing a dedicated assistant by the bedside to assist with feeding (this could be a staff member, family or informal ca rer). Modern packaging (prepacked margarine, snack boxes) can be obstructive Where normal feeding is impossible, eg after acute stroke, the dietician can provide assessment, monitoring and advice to the patient (and family) regardi ng arti \201 cial feeding (see b \200\230Nutrition \200\231, p.356) OTHER MEMBERS OF THE REHABILITATION TEAM 97 Pharmacists Pharmacists train for at least 4 years, leading to the MPharm degree. See the R oyal Pharmaceutical Society website, M www.rpharms.com . \200 Pharmacists are involved in preparation, prescribing, packaging and dispensing of medicines. They are key to the system delivering quality drug use to outpatie nts and inpatients, to older people Gatekeepers of many health community formularies (limited drug lists optimizing costs and effectiveness). They advise on all aspects of prescribing, espec ially interactions and dosing Issues where pharmacists may help: \200 High frequency of adverse drug reactions (up to 1 7 % of hospital admissions) Underuse of medications, eg preventatives in asthma \200 Poor concordance/compliance/adhe rence \200 Poor administration technique, eg inhalers \200 Frequent and complex changes in medication \200 Poor communication with primary care on discharge \200 Absence of f ull medication history on admission The NSF for older people states that all patients > 75 should have their medicines reviewed at least annually, and those taking four or more medi- cines 6 monthly. Every area must have schemes for older people to access help from pharmac ists in using their medicines. 98 CHAPTER 4 Rehabilitation Social work and care management Social workers are trained to degree level (3/4 years), or postgrad- uate diploma. See the British Association of Social Works website, M www.basw.co. uk . Care managers may have less formal training. \200 Care managers are based in both co mmunity and hospital settings, and may work with patients of all ages The quality of support that they provide to a geriatric medicine service is a key determinant of patient throughput and quality of care Any inpatient clinical area managing the needs of older people should have signi \201 cant input from a social worker with experience in working with older people Many EDs in UK hospitals now have a dedicated social worker, aiming to avoid admissions by optimizing access to social care \200 To function effectively, soc ial workers must have a detailed understanding of local services and facilities, how those services are accessed, as well as about supporting information such as transportation, costs, and waiting lists Elements of their role include: \200 Assessment of client needs, often informed by the MD T in hospital settings Translation of care needs into a package of care \200 Monitoring delivery of care and mod ifying its content or providers if necessary Providing patients and families with details of care homes that can meet the patient \200\231s needs, in the desired geographical area Providing advice about \201 nances and \201 nancial support, care homes, and home care Performing \201 nancial assessments to determine who will fund their own care, and who will receive assistance Counseling and support, to patients and families \200 Crisis management. For example, if a carer becomes ill or dies, a care package may be increased urgently, or emergency admissi on to a care home arranged. \200\230Social admission \200\231 to hospital should be a last resort, unless the condition of the patient has also changed, in which case urgent medical assessment, perhaps in a hospital, is essential Arranging short breaks (for the carer) or respite care (for the patient) COMMUNITY NURSES AND HEALTH VISITORS 99 Community nurses and health visitors Both are trained nurses with further postgraduate trai ning and experience that enables them to work more independently in community settings. The ir precise role and professional relationships varies greatly between districts. Community nurses Usually work for one or more GP practices, providing domiciliary nursing s ervices in excess of those provided by non-nurse carers. A district nurse is a community nu rse who has undergone further training. Specialist skills include: Wound care \200\224 assessment and treatment \200 Insulin injections and diabetes monito ring \200 Continence management \200 Bowel management \200 Chronic disease management \200 Education, of patients and carers (eg PEG feed, catheter care) Although caring for adults of all ages, much of their work involves older people, especially the frail elderly. They are often an excellent source of information about older people admitted to hospital, often having fre- quent contacts with frail elderly people who are unable to leave the hom e and are therefore seen only rarely by GPs. Community matrons are experienced senior nurses who are responsible for identifying and car e coordinating high intensity users of health-care. They coordinate agencies for complex, f rail and often elderly patients to promote well-being and try to obtain maximum ef \201 ci ency from primary care and secondary care providers. Often this involves trying to reduce e mergency admissions to hospital and/or calls to out-of-hours GPs. Health visitors Again, HVs usually work with one or more GP practice, but the domi- nant fo cus is on health promotion. Most work with mothers and babies/ /children, but they can work with any age group. Some HVs specialize in working with older people and carers. They may help older people maintain independence by: \200 Providing information about local activi ties \200 Advising on bene \201 ts \200 Advising on help available from social service s to support them in their homes Visiting people at home \200 Arranging respite care See the Community Practitioners \200 \231 and Health Visitors \200\231 Association website, M www.unitetheunion.com/cphva . This page intentionally left blank 101 Chapter 5 Falls and funny turns Falls and fallers 102 Assessment following a fall 104 Interventions to prevent falls 106 Sy ncope and presyncope 108 HOW TO Distinguish syncope and seizures 110 Balance and dysequilibrium 112 Dizziness 114 HOW TO Manage multifactorial dizziness \200\224 clinical example 115 Drop attacks 11 6 Orthostatic (postural) hypotension 118 Postprandial hypotension 120 HOW TO Measure postural blood pressure 121 Carotid sinus syndrome 122 HOW TO Perform carotid sinus massage 123 Falls clinics 124 102 CHAPTER 5 Falls and funny turns Falls and fallers A fall is an event that results in a person non-intentionally coming to r est at a lower level (usually the \202 oor). Falls are common and important, affecting 1/ 3 of people living in their own homes each year. They result in fear, injury, dependency, i nsitutionalization and death. Many can be prevented and their consequences minimized. Factors in \202 uencing fall frequency \200 Intrinsic factors . Maintaining balance \200\224 and avoiding a fall \200\224 is a complex, demanding, multisystem skill. It requires muscle strength (power: weight ratio), stable but \202 exible joints, multiple sensory modalities (eg proprioception, vision, eye sight), and a functional peripheral and central nervous system. Higher level cognitive function per mits risk assessment, giving insight into the danger that a planned activity may pose Extrinsic factors . These include environmental factors, eg lighting, obstacles, the presen ce of grab rails and the height of steps and furniture, as well as the softness and grip of the \202 oor Magnitude of \200\230stressor \200\231 . All people have the susceptibility to fall, and t he likelihood of a fall depends on how close to a \200\230fall threshold \200\231 a person sits. Older people, especially with disease, sit closer to the threshold, and are more eas ily and more often pushed over it by stressors. These can be internal (eg transient dizzine ss due to orthostatic hypotension) or external (eg a gust of wind, or a nudge in a crowded shop); they may be minor or major (no one can avoid \200\230falling \200\231 during comple te syncope) If insight is preserved, the older person can to some extent reduce risk, by limiting hazar dous behaviors and minimizing stressors (eg walking only inside, avoiding stairs or uneven surfaces, using walking aids or asking for supervision). Factors in \202 uencing fall severity In older people, the adverse consequences of falling are greater, due to: \200 Multiple system impairments which lead to less effective savin g mechanisms . Falls are more frightening and injury rates per fall are higher Osteoporosis and increased fracture rates \200 Secondary injury due to post-fall immobili ty, including pressure sores, burns, dehydration, and hypostatic pneumonia. Half of older p eople cannot get up again after a fall Psychological adverse effects including loss of con \201 dence Falls are almost always mul tifactorial. Think: \200 \200\230 Why today? \200\231 Often because the fall is a manif estation of acute or sub-acute illness, eg sepsis, dehydration or drug adverse effect \200 \200\230 Why this person? \200\231 Usually because of a combination of intrinsic and extrinsic factors that increase vulnerability to stressors 2A fall is often a symptom of an underlying serious problem, and is not a part of normal ag eing. FALLS AND FALLERS 103 Banned terms The terms simple fall and mechanical fall are used commonly, but they are faci le, imprecise, and unhelpful. \200\230Simple \200\231 usually refers to the approach adopt ed by the assessing doctor. \200 For every fall, identify the intrinsic factors, extrinsi c factors, and acute stressors that have led to it Within each of these categories, think how their in \202 uence on the likelihood of future falls can be reduced 104 CHAPTER 5 Falls and funny turns Assessment following a fall Think of fall(s) if a patient presents: \200 Having \200\230 tripped \200\231 \200 With a fracture or non-fracture injury \200 Having been found on the \202 oor \200 With secondary consequences of falling (eg hypothermia, pneumonia) Pa tients who present having fallen are often mis-labeled as having \200\230collapsed \200 \231, discouraging the necessary search for multiple causal factors. Practice opportunistic screening \200\224 ask all older people who attend primary or secondary care whether they have fallen recently. History Obtain a corroborative history if possible. May often need to use very speci \201 c, detailed, and directed questions. In many cases, a careful history differentiates betwee n falls due to: \200 Frailty and unsteadiness \200 Syncope or near syncope \200 Acute neurological problems (eg seizures, vertebrobasilar insuf \201 ciency) Gather information about: \200 Fall circumstances (eg timing, physical environment) \200 Symptoms before and after the fall \200 Clari \201 cation of symptoms, eg \200\230dizzy \200\231 may be vertigo or presyncope \200 Drugs, including alcohol \200 Previous falls, fractures and syncope ( \200\230faints \200\231), even as a young adult \200 Previous \200\230near-mi sses \200\231 \200 Comorbidity (cardiac, stroke, Parkinson \200\231s disease, seizures, c ognitive impairment, diabetes) Functional performance (dif \201 culties bathing, dressing, toileting) Drugs associated with falls Falls may be caused by any drug that is either directly psychoa ctive or may lead to systemic hypotension and cerebral hypoperfusion. Polypharmacy ( > 4 dr ugs, any type) is an independent risk factor. The most common drug causes are: \200 Benzodiazepines and other hypnotics \200 Antidepr essants (tricyclics and serotonin selective reuptake inhibitors (SSRIs) Antipsychotics \200 Opiates \200 Diuretics \200 Antihypertensives, especially ACE inh ibitors and A -blockers \200 Antiarrhythmics \200 Anticonvulsants \200 Skeletal muscl e relaxants, eg baclofen, tizanidine \200 Hypoglycaemics, especially: Long-acting oral drugs (eg glibenclamide) \200 Insulin ASSESSMENT FOLLOWING A FALL 105 Examination This can sometimes be focused if the history is highly suggestive of a par- tic ular pathology. But perform at least a brief screening examination of each system. \200 F unctional. Ask the patient to stand from a chair, walk, turn around, walk back and sit back down ( \200\230Get up and go test \200\231). Assess gait, use of wal king aids, and hazard appreciation (eg leave an obstacle in the way and see how they negoti ate it Cardiovascular. Always check lying and standing BP. Check pulse rate and rhythm. Listen for murmurs (especially of aortic stenosis) Musculoskeletal. Assess footwear (stability and grip). Remove footwear and examine the feet. Examine the major joints for deformity, instability, or stiffness Neurological. To identify stroke, peripheral neuropathy, Parkinson \200\231s disease, vestibular disease, myelopathy, cerebellar degeneration, visual impairment, and co gnitive impairment Tests Vitamin D de \201 ciency is common in older adults, and evidence suggests that repla cing it reduces fall, so always check and replace appropriately. Many other tests are of limited value, but the following are considered routine: \200 FBC \200 B 12 , folate \200 U, C + E \200 ECG \200 Glucose \200 C alcium, phosphate \200 TFT If a speci \201 c cause is suspected, then test for it, eg: \200 24hr ECG in a patient with frequent near-syncope and a resting ECG suggesting conducting system disease Echocardiogram in a patient with systolic murmur and other features suggesting aortic stenosis (eg slow rising pulse, left ventricular hypertrophy (LVH) on ECG ) Head-up tilt table testing (HUTT) in patients with unexplained syncope, normal resting ECG, and no structural heart disease However, all tests have false positive rates, and even a \200\230true positive \200\231 \201 nding may have no bearing on the patient \200\231s presentation. For example, a patien t falling due to osteoarthritis and physical frailty will not bene \201 t from echocardiog ram that reveals asymptomatic mild aortic stenosis. 2Use tests selectively, based on your j udgment (following careful history and examination) of the likely factors contributing to f alls. Further reading Kenny RA . ( 2008 ). Evidence-based algorithms and the management of falls and syncope in the acute medical setting . Clin Med 8 : 157 \200\223 62 . 106 CHAPTER 5 Falls and funny turns Interventions to prevent falls The complexity of treatment re \202 ects the complexity of etiology: \200 Older people who fall more often have remediable medical causes \200 Do not expect to make only one diagnosis or intervention \200\224 making minor changes to multiple factors is more powerful Tailor the intervention to the patient. Assess for relevant risk factors and work to modify each one \200 A multidisciplinary approach is key Reducing fall frequency \200 Drug review . Try to reduce the overall number of medication s. For each drug, weigh the bene \201 ts of continuing with the bene \201 ts of reduction or stopping. Stop if risk is greater than bene \201 t. Reduce if bene \201 t is likely f rom the drug class, but the dose is excessive for that patient. Taper to a stop if withdraw al effect likely, eg benzodiazepine Treatment of orthostatic hypotension (see b \200\230Orthostatic (postural) hypotension \200\231, p.118) Strength and balance training . In the frail older person by a physiotherapist, exercise classes, or disciplines such as Tai Chi Walking aids . Provide an appropriate aid and teach the patient how to use it (see b \200\230Walking aids \200\231, p.88) Environmental assessment and modi \201 cation (often by OT; see b \200\230Occupational therapy \200\231, p.91) Vision . Ensure glasses are appropriate (avoid vari- or bifocal lenses) \200 Reducing str essors . This involves decision making by the patient or carers. The cognitively able patient can judge risk/bene \201 t and usually modi \201 es risk appropriately, eg limiting walking to indoors, using a walking aid properly and reliab ly, and asking for help if a task (eg getting dressed) is particularly demanding. However: \200 Risk can never be abolished \200 Enforced relative immobility has a cost to health \200 Patient choice is paramount. Most will have clear views about risk and how much lifestyle should change Institutionalization does not usually reduce risk Preventing adverse consequences of falls Despite risk reduction, falls may remain likely. I n this case, consider: \200 Osteoporosis detection and treatment \200 Teaching patients how to get up . Usually by a physiotherapist \200 Alarms , eg pullcords in each room or a pendant alarm (worn around the neck). Often these alert a distant call center, which summons more local help (home war den, relative, or ambulance) Supervision . Continual visits to the home (by carers, neighbors, family, and/or voluntary agencies) reduce the duration of a \200\230lie \200\231 post-fall \200 Change of accommodation . This sometimes reduces risk, but is not a panacea. A move from home to a care home rarely reduces risk \200\224 care homes are unfam iliar, often have hard \202 ooring surfaces, and staff cannot provide continuous supervis ion INTERVENTIONS TO PREVENT FALLS 107 Preventing falls in hospital Falls in hospital are common, a product of admitting acutely u nwell older people with chronic comorbidity into an unfamiliar environment. Multifactorial interventions have the best chance of reducing falls: Treat infection, dehydration, and delirium actively \200 Stop incriminated drugs and avoi d starting them \200 Provide good quality footwear, and an accessible walking aid \200 Provide good lighting and a bedside commode for those with urinary or fecal urgency or frequency \200 Keep a call bell close to hand \200 Care for the hig hest risk patients in a bay under continuous staff supervision Interventions that are rarely effective and may be harmful \200 Bedrails (cotsides). Inju ry risk is substantial: limbs snag on unprotected metal bars and patients clamber over the rails, falling even greater distances onto the \202 oor below Restraints. These increase the risk of physical injury, including fractures, pressure sores , and death. Also increase agitation Hip protectors \200 Impact absorptive pads stitched into undergarments \200 Limited evi dence that they are effective in hospitals although there is some evidence in a care home setting Success relies on meticulous use which is dif \201 cult \200\224 they are tricky to put o n, can be uncomfortable, and multiple pairs ( 40 each) are needed if incontinence is a pro blem Further reading Gillespie LD , Robertson MC , Gillespie WJ , et al . ( 2009 ). Intervention s for preventing falls in older people living in the community . Cochrane Database Syst Rev 2 : CD007146 . Oliver D , Connelly JB , Victor CR , et al . ( 2006 ). Strategies to prevent falls and frac tures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyzes . BMJ 334 : 82 . 108 CHAPTER 5 Falls and funny turns Syncope and presyncope Syncope is a sudden, transient loss of consciousness due to reduced cer- ebral perfusion. The patient is unresponsive with a loss of postural control (ie slump s or falls). Presyncope is a feeling of light-headedness that would lead to syncope if corr ective measures were not taken (usually sitting or lying down). These conditions: Are a major cause of morbidity (occurring in a fourth of institutionalized older people), r ecurrent in 1/3. Risk of syncope increases with advancing age and in the presence of cardio vascular disease Account for 5 % of hospital admissions, and many serious injuries (eg hip fracture) Cause considerable anxiety and can cause social isolation as sufferers limit activities, in fear of further episodes Causes These are many. Older people with decreased physiological reserve are more susceptib le to most. They can be subdivided as follows: \200 Peripheral factors Hypotension may be caused by the upright posture, eating, straining, or coughing; and may be exacerbated by low circulating volume (dehydrati on), hypotensive drugs or intercurrent sepsis. Orthostatic hypotension is the most common c ause of syncope Vasovagal syncope ( \200\230simple faint \200\231) Common in young and old people. Vagal stimulation (pain, fright, emotion, etc.) leads to hypotension and syncope. Usually, an autonomic prodrome (pale, clammy, light-headed) is followed by nausea or abdominal pain, then syncope. Benign, with no implications for driving. Diagnose with caution in older peo ple with vascular disease, where other causes are more common Carotid sinus syndrome \200 Pump problem . Myocardial infarction or ischaemia, arrhythmia (tachy- or bradycardia, eg ventricular tachycardia (VT), supraventricular tachycardia (SVT) , fast atrial \201 brillation (AF), complete heart block etc.) Out \202 ow obstruction , eg aortic stenosis \200 Pulmonary embolism The main differenti al is seizure disorder, where the loss of consciousness is due to altered electrical activi ty in the brain (see b \200\230Epilepsy \200\231, p.166). 2 Stroke and TIA very rarely cau se syncope, as they cause a focal not a global de \201 cit. Brainstem ischaemia is the rar e exception. History The history often yields the diagnosis, but accuracy can be dif \201 cult to achie ve \200\224 the patient often remembers little. Witness accounts are valuable and should b e sought. Ensure that the following points are covered: Situation \200\224 was the patient standing (orthostatic hypotension), exercising (ischaemia or arrhythmia), sitting or lying down (likely seizure), eating (post- prandial hypotension), on the toilet (defecation or micturition syncope), coughing (cough s yncope), in pain or frightened (vasovagal syncope)? SYNCOPE AND PRESYNCOPE 109 Prodrome \200\224 was there any warning? Palpitations suggest arrhythmia; sweating with pa lpitations suggests vasovagal syndrome; chest pain suggests ischaemia; light-headedness sug gests any cause of hypotension. Gustatory or olfactory aura suggests seizures. However, ass ociations are not absolute, eg arrhythmias often do not cause palpitations Was there loss of consciousness? \200\224 There is much terminology