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Um Oh, so hello everyone. This is our third talk of the series um with one of our doctors who is an I MT two who is applying for Jerry's next year. And I think it's gonna be a really good talk on falls and frailty. So hopefully will be really helpful for medical students, people interested in Jerry um covering lots and hopefully you'll be able to learn lots and we'll be go through at the end our next lecture dates for Geriatrics. Um and me and Viv will be on the chat throughout. So if you have any questions um about the series or anything that's going on, just let us know. Um But yeah, I'll hand it over to. Ay, thanks very much Jesser. Good evening, everyone. Uh As just mentioned, I'm a, I'm one of the I MT twos working actually on Jerry's at the moment in Northwest London. Um I also worked with mindedly for the webinar lead and then I saw we had a series on so I decided to hop in and hopefully help out with uh it's quite useful talk, I think in terms of something that we'll see a lot of on medical take, especially at this time of year. Um, it's quite useful topic to get familiar with and comfortable with. Um, because there's a lot that we can actually do to assess and manage and reduce the risk of falls in older adults, which has a lot of tangible long term benefits. So hopefully at the end of this talk, you'll have a slightly better idea as to how to approach uh, this topic and and kind of how you would manage these patients when you see them in the hospital. So by the end of the session, uh hopefully we'll all be able to identify some of the key multifactorial causes of falls in older adults. And some of the things I'm gonna talk about include cardiovascular causes, musculoskeletal, neuropsychiatric and environmental factors. I also wanna go go uh go through how to conduct a thorough assessment of patients presenting with falls, including some of the key pearls of wisdom in terms of history taking and physical exam components. And I also wanna highlight the role of the MDT in this for anyone who's done a Gerry's job. I'm sure you're very familiar with talking quite frequently with the occupational therapists, physical therapists and the discharge teams. I'm just gonna highlight some of the ways in which our work overlaps with some of the stuff that they do. We're also gonna briefly touch on the red flags that require urgent attention, things like head trauma, suspected fractures how to assess and work these patients up. And then I'm gonna briefly talk to you some of the investigations that we're commonly gonna use in the context of falls to identify why someone's had a fall. Um, and I'm gonna kind of sign post how we arrive at deciding on these investigations. The other important topic that I'm gonna talk about towards the end of the lecture is, uh, the topic of bone health and specifically how we assess bone health objectively using a few different tools that look at fracture risk and also how we then, um, apply these to then decide on a management strategy. And obviously, if anyone has any questions as we go along, please pop them in the chat. Um I can either answer them as we go along or we can do a bit of AQ and a at the end. So it sounds like a bit of a redundant question. But I think it's important to think about why falls are actually important because a fall in and of itself, as many geriatric consultants often say is a symptom of an underlying health issue. It's often the tip of the iceberg when it comes to identifying what's actually going on with someone. Um And it's important to recognize it as such. There's also a big economic impact of falls. Uh This figure that I've quoted here was actually from 2014. I couldn't find anything more recent than that. Um but as of 2014 falls cost to the NHS at least 2.3 billion lbs each year. And I'm sure that figure has gone up since then. Um, especially because of the fact that um we have an increase in the aging population. Uh, there's a lot of er, wider kind of societal and economic issues associated with this. Um, and the presence of things like multimorbidity, polypharmacy and frailty are all very important to this. Basically, we've gotten much better at keeping sick people alive for much longer. And obviously, that's a really good thing in terms of extending qual extending life expectancy. But it does come with certain issues that we weren't previously dealing with in healthcare 10 or even 20 years ago. So that's something that I think we just need to bear in mind as I'm going through the rest of the talk, understanding why someone has had a fall is really important in order to guide how to manage their care both in the acute setting whilst they're in the hospital and also in the longer term. And in turn, uh this should hopefully reduce the burden of falls on the system as a whole and can red uh result in better patient outcomes. So the key point just to draw home at this point is that falls in the elderly are very commonly multifactorial and it's a combination of medical issues, social issues, environmental issues. Um and it's really important to think about all of these, when we're assessing these patients to establish how we're best going to manage them going forwards. So why do older people fall? I think one of the more common things that we think about in this context is cardiovascular causes. And a lot of these clues can be picked up in a good history when, when you're doing your, your admission larking. And so some of the clues in the history that suggest that there might be a cardiovascular precipitant of a fall would include features such as dizziness, palpitations, sudden loss of consciousness or a background of previous cardiovascular disease. And we often see a quick recovery phase after loss of consciousness if it's a cardiovascular etiology, some of the common categories of cardiovascular causes of falls include arrhythmias, valvular disease and postural hypotension. So let's quickly uh go over some of the common arrhythmias that you might see. So sinus node dysfunction uh is something that's very common in older adults. And it includes things like sinus, bradycardia and sinus pauses. The symptoms of this typically would include things like lightheadedness, fatigue, or syncope, and something that we often see is what's termed the sick sinus syndrome. Whereby due to age related calcification, the sinus uh note doesn't work as well as it once used to, that can result in these transient episodes of bradycardia which can sometimes result in falls. Uh The management of this typically would be with uh pacemakers, especially if symptomatic. For example, if the patient has had a fall that's led to a neck of feur fracture, but that's something that we'll touch on a little bit later on. Another common thing that we will see on the admission ec GS of these patients who've had cardiovascular falls, um, is heart blocker whereby the atria and the ventricles aren't quite communicating in the same way as, um, as as they would in healthy individuals. And the more worrying ones that we would often see and the ones that would mandate pacemaker insertion would be a second degree or remove its type two heart block uh where you have intermittent drug beats. Uh This has a risk of progressing into its third degree heart block, whereas there's complete association between the atrial activity. So the P waves and the ventricular activity in the QR S complexes and that's quite a risky rhythm because essentially uncoordinated electrical activity results in irregular cardiac output and often results in um cerebral hypoperfusion and leading to syncope and leading to folds. So that's brady arrhythmias. Uh We often also see tachy arrhythmias and one of the most common ones that we we I'm I'm sure we've all seen uh in the hospital is atrial fibrillation or af this is particularly troublesome when there's a rapid ventricular response. Um Again, for the same reason as as mentioned before. Um the topic of af in and of itself is a very, very broad topic. I'm not gonna go too much into detail about it in this talk. Um But broadly, the principles of atrial fibrillation management focus on rate versus rhythm control. And we more often than not, particularly in the elderly patients prefer a rate control strategy that's normally done either with beta blockers, things like bisoprolol er, or things like digoxin. Uh There are a few other options as well but those are the main ones that we'll use. Um, and sometimes a rate control, sorry, a rhythm control strategy will be used that could either be pharmacological or electrical. Um, a another consideration with that is of course, anticoagulation, which is a whole different topic as well, that also increases the risk of significant falls and that it's always a decision that needs to be weighed out quite cautiously when you're deciding whether to start someone on something like Apixaban, something that's less commonly seen uh is ventricular tachycardia. The reason it's less commonly seen is because it's generally less well tolerated. It's um it carries a much higher risk of uh major adverse events like cardiac arrest, but you do sometimes see patients who are just kind of chugging along with a, with a ventric tachycardia on a, on a monitor, which can be a bit of a scary situation. Um Again, this is something that needs to be addressed. Um, it's a very different management to um a um A s and if you ever see this acutely in the hospital you would just follow your A LS um management but provided that they're stable. Um You would consider things like pacing and pacemaker insertion plus minus ICD insertion as well. There's a few common arrhythmias that we often see that can manifest with syncope and therefore falls moving on a little bit to valvular pathology. Um The most common valvular pathology that I'm sure we've all heard um when, when you've auscultated the chest and also seen commonly is aortic stenosis. And I remember when I was in med school, uh one of my registrars was telling me about the, the pneumonic sad. So, syncope, angina and dyspnea as one of the easy ways to remember exactly what the symptoms of this are. So, that's commonly how aortic stenosis presents. Uh There.