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Hi, everyone. Welcome to med education. My name's Jing Jing and I'm usually on the support desk. It's really great to have you today for our talk. We're joined today by Doctor Martin Yates, who's a retired consultant, geriatrician, general physician, and former psychiatrist. Now welcoming in the Salford Royal Hospital as a geriatrician today, Doctor Yates will be teaching us about falls. If you have any questions for him, please leave them in the chat and he'll answer them as we go along. I'll let you take it from here then. Thanks. Thank you. And good morning everybody. I'd like to talk about falls today, falls particularly in the elderly, but falls in any age group. I think medicine and medical education in my experience teaches us to approach things like chest pain and dyspnea very well. But I think we're less good often at approaching things like falls because I think that the the etiology of falls um consist of both medical issues but also environmental issues um and psychological issues too. Um etiologies that really fall outside of perhaps a lot of traditional medical thinking. Um and the etiology of falls is multifactorial and multidisciplinary. And then so the treatment and the management of falls needs to also, if it's going to be effective, be multifactorial too. Um, so moving on to my first slide. Um, oops, sorry, I've gone accidentally a little bit too far. Um, just a few kind of demographics about falls. Um, I practice in a hospital in the north of England. Um, and this is, er, data from, er, from, er, lir from UK studies, different studies. but just to give a, a flavor of, of the importance of falls. So, so approximately 30% of over 60 fives will fall each year, the majority of them are in their own home. Um About 40% of fall as seen by ambulance crews are not taken to hospital after they've fallen again, about 40% will have no injuries and about 20% of people who fall at home will refuse to go to hospital. Even if the ambulance crews feel that they would benefit from going to hospital. I think very importantly, about 25% of over 65 A&E attendances are due to falls and certainly in terms of my inpatient work, I have a lot of patients on my ward who have fallen in the community and of course, some of them who will continue to fall in hospital too. Um Of the a and attendees, about 60% are out to hospital. So roughly half and about 70% of them. So roughly two thirds will have some injury. Um and about 10% of them will have fractures or serious injury. Um, roughly in the study of elderly fallers, about 12% of them, even with no neurological signs had evidence of an intracranial bleed. Um, often subdural hematomas. And just empirically, I think as we tend to use more in the way of anticoagulants, particularly for af and stroke prevention. It does seem to me in recent years, I'm seeing more and more um intracranial bleeding with falls, um untreated, about half of fallers will fall again in the following year, particularly those who have fallen indoors and are unable to get up. This is a marker essentially for, for frailty and only a minority of fallers are for a comprehensive falls assessment. Um Falls are part of frailty syndromes, what used to be called the geriatric giants. Um that comprises confusion, delirium and dementia falls. Of course, incontinence, both urinary and fecal and immobility and the characteristics of the frailty syndromes are they, they are often a manifestation of a nonspecific presentation of illness as I will go on to describe. So, so often with a number of different illnesses will fall. So it's not uncommon to see falls after someone develops pneumonia or a urinary tract infection or a fall is a manifestation of just being started on an opiate or something like that. I suppose an analogy in pediatrics will be a, a baby that cries because it's got colic or because it's hungry or because it's frightened and crying is the manifestation of, of many different things. Um As I'll go on to describe often in the frailty syndrome, there's multiple comorbidities, both acute and chronically coexisting and these comorbidities all need addressing because if they're not addressed, then there's going to be some aspects of etiology that just aren't man and therefore the chance of fall is that much great. Um in the frailty syndromes, illnesses are associated with cognitive and functional decline. And there's major social, functional psychological aspects to illness in terms of things like um interaction with others, getting out into the community, depression, anxiety and things like that. Um And another major characteristic of the frailty syndromes is the often inappropriate polypharmacy and vulnerability side effects um that um manifest. So, so this is kind of my own way of approaching thinking about falls. I split falls etiologies up into acute and chronic aspects. Um extrinsic to the patient and intrinsic and then intrinsically generalized issues and focal issues and bifocal, I mean, and the take home message, I think essentially of this talk is that there's four major aspects to the etiology of falls and they are cardiovascular aspects, central nervous system aspects, drugs and musculoskeletal issues. So, acutely, um any acute illness can lead to a fall. So it's very typical to find pneumonia, a urinary tract infection, perhaps pulmonary edema presenting as a fall. Um intrinsic acute things. Um cardiovascular wi would be something like syncope. So perhaps cardiogenic syncope and arrhythmia or classically orthostatic hypertension. Um, a patient who's just started to have a epilepsy and fits someone who's developed vertigo, perhaps benign positional vertigo or who's had her stroke. Um I vividly remember a number of years ago seeing a lady on an orthopedic ward who'd had a, a hip surgery and a hip repair and it was only noticed, um, a couple of days after the hip surgery that they were having difficulty mobilizing. And the reason was that she'd had a stroke and then she had a hemiparesis and that's why she'd fallen delirium is a, is a classical, um, cause of falls. Um, drugs are important, um, just been started on drugs, particularly cardiovascular and psychiatric drugs that cause often orthostatic hypertension or confusion. Um, a musculoskeletal um causes acutely, um such as pain, pain, painful, knee pseudogout or something like that acutely in a, in a knee causing forms. Um, and then of course, extrinsically, there are both personal and environmental hazards. I'll go on to describe some patients scenarios. Um, but, um, just, um, perhaps having perhaps something like a new carpet fitted in a house that hasn't been nailed down properly and a trip hazard can lead to patients falling over. So they are all the sort of acute things to think about. And then, of course, chronically, um, there are um chronic medical disorders like recurrent syncope, as I say, often orthostatic hypertension patients who have epilepsy. Um, vertigo, um PD stands for Parkinson's disease. I do apologize if there are some, uh, um, abbreviations I've used that are unfamiliar. I'll try and explain them all. C va stroke patients with dementia and not infrequently fall over patients may well be on drugs. They've been on for some time that are causing problems and musculoskeletal disorders like osteoarthritis are a chronic, sorry, a common backdrop to falls and of course, personal and environmental hazards that have been around for quite some time such as perhaps steep stas or um rugs and things that are in dangerous positions in the house. Um Sometimes animals, I've had patients in the past who have fallen over their dogs and cats. And on one occasion, I had a, a gentleman who presented with a fall, having fallen over his wife. I'm not quite sure how that came about, but, but these, these hazards all play a part in falls and it's important to, to think of all these areas um when we're addressing the etiology of falls. So I want to take just through some, just some real life clinical patients. I've looked after now just to kind of explain how, how they fit into that rubric of log I've just described. So Mrs BF was an 89 year old lady with no significant past medical history. She'd been recently been given bifocal spectacles. I've got bifocals on at the moment and um my bifocal spectacles have two lenses at the bottom, I have a lens that set up for me to see the screen at about 30 centimeters away. And the top lens allows me to see into the distance because of the focal length of the lower lens just here. Of course, if I look down at my feet, I just can't really see them very clearly. So bifocals are very dangerous to go up and down stairs and things like that. This is a lady that had been recently been given bifocal spectacles. Um She was very proud of her spectacles. Um She went out to do her shopping. She'd lived in the house she was in for 60 odd years, she knew the way very, very well. And on her way to the shops with her bifocals on, she tripped over the curb and she sustained a collies fracture to her left wrist. Um She got taken to an A&E department. She had a fairly perfunctory falls assessment and they put a plaster of Paris on her arm and sent her home the following day. Of course, she hadn't made it to the shop so she still needed um her provisions. So she went back to the shops with the spectacles on again. It was the same spectacles, the same curve and she fell again, tripped and sustained a right collis fracture. And at this point, I saw an, an A&E department with her arms upright like this with two collis fractures. This was a classic example of an extrinsic fall and there was essentially nothing wrong internally. She wasn't acutely unwell and she had no acute or in fact, chronic intrinsic factors. This was just an external um agent causing her fall. And it's very, very important to ask about spectacles and visual problems in general. When we have a fall, a fall and falls assessment. Mrs AC um was an 82 year old lady with longstanding diabetes. She had been presyncopal on standing for years. Um but, but I had never fallen. So when she stood up, she'd feel a bit lightheaded, but she hadn't fallen. And then she um developed dysuria um a fever and she presented with a fall, she had a lying and standing BP done. And the three minute drop, which I'm going to describe in a little bit, which is the important drop. It's the 2 to 3 minute drop rather than the immediate drop. It is important um showed 60 millimeter systolic drop in BP, which um is very significant. Um She had her urinary tract infection, which is what was giving rise to the dysuria treated and having that treated the drop reduced to 30 millimeters of mercury after treatment. And she was once again a little bit symptomatic from the Presyncope, but her fall stopped. And this is an example of an acute generalized illness on a chronic focal illness. So, the urinary tract infection is the generalized illness and the focal illness is the orthostatic hypertension secondary to diabetes. Diabetes in the UK is the most common cause of an autonomic neuropathy. Um Mr A Y A is a gentleman. I saw him a few years ago when I was on holiday. Um he was a 23 year old gentleman with no significant past medical history. Um I saw him walk over a chain suspended between two bollards on the sea front in a resort um to a bar at about four pm. Um And I saw him come back at about 11 pm and when he tripped over the chain um and sustained an orbital hematoma. Um and I, I went to his aide, um a very simple case, but this is an example if you like of an acute focal illness. Um and an extrinsic factor, the focal illness, though not an illness such was was drug intoxication, alcohol. In this case, an extrinsic factor was the chain. Um Either thing taken apart. Um may well have not led to the fall, he'd crossed the chain earlier on in the day without any problems. Um and had the chain not been there then he, he may well have not fallen over, but it's the combination of both things that brought about the phone. Um Mr SD was an 86 year old man with Alzheimer type dementia um repeatedly seen to fall over in his nursing home and known to be very unsteady and mobilizing. Um he was seen having presented with a fall, he had no acute illnesses. No orthostatic hypertension, hadn't had any epilepsy any fits. He was on no essentially culprit drugs and there were no low limb musculoskeletal problemss. And this is an example of a fall due to a chronic focal illness. In this case, dementia, dementia doesn't just affect memory. Um it affects behavior um and it can also affect processing of sensory input and to remain stable whilst moving. It's important to in real time um bring together sensory inputs from the lower limbs, visual inputs, vestibular input, cerebellar input and adjust them in real time and often in dementia, this is something that isn't done particularly well and this can be a cause of, of falls in the elderly. Um Mr Ss um was one of my ss a number of years ago. He was a fit and well, 30 odd year old man with occasional locking of his left knee. Um He presented having stood up his knee locked and due to the pain he developed vasovagal syncope. Um This is an example of an acute focal illness um on a chronic focal illness. So this is a vasovagal syncope um on a semi lunar cartilage tear. So, in terms of assessment for falls, um it's important to consider any acute medical illness may be associated with a fall. Um Don't forget the extrinsic factors of, as I've mentioned. Um sometimes the um the type of fall and injury will give you a clue as to what's caused the um the fall. So trips with preserved protection reflexes often allow the arms to come up resulting in risk. A iar fractures. A witness account is, is worth its weight in gold, particularly if there's been a loss of consciousness. Um then a history and examination aimed at the four big areas that I've I've mentioned and I've put them in yellow here to emphasize their importance. So, syncope is very important to think about um approximately a quarter of of falls associated with loss of consciousness, particularly cardiogenic syncope and orthostatic hypertension. Um Always remember um not particularly in terms of etiology for falls. Perhaps that any syncope from sitting is cardiogenic till proven otherwise. Um the big one particularly with elderly patients is orthostatic hypertension. Um And it's important to remember about 30% of syncope patients will have amnesia for the event. Um So, taking a history isn't always fabulously reliable from patients, particularly if they've had syncope and obviously, particularly if they have um cognitive problems. Um syncope usually leads to a forward fall um often with facial injury. So black eyes, broken noses, things like that neurological disorders are very important to think about and look at and look for particularly visual defects. Um So things like hemianopia and of course, spectacles, as I've mentioned before, vertigo as a cause of falls, seizures. Parkinson's disease, stroke disease, dementia, approximately all, third of all fallers will have some degree. Pardon me, of cognitive impairment, drugs, particularly psychoactive and cardiovascular drugs are important. Um psychoactive drugs because of altered levels of consciousness. Cardiological drugs usually um through um the genesis of hypotension and syncope and lower limb musculoskeletal disorders are very important, too painful knees, uh painful hips locking knees, things like that. Um other things to think about and nutrition, particularly vitamin D. So vitamin D is important, not just in terms of calcium metabolism, but vitamin D is also important in terms of muscle strength and particularly in climates where there's not great access to sunshine. Vitamin D deficiency is often very common. So particularly in the United Kingdom, particularly in patients who are in nursing homes and so measuring vitamin D levels and generally getting some measure of nutrition often in terms of sarcopenia, that is muscle mass, muscle strength is important. Your incontinence is also important in terms of falls and some patients who are incontinent um are prone to incontinence will be rushing to try and get to the toilet and may fall because they're in something of a hurry. And sometimes if they are incontinent, there's a slip risk in urine or sometimes feces that can cause falls. Also important is the fear of falling. Um One of the natural and understandable reactions to falling is to not attempt to mobilize, to sit and, and become rather sedentary. The problem about sitting down or lying down and not walking is that very soon, um, BP re regulates if you spend a lot of time lying or sitting down so that when you do stand up, you tend to get an orthostatic drop which can lead to falling. And of course, if you don't tend to mobilize and move around much, you tend to lose muscle mass. So, paradoxically, a fear of falling and, and diminished mobilizing can actually increase the risk of falls. Environmental hazards are also important as I have spoken about an inappropriate footwear. So going outside in slippers perhaps in the snow to empty the bins and things like this or sometimes um inappropriate walking aids. I've had a number of patients over the years that have actually fallen over their zimmer frames or their walking sticks because they've been used incorrectly. Um, medication, as I mentioned is very important, particularly large numbers of medicines, about 80% of fallers are taking four or more medicines and particularly as I say, psychotropic medications usually due to diminished consciousness levels. Of course, alcohol is a big risk factor for falls, um particularly with older patients, sedatives. So drugs like Temazepam zic tranquilizers, um diazePAM again, or the major tranquilizers, things like risperiDONE dien and antidepressants. Um particularly some of the all in our old fashioned um tricyclic antidepressants like amitriptyline um that have sedating side effects and some um uh alpha blockade as well. Um are associated with falls, um neurological um uh drugs. So, drugs that induce parkinsonism drugs like um haloperidol and things like that. And even the antiemetics like metoclopramide, which have dopaminergic antagonistic properties can lead to parkinsonism and and falls risk. Um and um cardiovascular medicines too. Um so usually through uh arrhythmias or orthostatic hypertension. So, drugs like ace inhibitors, ace two receptor antagonists, calcium channel antagonists, beta blockers and digoxin. Hi, Doctor Yates. Um We've got one question in the chat from Chris A. Could you explain once again how urinary incontinence can be a risk factor for a fall? Yeah, surely. So um so some patients who know that they have detrusor instability will not get much warning that they need to get to the toilet. So if they get the warning that they need to urinate, they'll jump up from the chair very quickly. And if they have a propensity to orthostatic hypertension, that quick jump up can be enough to drop the BP and then they'll rush off to the toilet, probably not taking very much care about how they're walking. So they may trip over a rug or a table leg or something like that. So that's part of it. And sometimes if they are actually incontinent say on their way to the toilet, they can then slip on the urine, just the actual liquid or sometimes feces if they are fecal incontinence and fall down too. So, so that's kind of the importance of urine incontinence, fecal incontinence to falls. And of course, it's not infrequent to find falls and incontinence in the same group of people because they are after all, all part of the same sort of frailty syndromes. Great. Thank you very much. Lovely. Hope, hope that helps. Um, ok, so when you're taking a history, what should we try and sort of um, focus on? And again, I've put in yellow, the things that are kind of the focal, um, things to falls that are really important. Um So first question would be um is it a trip? Is it a slip where have they fallen? Um Were they wearing bifocals or sunglasses inside or something like that? What footwear did they have on? Um had they been tottering around in high heels inappropriately on a carpet or something like that or had they gone out in slippers? Um Also sometimes worth knowing and thinking about is, is Onychogryphosis, overgrown toenails that can cut into the bottom of the feet and cause pain and falls. Um Were they unwell at the time? Was there any evidence of an acute illness? Were they feverish? Um had they got urine or a dysuria or kind of something like that? Are they coughing up any green sputum or something kind of like that? Is it a first fall or is it a repeated fall? This gives a measure of whether it's an acute illness or it's acute or focal chronic disorders to the etiology of falls? Getting some idea of the narrative what's the story? What had been going on? Does the story suggest syncope? Did they see their vision narrow? Did they um get feel sweaty or sickly before the fall? Um Did they have the spinning sensation of, of vertigo? Is there anything to suggest a fit? Have they bitten the tongue, particularly the sides of the tongue, not the end of the tongue that can be bitten in just a simple fall? Um Was there any pain from hips knees? They just been started on any new drugs? And of course, the etiology of the fall is important, but the consequence of the falls are also important. So is there is there any pain after the fall? Anything to suggest a broken bone, a shortened, internally rotated leg, for example, suggesting a hip fracture or painful ribs? Um It's also important to ask even if they don't have any associated problems perhaps with this fall. And do they usually get symptoms suggestive of orthostatic hypertension? Remembering of course, that that a number of patients through cognitive impairment or through syncope won't remember the fall very well. So somebody who will tell you that they, they can't really remember much about this fall, but usually every time they stand up and they go lightheaded would make me wonder whether this fall that they can't remember has actually been due to orthostatic hypertension too. Do they have symptoms suggestive of carotid sinus hypersensitivity? CS? So when they turn their head, one way or the other? Um Do they feel like they're about to pass out, particularly if they're wearing a tight collar that can, um, constrict and rub on the carotid sinuses again. Is there any symptoms suggestive of vertebrobasilar insufficiency when they turn their head one way or the other? Do they develop the vertigo diplopia, perhaps dysarthria? Um Is there anything to suggest vertigo usually as an issue every time they turn over in bed? Do they get a spinning sensation? The sort of thing that you see with benign positional vertigo? Um are they normally epileptic? Um are they history of fits and do they suffer with painful joints anyway, in terms of examination, again, these are the four big areas that we've spoken about a number of times. So, cardiovascular examination is really important. What's the heart rate? Um what's the rhythm? Is it regular or irregular? Is there anything to suggest aortic stenosis? Anything to suggest um cardiac failure, biventricular failure? Um One of the most important things to do in any for are lying and standing blood pressures and I'll go on to talk to about those in a minute. So what's the lying and standing BP immediately and at three minutes? And what are the symptoms immediately in three minutes? Too? Central nervous system examination is really important too. What's the vision like? What's the acuity like? And the visual fields? Is there anything to suggest pyramidal weakness such as you might find in a stroke, sensory problems that you might find in, say diabetes or peripheral neuropathy, anything extrapyramidal that suggests parkinsonism or cerebellar problems. What's a rough idea of the cognition? Are they orientated in time place and person? It's important to look at the musculoskeletal system. What's the lower limb function like? Is it painful to bend the hips and the knees? And what's the gait like if they, if they are um safe to walk? Um And of course, any acutely relevant symptom system, sorry. So if patients tell you that they, they're coughing up green phlegm and blood or something like that, it's clearly important to examine the respiratory system. Um This is probably in many ways the most important slide. And if you, if I were doing a good falls history and assessment on a patient, it would probably take me round about 45 minutes to an hour. Um and often particularly on a busy medical take. That's, that's time, that's hard to come by. So if you are pressured for time, then I think this is the minimum examination that you need to be done. And of course, if you have a patient with fairly advanced dementia where perhaps you can't take a history examination is going to be crucial and you could do most of this examination and fairly quickly in probably under about five minutes and it wouldn't be a bad falls assessment. Ok. So falls management clearly has to be multidisciplinary and multifactorial given the etiology of, of the, of the problem. Um good falls management can reduce the number of falls by about 25% but unfortunately not consistently the number of falls or their injuries. So it actually, it means that people still fall, they just don't fall quite as frequently. And unfortunately, falls management is very difficult in patients who are cognitively impaired. So in terms of the interventions, what are the important things? Um well, the following couple of slides come from the World Health Organization's advice on falls management. And these are the four most important things to address in falls management. A medication review, particularly looking at unnecessary polypharmacy, particularly psychiatric and cardiovascular medicines. And of course, it's also important to bear in mind mind, particularly given the nature of most falls who will be elderly. Um the the benefits and the needs for um osteoporosis, opiate prevention. So, drugs like bisphosphonates calcium and vitamin D, it's really, really important um to look into um orthostatic hypertension treatment. And I'll go to talk about that in a moment. Um It's really important to think about visual vision optimization, taking off the bifocals if the patients are walking around, particularly going upstairs and downstairs, perhaps seeing about getting cataracts operated on and things like that. And interestingly, the most efficacious intervention in intervention involves prevention isn't a medical intervention at all. It's physiotherapy aimed at balance and muscle strength. And I think this just kind of shows the really um important the real importance of having multidisciplinary falls management involving physicians, nursing staff, physiotherapists, occupational therapists and psychologists, if available to look into fear of falling home visits to look into environmental hazards and things like that. Other very important things are nutritional optimization, trying to build up muscle and mass and muscle strength podiatry. Um Looking for those overgrown toenails and things like that, um wearing the right footwear in the right environment. Continence management as we've discussed before. Um looking into fear of falling, um looking at good lighting, um appropriate flooring, nailing down, ill fitting carpets and things like that and generally moving hazardous environments, particularly at home. Something that an occupational therapist would be an expert in managing. So just going on very briefly to discuss orthostatic tension, which is a very important part of of falls management, orthostatic hypertension or postural hypotension presents with unsteadiness on standing falls. And if extreme, even daytime confusion, some patients have such a marked orthostatic drop that I going from lying to sitting. Um they will hypo perfuse their brain and they essentially become um mildly delirious. Um etiology is a number of different things. Um volume depletion is important. So, poor oral input, particularly if the weather is particularly hot as it is in the United Kingdom at the moment, excess use of diuretics um never forgetting Addison's disease. Um So hypofunction of the adrenals leading to a lack of aldosterone and cortisol. Um which can cause quite marked and profound orthostatic hypertension, diarrhea again, which can cause volume depletion. Um the presence of vasodilating drugs, things like calcium channel antagonists. Um ace inhibitors, severe varicose veins that allow venous pooling in the lower limbs. Um autonomic failure seen in diabetes, immobility and old age, sometimes in in general um Lewy body dementia lbd, um shy drage syndrome of a multisystem atrophy and perhaps paradoxically and sometimes something that's not greatly understood um hypertension. So, um hypertension can cause orthostatic hypotension. And this is seen classically as a presentation of pheochromocytomas, adrenaline secreting tumors. And what happens and happens in hypertension in general is if the barrow receptors in the aortic arch in the carotid bodies are hammered by very high BP, they can desensitize and not work so well. So that when a patient actually stands up, um they don't pick up the postural drop and therefore, orthostatic hypertension can ens um and I'll explain the approach to that in a moment. So in terms of examining for orthostatic hypertension, and this is something that's often poorly done in hospitals because though to do, it's quite time consuming to do um because it involves lying someone, a supine for about 10 minutes to start with and often that's very difficult in say an outpatient setting where time is limited. Um the best time, of course to do, look for an orthostatic drop is therefore first thing in the morning when a patient's been lying down overnight. So one puts on the sphygmomanometer cuff deflated and keeps the patient lying for about 10 minutes. Um One then stands the patient sorry, measures the BP lying. Um and the pulse rate as well. If if possible, you stand the patient with support as well just in case they do develop symptoms and fall over and measure the BP immediately. But what's really important um is then to try and keep the patient standing and measure the BP at 2 to 3 minutes again with a pulse rate if possible and note the symptoms. Um, a standard significant drop is a 20 millimeter drop in systolic BP or 10 millimeters diastolic drop or to an absolute systolic of less than 100 millimeters of mercury. But what's really important to remember is that you're measuring the BP in a large artery in the arm. And what you really want to do is measure the BP across the circle of will in the brain. Um And that possible ethical to do that. But many of our elderly patients will have stenosis all over the their small vessels within their brain. So even a 15 mli systolic drop in the arm can be a 30 or 40 millimeter systolic drop in the brain. So if I were to stand someone up at three minutes, find a 15 millimeter drop that the patient was gone very wide and roll their eyes and look to be about to faint. I would take that very seriously. So, it's a tie in of the symptoms and the drop if there's no drop at all at three minutes, but patients are still feeling um, not right or unsteady, then I'd be tending to think of other causes like perhaps benign positional vertigo and things like that. So, what to do about it? Well, if, um, there is a, a AAA drop, um significant drop and the supine BP is, is low or normal. And then the aim is to try and increase the two lb BP by stopping culprit medications like um ace inhibitors, if possible or calcium channel antagonist or whatever, or if the patients are dehydrated to rehydrate them. Um If however, the supine hypertension with an orthostatic drop, then it's important to slowly and gently reduce the supine BP, warning the patients that they'll tend to get more symptomatic for a couple of weeks before they improve as the baroreceptors reset themselves and to use a drug that has a long half life and a slow onset. So perhaps something like amLODIPine or a thiazide diuretic and as the supine BP settles, then often the orthostatic drop improves as well. I think perhaps just one thing to say about lying, standing blood pressures is sometimes it's very difficult because of other things going on with the patients. Perhaps things like rheumatoid arthritis to get a lying and standing BP. And sometimes I'm asked whether sitting standing BP is enough. I think the answer is yes. If the sitting to standing BP shows a significant drop with symptoms, then the lying to standing BP would only show a bigger drop. But the problem is that if the sitting to standing BP doesn't show a significant drop, then you don't really know what would happen in the the more accurate scenario of lying to standing BP. Um And that's my final slide. So thank you all for attending and I'm happy to take any questions. Thank you very much, Doctor Yates. Um Any questions, please pop them in the chat. We've got a lot of thank you on the chat. Oh, you're all very, very welcome. And I hope that's um been of some help and some use. Uh We've got one question, uh any examination to say that fall is due to frailty. Um I, I think um the I think frailty is, is one of those things that's almost easier to recognize um than it is to sort of um describe in many ways. Um um it's frailty um is perhaps more obvious in, in very elderly patients. Um, patients who have a dementia, a history of delirium, a history of incontinence or repeated falls. I think often the archetypal sort of patient would be a lady perhaps in her mid eighties with dementia with very low muscle mass and very thin arms thin legs. Um, as I say, prone to confusion, um Incontinent, it's, it's the presence of the frailty syndromes that I described in one of the early slides that would suggest that frailties played a big part in the falls and particularly if the falls are repeated. So, you know, it's not just one fall, it's, it is a repeated pattern of falls. Um You know, as I say, if it's particularly associated with other frailty syndromes, right? That makes sense. If you have any other questions, please do pop them in the chat. But otherwise thank you so much for joining us. A feedback form will be emailed to you and once completed your attendance certificate will be on your medo account and do join us at our next event, which is on spinal emergencies, I believe. Oh, we've got another question. How much blood volume depletion is required for IV blood access? I think it's in terms of um it's a start to give an actual sort of volume. But um it would be, I'd be thinking about someone who I'd say a history of um diarrhea and vomiting associated with an acute onset of hypotension and falls, or someone who's on say quite a big dose of diuretics, particularly if you've measured the ure and electrolytes. And they've got a suggestion of pre renal acute renal failure. So, a raised urea and creatinine associated with a tachycardia and hypotension and falls. So it's the, it's the narrative of the fall. Somebody who doesn't usually fall perhaps, but they present with diarrhea and vomiting and then on examination, they tachycardic and the hypotensive, they're the sort of patients that, you know, I'd be wanting to carefully put up some, some IV fluids and slowly volume replete them always bearing in mind. Of course, that a lot of elderly patients do have a history of heart failure. And so if you're going to replace fluids, you need to do so, you know, quite carefully because it's very easy to overdo it and turn somebody with hypotension and an orthostatic drop into somebody with pulmonary edema, which is obviously what you don't want to do. Um So yeah, so, so a narrative that suggests hypotension and then findings on examination that suggest um hypotension tachycardia too. Um And I think I've just seen another question. Um Yeah. OK. So, so this is a question about um orthostatic hypertension. So, um when all of us stand up and I'm sure when I stand up and I've been sat down now for the best part of an hour when all of us stand up at any age, there'll be a small drop in BP that that's normal when your youthful and your autonomic are working fabulously well, what happens is that, that slight systolic drop is picked up by the barrow receptors in the aortic arch and in, in the carotid body in the neck and that small systolic drop causes the autonomic to kick in the sympathetic nervous system kicks in, you get vasoconstriction and perhaps a slight tachycardia and most of the vasoconstriction stops venous pooling in the lower limbs and maintains the perfusion to the brain. Um What and so BP comes up in people with an autonomic nervous system that's working fine. And by 2 to 3 minutes in normal individuals, the BP will be the same as it was um lying down or sitting down or even a little bit higher. Um What happens in patients who have a significant orthostatic drop is that um the systolic drops initially, um and, and then it continues to fall away. So at 2 to 3 minutes, it will be still falling slowly away. And if you think of sort of, you know, clinically, most drops that you get that lead to somebody falling. It's often a patient who's been sat down on a chair and they get up and they go into the kitchen to make a cup of tea or a coffee or something like that. And it's after they've been stood for maybe a minute, two minutes, they fall down and suffer their injury. So the 223 minute drop is important because that's often clinically relevant to, you know, to the presentation of their fall and, and it's the, that's the drop that will allow you to see exactly what's going on. If you just measure the drop straight away, you see you'll see a drop in everybody, but it's the drop at 2 to 3 minutes that will be present in those who have significant orthostatic hypertension and, and that 2 to 3 minute drop won't be seen in normal people. Great. Thank you very much that all makes sense. You've got one comment who said uh I personally love the way you explain things in a direct and simple way. So, thanks a lot. You're very welcome. You're very welcome. Any last questions? Do you pop them in the chat? Otherwise, I, I think we might call it a day. Is that ok? Doctor Yates? That's absolutely fine. Thank you very much and thank you for all your help ging. I certainly couldn't have done it without you. Thank you very much for everyone for attending.