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OPIC (Y4) > 3- Falls, frailty, osteoporosis and fragility fractures > Flashcards

3- Falls, frailty, osteoporosis and fragility fractures Flashcards

1
Q

define frailty

A
  • ageing related physiological changes (>65) across multiple body systems (phys and mental) causing loss of physiological reserve.
  • increased vulnerability to a wide range of stressors
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2
Q

Geriatric giants

A
  • Immobility
  • Instability (Falls)
  • Incontinence
  • Impaired memory (Dementia, Delirium)
  • Iatrogenesis (Caused by us!)
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3
Q

presentations of illness in the frail

A
  • Frail older people will often not have the ‘classic’ symptoms of common illnesses.
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4
Q

phenotypic def of fraility

A
  • low grip strength
  • low energy
  • slowed walking speed
  • low physical activity
  • unintentional weight loss
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5
Q

assessment of frailty parameters

A
  • Bedside
    • walking speed
    • timed up and go
  • Primary care
    • Electronic frailty index - eFI (based on Rockwood)
  • Secondary care
    • Rockwood) (clinical frailty scale)

§

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6
Q

gold standard intervention for frailty

A

Comprehensive geriatric assessment (CGA)

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7
Q

Rockwood (Clinical Frailty Scale)

A

Scale of 1 (very fit) to 10 (terminally ill)

can be used to score frailty in those with dementia

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8
Q

Comprehensive geriatric assessment (CGA)

A

Multidisciplinary diagnostic and treatment process

Comprehensive Geriatric Assessment (CGA) is a process of care comprising a number of steps. Initially, a multidimensional holistic assessment of an older person considers health and wellbeing and leads to the formulation of a plan to address issues which are of concern to the older person (and their family and carers when relevant). Interventions are then arranged in support of the plan. Progress is reviewed and the original plan reassessed at appropriate intervals with the interventions reconsidered accordingly

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9
Q

frailty and outcomes

A
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10
Q

falls can be divided into

A

syncopal and non syncopal falls

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11
Q

syncopal falls

A

temporarily losing consciousness due to a disruption of blood flow to the brain, often leading to a fall.

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12
Q

cause of syncopal falls

A
  • vasovagal
  • postural/orthostatic hypotension
  • cardiogenic
  • aortic stenosis
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13
Q

vasovagal

A
  • Vagus nerve receives a strong stimulus, such as an :
    • emotional event
    • painful sensation
    • change in temperature it can
  • Stimulate the parasympathetic nervous system
  • Parasympathetic activation counteracts the sympathetic nervous system, which keeps the smooth muscles in blood vessels constricted.
  • As the blood vessels delivering blood to the brain relax, the blood pressure in the cerebral circulation drops, leading to hypoperfusion of brain tissue. This causes the patient to lose consciousness and “faint”
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14
Q

non syncopal falls

A
  • stroke
  • seizure
  • trip
    • unstable balance
    • slow gait
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15
Q

history for a fall

A

collateral history important here

Presenting complaint

  • Before the fall
  • During the fall
  • After the fall

PMH

DH

SH

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16
Q

before the fall

A
  • Any pre-syncopal symptoms e.g. feeling dizzy, light-headed, palpitations?
  • What were they doing?
    • Getting up from lying/sitting (postural hypotension?)
    • From the toilet (vasovagal?)
    • In the middle of walking (arrhythmia?)
    • Turning their head (carotid sinus hypersensitivity?)
  • How is their general health? Any infective symptoms (e.g. dysuria, cough, cellulitis?)
  • How do they usually mobilise? Do they walk independently or use a stick/sticks/frame/need supervision (implying underlying frailty and poor mobility?)
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17
Q

during the fall

A
  • Do they remember falling?
  • Was it witnessed?
    • If so, obtain a detailed collateral history
    • If not, assume that there may have been some loss of consciousness (LOC)
  • Was there any LOC?
  • Are they able to describe the mechanism of the fall?
    • If they say they ‘must have tripped’ this is not the same as remembering a definite mechanical reason for the fall!
  • Where they able to put out their hands to prevent injury?
    • A fractured wrist where they have tried to protect themselves is consistent with no LOC
    • A significant head (e.g. black eye) is consistent with no attempt to protect themselves, and as such LOC (likely sudden onset – e.g. arrhythmia) prior to the fall.
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18
Q

after the fall

A
    • Any limb jerking or urinary/faecal incontinence to imply seizure?
      * Some myoclonic jerking following a syncopal episode is not uncommon, so do not read too much into this
      • Were they well-oriented following the fall?
        • Rapidly recovering orientation is in keeping with no LOC, or syncopal episode
        • Persistent confusion/drowsiness implies a post-ictal state and potential seizure as cause
      • Were they able to mobilise independently following the fall?
        • If not, and secondary to pain, be on the lookout for bony injuries
        • Confused patients can often fail to localise pain
      • How long were they on the floor for?
        • The longer the lie, the higher the risk of rhabdomyolysis: ensure as CK is checked
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19
Q

PMH for fall

A
  • DM- hypoglycaemia, peripheral neuropathy
  • Hypertension- antihypertensives
  • Epilepsy
  • Previous falls
  • Cardiac history
    • palpitations
    • ischaemic heart disease
  • Stroke
  • continence history- mobilising at night
  • State of vision
  • Cognitive impairment
  • Bone health
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20
Q

DH for fall

A
  • Anti-hypertensives
    • May lead to postural hypotension
  • Alpha-receptor blockers in male patients with prostatism
    • g. tamsulosin
    • Can cause a profound postural drop in BP
  • Antihyperglycaemics
    • Use of insulin or sulphonylureas can cause hypoglycaemic events
  • Analgesia
    • Side-effects of drowsiness can increase the risk of falls
    • Evidence of poor-pain control can imply frailty and poor mobility
  • Bone Protection
    • Vitamin D replacement
    • Calcium replacement
    • Bisphosphonates
  • Steroid Use
    • g. long-term use in COPD with multiple exacerbations or in polymyalgia rheumatic (PMR)
    • Associated with increased risk of fragility fracture secondary to effects on bone
    • Long-term use associated with proximal myopathy, and subsequent frailty-associated falls risk
  • Diuretics
    • Use of diuretics is associated with increased urinary frequency, and the associated issues with continence as discussed above
    • Check the timings of administration, and try to not prescribe your diuretics in the evening if possible (if BD dosing, give the second dose at lunchtime) – this will help to avoid nocturnal micturition
  • Anti-epileptics
  • Anti-cholinesterase inhibitors
    • Implies the diagnosis of dementia (if not already established from past medical history)
    • Associated with increased risk of syncope (and hence syncope-related falls)
  • Anti-coagulants
    • Risk of bleed (e.g. subdural haematoma) if patient on warfarin or novel oral anticoagulant (NOAC)
    • Have a lower threshold for a CT head
  • Psychotropic Drugs
    • g. SSRIs, benzodiazepines, dopamine antagonists can all increase the risk of falls
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21
Q

SH for fall

A
  • House/flat/bungalow
  • Stairs and associated equipment (e.g. stair rails, stair lift)
  • Upstairs/downstairs toilet/commode
  • Who else is at home with the patient
  • Any pre-existing package of care (POC)
  • Level of independence for activities of daily living (ADLs)
  • Alcohol history
    • Potential associated alcohol neuropathy
    • Intoxication-related falls
    • If history of dependence, offer support to help quit, and monitor for withdrawal
  • Smoking history
    • Should always form part of every social history
    • Again, offer support to help quit
  • Who does cooking/shopping/cleaning of house?
  • Do they have a pendant alarm?
  • Do they have a key safe?
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22
Q

Examination for fall

A
  • A full formal clerking should then be performed to assess for both any sign of injury as a result of the fall, but also to gain a better understanding into possible causes.
  • On a system-by-system basis, here are a few things to keep in mind and look out for.
  • Cardiovascular
    • Pulse
      • Regular/irregular to imply AF or intermittent heart block?
      • Strong or weak (weak may suggest underfilling)?
    • Blood pressure
      • Always try to obtain 3 postural (lying to standing) blood pressure readings
      • Ensure they are taken correctly (do not settle for a “lying to sitting”)
    • Murmurs
      • ESM to imply aortic stenosis as a cause of syncope?
      • PSM to imply MR and CCF/AF from atrial dilatation
  • Respiratory
    • Evidence of LRTI/pneumonia as an underlying infection?
    • Evidence of chronic respiratory problems leading to SOB and increased frailty?
    • Equal, pain-free air entry?
      • Inspiration can be limited by the pain from fractured ribs from the fall
      • Hypoventilation (and associated atelectasis) due to pain is a risk factor for pneumonia
  • Abdominal
    • Evidence of constipation that might be leading to a delirium?
    • Evidence of an enlarged bladder (urinary retention) leading to a delirium?
  • Neurological
    • Please do not document neurology as “grossly normal”
      • “Grossly normal” equates to “couldn’t be bothered to examine”
    • Instead, do a formal neurological examination for:
      • Evidence of stroke/disability from previous stroke
      • Cerebellar signs to imply balance is impaired
      • Peripheral neuropathy from alcohol or diabetes that reduces proprioception and balance
      • Check their gait and use of walking aids
    • Mental state and cognitive assessments (click on links below for details)
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23
Q

Investigation for fall

A
  • ECG
  • Blood glucose
  • Urine dip
  • Blood tests
    • FBC
    • UandE
    • CRP
    • calciuma nd phosphate
    • liver function (alc abuse)
    • clotting
  • Imaging
    • X-ray
    • CT head
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24
Q

screening tool for falls

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25
Q

inpatient management of people with falls

A
  • Identify those who are at high risk of further falls to help reduce the chance of an in-patient fall
    • 1-1 nursing may be required for confused/delirious patients
    • Low-rise beds and mattresses on the floor to reduce the risk of injury
    • Non-slip socks
    • Adjustment of medication regimens to reduce falls risk
  • Training how to use appropriate walking aids is very important to help reduce falls
  • Additional support
    • POC if going back home
    • May require placement to ensure safety, either RH or NH based on level of dependence
26
Q

outpatient management after fall

A
  • Home visits can be helpful in frail patients who might have cluttered houses with uneven floors
  • Modification of the home environment
    • Downstairs living
    • Commode
    • Hand rails
    • Stair lift
    • Hospital bed
    • Hoist
  • Pendant alarms
    • Newer models have in-built impact sensors that are set-off as a fall happens
  • Follow-up
    • Specialist geriatric clinic follow-up
    • Falls clinic
    • Balance classes
27
Q

assessment of falls and identification of cause

A

multifactorial assessment

28
Q

Action after being a fall

A
  • Basic advice
    • Drink plenty
    • Stand up slowly
    • Remove loose carpets/leads
    • Sensible slippers
    • Good lighting
  • OT assessment
  • Social work/ PCC assessment
    • Do they need more help at home?
  • Opticians/audiologists
  • If A and E write a complete GP letter
    • Needs a medication review
29
Q

Practical solutions to minimise risk of falls

A
  • Clean up clutter
  • Remove tripping hazards
  • Install grab bars and handrails
  • Avoid loose clothing
  • Ensure lighting is right
  • Wear shoes
  • Make it nonslip
30
Q

orthostatic hypotension

A
  • Symptoms occur after standing from a sitting or lying position
  • Can cause syncope if drop in blood pressure is severe enough
  • Normally defined as a drop of 20mmHg or more
  • The problem with standing
31
Q

Cardiac/cardiopulmonary disease- exertional syncope

A
  • Syncope caused by a cardiac disease of abnormality
  • Can be electrical, structural or coronary cause
  • Family history of cardiac disease or sudden cardiac death
  • Preceding chest pain or palpitation
  • Past medical history of heart disease
  • Abnormal ECG
    • Electrical
      • Bradycardias
      • Tachycardias
    • Structural
      • Aortic stenosis
      • Hypertrophic obstructive cardiomyopathy
    • Coronary
      • MI/IHD
32
Q

Aortic stenosis

A
  • Narrowing of aortic valve
  • Harder to push blood through aortic valve
  • During exercise, when the heart has to work harder, the stenosis can limit CO and therefore fail to adequately perfuse the brain
  • If AS with syncope- survival of 2-5 year if untreated
33
Q

seizures

A
  • A generalised tonic-clonic seizure is a cause of loss of consciousness and will cause a fall
  • However it is not syncope
  • Be are of new epilepsy in the elderly
  • 2nd peak in incidence rate is in over 80s
  • Seizure can often be subtle
34
Q

seizures vs syncope

A
35
Q

non-syncopal falls

A
  • Fall in which the cause is not a syncope
  • A fall with loss of consciousness following a head trauma is still a non-syncopal fall
  • Trips and slips fall in the category

Often the fall can be the end result of an intercurrent illness such as an

36
Q

multifactorial falls

A
  • Many falls will be a result of more than one thing
  • Imagine a pt with OA and Diabetic neuropathy
  • Add infection on top of this
37
Q

medications which cause falls

A
  • Antihypertensives
    • hypotension
  • Drugs which reduce blood glucose
    • Hypoglycaemia
  • Medications which effect the brain
    • i.e. cause sedation of drowsiness
38
Q

after a fall frail patients are at risk of

A

fragility fractures

39
Q

fragility fractures

A

occur due to weakness in the bone, usually due to osteoporosis. They often occur without the appropriate trauma that is typically required to break a bone. For example, a patient may present with a fractured femur after a minor fall.

40
Q

which tool is used to predict risk of fragility fracture

A

A patient’s risk of a fragility fracture over the next 10 years can be predicted using the FRAX tool.

  • age
  • BMI
  • co-morbidities
  • smoking
  • alcohol
  • family history
  • DEXA
41
Q

most common sites of fragility fracture

A

spine (vertebrae), hip (proximal femur) and wrist (distal radius)

42
Q

RF for frag frac

A
  • glucocorticoids
  • low body weight
  • smoking
  • alcohol use
  • family history of fracture
  • older age
  • female sex
  • history of falls
  • type 2 diabetes
  • prior history of fragility fracture
43
Q

Osteoporosis

A

is a condition where there is a reduction in the density of the bones.

44
Q

Osteopenia

A

refers to a less severe reduction in bone density than osteoporosis. Reduced bone density makes bone less strong and more prone to fractures.

45
Q

prevention of recurrent falls

A
46
Q

RF for osteoporosis

A
  • Older age
  • Female
  • Reduced mobility and activity
  • Low BMI (under 18.5 kg/m2)
  • Rheumatoid arthritis
  • Alcohol and smoking
  • Long term corticosteroids. NICE suggest the risk increases significantly with the equivalent of more than 7.5mg of Prednisolone per day for more than 3 months)
  • Other medications such as SSRIs, PPIs, anti-epileptics and anti-oestrogens.
47
Q

which chemotherapy can cause osteoporosis

A

Aromatase inhibitors lower circulating oestrogen levels to almost unrecordable levels in postmenopausal women, predisposing them to bone loss with an increase in fracture risk.

48
Q

which scan is used to measure bone mineral density

A

DEXA scan (dual-energy xray absorptiometry)

49
Q

how do dexa scans work

A

brief xray scans that measure how much radiation is absorbed by the bones, indicating how dense the bone is. The bone mineral density (BMD) can be measured at any location on the skeleton, but the reading at the hip is key for classification and management of osteoporosis.

Bone density can be represented as a Z score or T score.

  • Z scores represent the number of standard deviations the patient’s bone density falls below the mean for their age.
  • T scores represent the number of standard deviations below the mean for a healthy young adult their bone density is.
50
Q

parameters for osteoporosis and osteopenia using DEXA

A
51
Q

assessing for osteoporosis in

A

FRAX

  • women >65
  • men >75
  • younger patients with risk factors
    *
52
Q

low risk FRAX scroe

A

reassure

53
Q

medium risk FRAX

A

offer DEXA scan and recalculate the risk with the results

54
Q

high risk FRAX

A

offer treatment

55
Q

management of osteoporosis

A
  • non-pharmacological
    • lifestyle changes
  • pharmacological
    • Vitamin D and calcium
    • bisphosphonates
    • denosumab
    • strontium ranelate
    • raloxifene
    • HRT
56
Q

lifestyle changes for osteoporosis

A
  • Activity and exercise
  • Maintain a health weight
  • Adequate calcium intake
  • Adequate vitamin D
  • Avoiding falls
  • Stop smoking
  • Reduce alcohol consumption
57
Q

biphosphonates MOA

A

interfering with osteoclasts and reducing their activity, preventing the reabsorption of bone.

58
Q

biphosphonates examples

A
  • Alendronate 70 mg once weekly (oral)
  • Risedronate 35 mg once weekly (oral)
  • Zolendronic acid 5 mg once yearly (intravenous)
59
Q

bisphosphonates adverse effects

A
  • Reflux and oesophageal erosions
  • Atypical fractures (e.g. atypical femoral fractures)
  • Osteonecrosis of the jaw
  • Osteonecrosis of the external auditory canal
60
Q

how should oral bisphosphonates such as alendronic acid be taken

A

Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this.

61
Q

other treatments of osteoporosis

A
  • Denosumab is a monoclonal antibody that works by blocking the activity of osteoclasts.
  • Strontium ranelate is a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction.
  • Raloxifene is used as secondary prevention only. It is a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus.
  • Hormone replacement therapy should be considered in women that go through the menopause early.

OPIC (Y4) (20 decks)

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