Case 6 - Falls Flashcards
Suggest as many risk factors for falls in the elderly as you can?
Age
Poor vision
Unsafe environment - steep stairs, wet floor, poor lighting, slippy mats, wires, furniture
Osteoporosis / osteopenia
Lack of balance
Muscle weakness - deconditioning with old age, stroke,
Postural / orthostatic hypotension (when you stand, your BP drops) - age, circulation issues, drugs (beta blockers / BP drugs that treat hypertension)
What are the 7 categories and some examples in each of these categories that increase risk of falling?
Neurological - confusion, cognitive impairment, depression, poor vision, balance, poor co-ordination
Unmodifiable - age,
Chemical
Cardiovascular - syncope
Environmental
Neuromuscular
Other
What is a fragility fracture?
A fracture from a low energy accident that would normally not result in a fracture - forces generally equivalent to a fall from standing height or less
Some fragility fractures can occur without a fall - coughing, lifting, bumping into things (minimal strain / stress)
A manjor risk factor is reduced bone density - e.g. in osteoporosis
Fragility fractures also have other risk factors and can occur in individuals without osteoporosis
What is osteoporosis?
Characterised by low bone mass (reduced bone density), microarchitectural disruption, and skeletal fragility
Diagnosis by using bone density test - DEXA - provides a t-score: a t-score of -1 or higher is normal, osteopenia is a t-score of -1 to -2.5, and a t-score below -2.5 indicates osteoporosis
The t-score compares against healthy participants of young adults
Resuts in decreased bone strength and increases risk of fracture
How can you tell if you have osteoporosis?
Normally, you cannot. You only find out after getting a fracture that results in hospitals running tests
What occurs in osteoporosis in relation to the trabeculae (found in the cancellous part of bone)?
Fewer crosslinks - horizontal trabeculae columns begin to disappear first and faster, then vertical trabeculae columns
Why are elderly people more at risk for osteoporosis?
Why are elderly women more at risk for osetoporosis?
Vitamin D deficiency - do not go out as much, diet, reduced liver / kidney function (less atcive vitamin D formed) - vitamin D increases calcium absorption
Increased PTH activity - PTH increases osteoclast activity to increase Ca2+ levels in the blood
Reduced stem cells in the bone marrow, so fewer stem cells become osteoblasts - in the elderly, the stem cells responsible for becoming osteoblasts follow a different path and become adipocyte cells instead (osteoclasts have a different precursor to the one used to form osteoblasts)
Menopause - fall in oestrogen results in reduced bone density because oestrogen maintains the rate of bone resorption the same as bone formation (equal osteoblast and osteoclast activity) by preventing osteoclast activity and increasing osteoblast activity. With reduced oestrogen, bone resorption activity increases and bone formation decreases
What is the mechanostat theory?
External forces, such as gravity, strain (muscle movement), etc., influence the mass and architecture of the bone
increased muscle = increased strain on bone
Increased strain = building bone mass, reduced strain = lose bone mass (conserves energy, weighs less)
Therefore this is a homeostasis mechanism
Mechanostat theory builds on wolfe’s law
What is sarcopenia?
What are risk factors for sarcopenia?
How does sarcopenia correlate to BMD?
A syndrome characterised by progressive ad generalised loss of skeletal muscle mass and strength
Low muscle mass can positively correlate with low bone mineral density (using the mechanostat theory)
Risk factors for sarcopenia = age, gender, and level of physical activity
Sarcopenia is correlated with physical disability, falls, low BMD, poor quality of life, and death
Guess the percentages for these factors - possible outcomes of hip fractures:
% - return to previous level of mobility
% - of those affected are female
% - are discharged to a residential home or…
% - die within 1 month
% - suffer post-op complications
% - die within a year
50% - return to previous level of mobility
75% - of those affected are female
10-20% - are discharged to a residential home or replacement
10% - die within 1 month - due to HAIs - UTIs, chest infections, frailty (death from co-morbities), sepsis, immobolity - blood cloths, heart failure
42% - suffer post-op complications
30% - die within a year
What is meant by the terms:
Garden I, Garden II, Garden III, Garden IV, Intertrochanteric
Garden II = intra-articular, undisplaced
Garden IV - completely displaced, intracapsular fracture
Is there a fracture in this image and where?
How can it be fixed?
Yes - Garden II - undisplaced, intra-articular fracture
Use a dynamic hip screw / alternatively a cannulated hip screw
Is there a fracture in this image and where is it?
What is the best treatment option?
Intertrochanteric fracture - displaced, extra-capsular
Intramedullary nail
Is there a fracture in this image and where is it?
Glut muscles have pulled the shaft up from the head - in the neck of the femur
Garden IV - completely displaced, intracapsular fracture
Total hip replacement
What is the difference between a total and hemi anthroplasty (hip replacement)?
Why might a hemi be preferrable?
Total = ball, neck, shaft and socket
Hemi = ball, neck, shaft
Fewer operative risks
Task 2a: Fill in label 1 in the doctors notes:
What are the actions of teriparatide, alendronic acid, rolaxifene ad zoledronic acid?
Choose from these 4 to pick label 1:
What are bisphosphinates?
1 = alendronic acid
Teriparatide = recombinant PTH injection, acts as a competitive inhibitor with PTH to prevent active pTH action by occupying the receptors
Rolaxifone =
Alendronic acid = oral
Zoledronic acid = IV
Biphosphinates = replenishes minerals (Ca2+ and Pi) in bone, also decreases osteoclast activity
Label 2 and 3 = ?
Label 2 and 3 = Calcium and colecalciferol
Calcium and colecalciferol
Vitamin D and chondroitin
Multivitamin and cod liver oil
Calcium and cod liver oil
Label 4 = ?
4 = falls clinic
Hip protector = hip pads (not very good evidence basis)
Metabolic bone clinic = deals with osteoporosis, GP can manage it though, don’t need specialist
Falls clinic = run by geriatric team, look at patient as a whole - think about all the comorbid factors
What explains Mrs Wilkins’ current mental state?
Dementia / progression from MCI
Delirium - acute confusional state, anyone can get it if their accident / illness is severe enough - affects brain acitivity resulting in confusion, aggression, withdrawal, delusions, hallucinations etc.
What (risk) factors may have contributed to Mrs Wilkins’ delirium?
Dementia
Grief / husband
Age
Hip fracture
Tired
Medications she’s on - esp. painkillers (opiods)
Constipation - (can also be caused by opiods)
UTI
Possible head trauma
Dehydration - fell on the floor for a while (long lie)
How can delirium be treated?
How can delirium be treated e.g. in Mrs Wilkins’ case?
Run tests to rule out obvious treatable causes e.g. infection, low Na+, low vit D, low blood sugar levels, electrolyte or metabolic abnormalities, intracerebral pathology
Bring familar objects, continuity of care - have same staff, regulate sleep cycle by making day and night obvious, relatives nearby, calender and note nearby re-explaining to them they are in hospital, rehydration, help people eat and drink at meal time with meal time buddies / red tray system (red = someone who needs more support during meals, everyone else gets a blue tray), laxatives, review medications
