Case 6: Falls Flashcards
What are the non- modifiable risk factors for falls?
- Age
- Gender
- History of falls
What are the neurological risk factors for falls?
- Cognitive impairment or Dementia
- Confusion/delirium
- Depression
- Poor vision
- Poor balance (arthritis, parkinson’s)
- Poor co-ordination
- Anxiety about falling
What are the environmental risk factors for falls?
- Home hazards
- Inappropriate footwear
- Insufficient home modification
What are the chemical risk factors for falls?
- Polypharmacy
- Drug culprits (e.g. corticosteroids)
- Alcohol
What are the cardiovascular risk factors for falls?
- Orthostatic hypotension (low blood pressure upon standing up)
- Arrhythmias
- Syncope (temporary drop in blood to the brain that causes fainting)
- Anaemia
What is collateral history?
Taking history of a patient from an onlooker or relatives.
How can you prevent falls?
- Clean up/declutter the environment
- Better feedback
- Do regular strength and balance activities (physiotherapy)
- Eyesight checks (optician’s)
- Reduce alcohol intake
- Correct low BP
What is delirium?
A worsening or change in person’s mental state that happens suddenly, over 1-2 days.
What are the 3 different types of delirium?
- Hyperactive
- Hypoactive
- Mixed
What are the symptoms of hyperactive delirium?
- Restlessness
- Agitation
- Delusions
- Hallucinations
- Disorientation
- Paranoia
What are the symptoms of hypoactive delirium?
- Withdrawn mood
- Drowsiness
- Unable to focus
- Less mobile
- Somnolent
What are the risk factors of delirium?
- Age
- Underlying cognitive impairment
- Social isolation
- Pain from fall
- Renal impairment
- Poor mobility (previous falls)
- Visual/hearing problems
- Alcohol
What are the triggers of delirium?
- Pain
- Infection
- Nutrition (deficiencies like Vit B12, folate, thiamine, Vit D)
- Constipation
- Hydration
- Medication (drug culprits)
- Electrolytes
What is the treatment of delirium?
1) Address the medical problem that caused it (correct glucose levels, stop medication that may be causing it, give antibiotics).
2) Ensure a supportive + calm environment for patient
What tests are carried out for a patient that’s had a fall and is delirious?
- ECG
- Blood tests
- Chest X-ray
- Urine sample (to test for UTIs)
- Hip X-ray
What are fragility fractures?
Fractures that result from mechanical forces that would not ordinarily result in a fracture (equivalent to falling from standing height).
What are the most common causes of fragility fractures?
- Osteoporosis
- Advancing age
- Other bone disorders (OI, acromegaly)
- Poor muscle strength
What is osteoporosis?
Reduction in the density of bone: bone is more porous because osteoclast activity > osteoblast activity. There is sequential trabeculae loss.
What are the risk factors for osteoporosis?
- Age: reduced Ca2+ / Vitamin D metabolism
- Female gender: loss of oestrogen means less inhibition of osteoclasts and less stimulation of osteoblasts
How is osteoporosis diagnosed?
- T score
What is the mechanostat theory?
Bone structure is influenced by mechanical loading. If there is a change in load, bone mass + structure will change.
If a patient is on bedrest, what will happen to their bones and muscle according to the mechanostat theory?
- Decrease in bone density (osteopenia initially)
- Atrophy of muscle due to disuse (sarcopenia)
What is sarcopenia?
- Progressive loss of muscle strength
- Usually comes with osteopenia
What are the most common sites for a fragility fracture?
- Vertebrae
- Hip (NOF)
- Wrist (Scaphoid bone)
What are the risk factors for fragility fractures?
- Age
- Female gender
- Ethnicity
- FHx of hip fractures (family history)
- Fall history
- BMI
- Smoking
- High alcohol intake (reduced oestrogen)
What are the 2 classes of hip fractures?
- Intracapsular (the head of the femur)
- Extracapsular
What can the extracapsular fractures be divided into?
- intertrochanteric
- subtrochanteric
What are the 4 classifications of intracapsular fractures?
- Garden I (non-displaced, partial)
- Garden II (non-displaced, complete)
- Garden III (partially displaced, complete)
- Garden IV (displaced, complete)
How are extracapsular NOF fractures treated?
- Dynamic hip screw (intertrochanteric)
- Intramedullary nail/ femoral nail (subtrochanteric)
Describe the blood supply to the femoral head
- Blood supply in femoral head is retrograde (goes from distal -> proximal)
- Medial circumflex artery supplies the head
Why are intracapsular fractures more dangerous than extracapsular fractures?
Blood supply is more likely to be disrupted causing AVASCULAR NECROSIS
How are non-displaced intracapsular fractures (Garden I + II) treated?
Dynamic Hip screw
How are displaced intracapsular fractures (Garden III + IV) treated?
- Total Hip replacement (both the head and the acetabulum are replaced)
- Hemi-arthroplasty (where only the head is replaced)
Even though THR have better post-operative outcomes, why are hemi-arthroplasties still performed?
THR have an added risk of hip dislocation for older patients with cognitive impairment. In HA, there is also…
- less blood loss
- shorter operative time
- quicker recovery.
What are the first line medications for people with osteoporosis, that have just had a fragility fracture?
Bisphosphonates -> these inhibit osteoclast activity
Which bisphosphonate would be given to the patient to take home?
Alendronic Acid (it can be taken orally unlike Zoledronic Acid which is given through IV infusion)
What medication can be given to menopausal women?
Raloxifene (Oestradoil receptor agonist)
Other than bisphosphonates, what other medications could be given?
- Vitamin D (cholecalciferol)
- Ca2+
What clinic would a patient that has suffered a fall be referred to?
Falls clinic -> occupational therapist
Would a Bone scan be needed to diagnose osteoporosis?
No- bone scans are where radioactive isotopes are injected into bone to look for bone infections/ cancers
What are the signs (what the doctor sees) of a hip fracture?
- Bony tenderness at hip/ groin
- Externally rotated hip
What are the symptoms (what the patient experiences) of a hip fracture?
- Hip/knee pain
- Unable to weight bear
