Clinical skills - Old Age & Falls Flashcards
Sensory mechanisms involved in balance
Vision
Proprioception
Tactile sense
Vestibular system
Types of balance
Static balance - standing
Dynamic balance - running, jumping etc
Adaptations to help us keep our balance
Ankle strategy
Hip strategy
Stepping
Arm movements
Ankle strategy to help keep balance
Uses muscles around ankle to correct loss of balance (static)
Hip strategy to help keep balance
Uses muscles around hip to correct loss of balance (static)
Corrects natural swaying
Stepping to keep balance
Changes base of support
Arm movements to help keep balance
Helps change centre of gravity
Stereoscopic vision
We have two slightly different view of same things due to our eye placement
Monocular vision
Seeing two different things (animals with eyes in side of head)
Things vision helps us detect
Distance
Movement
Orientation
Standing/ walking surface
Proprioception
Sense of position, movement, and force
Structures in body helping with proprioception
Stretch receptors in muscle and tendons
Mechanoreceptors in joints
Cervical spine
Hips, knees, ankles
What contributes to tactile sense
Deep pressure sensors in soles of feet
What reduces tactile sense
Standing on soft surfaces
What is vestibular system made up of
Otolith organs
Semi-circular canals
Function of otolith organs
Detect linear acceleration of head
Function of semi-ciciular canals
Detect angular acceleration due to endolymph
Vestibulo-optic reflex
Maintains visual fixation (despite head movement)
Vestibulo-spinal reflex
Keeps head level but can be overcome
Structures within cerebral cortex
Primary motor cortex (M1) Premotor cortex Supplementary motor area Parietal lobe Occipital lobe
Primary motor cortex function
Direct control, voluntary movement
Premotor cortex function
Motor acts linked to external stimulus
Supplementary motor area function
Internally curated motor acts
Parietal lobe function
Spatial awareness
Occipital lobe function
Visual perception
Basal ganglia role in balance
Timing cues for automatic movement
Postural reflexes
Cerebellum role in balance
Fine tunes postural adjustments
Makes ‘coarse adjustment’ for slow voluntary, movement
Coordinates rapid, ballistic movements
Reflexes that happen in the spinal cord
Stretch reflex
Crossed extensor reflex
Reflexes that happen in the brain stem
Maintenance of postural muscle tone
Righting reflexes
Aging effect on vision
Reduced acuity
Reduced contrast sensitivity
Reduced dark adaptation
Aging effect on sensation
Reduced proprioception
Reduced touch sensitivity in the foot
Aging effect on brain
Fewer neurones
Fewer nerve fibres
Slower reaction times
Impaired integration of sensory info
Aging effect on muscle
Reduced muscle mass
Reduced muscle strength
Slower contraction
Outcomes following a fall
Increased mortality, long term disability and earlier entry to residential care
Fragility fractures cost UK £4.4 billion over year
Who is targeted when giving out home assessments
High risk fallers Fallen before in <1yr Fall with injury Cognitive impairment Visual impairment Gait or balance impairment Fear of falling Leaving a rehab setting particularly post neck fracture NOF
Purpose of home assessments
Identify home hazards and recommend or arrange modifications
Assess and modify performance and function
Identify and agree strategies to reduce falls risk
Education and information giving
What should older people who have received treatment in hospital following a fall be allowed
A home hazard assessment and safety intervention/ medications
Local pathways for accessing home assessment - primary care
Supported care to home incl OT home assessment
Community OT
Falls vehicle: paramedic and OT
Local pathways for accessing home assessment - secondary care
A+E OPED OPAC wards OPAS
OPED
Older peoples emergency department, undergoes comprehensive geriatric assessment
OPAC
Older peoples assessment centre (nurse led discharge centre)
OPAS
Older peoples assessment service (consultant-led outpatient service)
How much of our population is 60+
Over a 1/5
What are the 3 broad groups older people belong to
Entering old age
Transitional phase – between a healthy active life and frailty
Frail older people
Proportion of NHS budget spent on 60+
~40%
Proportion of social service budget spent on 60+
~50%
Proportion of general and acute beds used by those 65+
Almost 2/3
NHS and social care action plan
Improve standards of care Extend access to services Ensure fairer funding of long-term care Develop services which support independence Help older people to stay healthy
Frailty
Not an illness, but a syndrome that combines the effects of natural ageing with the outcomes of multiple long-term conditions, a loss of fitness and reserves
Medical definition of frailty
Older people with 1/1+ chronic, long-term condition e.g heart disease, COPD
Older people who may not have a spp, diagnosed condition, but who may nevertheless require support from care services to live independently
and
Older people who are on the threshold of either of these two groups
Frailty syndromes
Deliriium Falls immobility - sudden change Continence problems Med management challenges
MDT approach for older pt’s and falls
GP & nursing team Family Social care OT PT SLT
MDT community services aim
Prevent Hosp admission - crisi management
Aim of rapid response teams
To prevent admission and set up immediate short term intervention plan
Consequences of hosp admission
Older people are at risk of deterioration
If admitted for inpatient hosp care, the oldest have readmission rates and highest rate of long-term care use after d/c
Why are older people at risk of deterioration when admitted to hosp
Factors affecting this are the environment, care delivery and risks
OT job role
identifies occupational performance issues & implement plans to facilitate independece
SLT job role
Anticipates and responds to the needs of individuals who experience speech, language, communication or swallowing difficulties
Activity limitation due to recurrent falls (+ subsequent injuries)
Not able to go out –> loss of social network and relationships
Activity limitation due to Parkinson’s
Difficult swallowing food and gripping cutlery –> no longer feels able to go ut for a meal
Age discrimination statistics
Experienced by 36.8% of people aged 65/ 65+
53% believe treated as a child
68% believe politicians see them as a low priority
Social aspect of aging
Physical and mental decline are not inevitable in later life.
As people grow older, they work to maintain their own sense of personal identity.
People may experience the self as ‘younger’ than the body.
Dementia and Alzheimer’s disease do not necessarily mean loss of self
Types of delirium
Hyperactive, hypoactive or mixed with features of both
Hyperactive delierium
pt may have heightened arousal, agitation, aggression, restlessness
Hypoactive delirium
presents with a withdrawn patient, that is quiet, with reduced oral intake decreased responsiveness and slowed motor skills.
More difficult to spot in a pt
Priorities of managing a pt with confusion
Maintaining patient safety by removing from potential harm
Identifying and treating precipitants
Managing symptoms
Importance of recognising delirium
Pts who develop delirium have worse outcomes
Longer periods of hospital stay
Increased risk of falls
Increased risk of pressure sores
Early recognition reduces these risks.
New confusion is now included in the NEWS early warning score
Postural hypotension
A drop in systolic BP of greater than 20 mm Hg or a drop in diastolic BP of greater than 10 mm Hg shortly after standing.
Hx for falls
Previous falls or fractures Hx of gait or balance problems Medications Detail SH incl mookilty aids, hazards home Hx of drug and alcohol DO they drive - relevant if syncope
Medications that can cause falls
Antihypertensives Anticholinergics Antipsychotics Sedatives Opiates Antidepressants, Hypoglycaemics
Examination for fallen pt
Gait assemsnt Cardiovascular assessment Neurological examination Examination feet and joints Check vision Check cognition
Cardiovascular assessment for fallen pt
Pulse rate and rhythm, lying and standing blood pressure (BP), and presence of cardiac murmurs.
What are we looking for in a neurological examination for a fallen pt
Evidence of stroke, Parkinson’s disease, peripheral neuropathy, foot drop, cerebellar signs, and proprioception problems.
Ix fir a fallen person
Bloods
ECG – arrythmia or cardiac disease
Lying and standing bp
Tilt table test for syncope
Blood for a fallen person
Check for anaemia, hypoglycaemia, dehydration, infection, vitamin B12/ D deficiency
Management after admission w/ a fall
Treat underlying medical causes and delirium
Treat postural hypotension
Medication review aiming for deprescribing
Ensure appropriate footwear
Gait and balance training by a pt
Environmental assessment by an OT
Consider use of pendant alarms, bed or chair sensors
Fludrocortisone
Corticosteroid used for treating postural hypotension
Fludrocortisone dosage
100mg – 400mg ODS
When are individuals entitled to care and support
The adult has eligible needs
The adult is an ordinarily resident in the area (their home is established there) AND
Either people cannot afford to pay full costs, person doesn’t have mental capacity or have asked local authority to meet their needs
Presentation of falls
Failure to cope
Found on floor
Delirium
Off feet
Asking a pt what happened during a falls
Incontinence or tongue biting Loss of consciousness Pt pale/ flushed Pt injured What part of the body had the first contact with the floor?
Aking a pt what happened after a fall
Ws the pt able to get up after
How long did it take them
Was the pt able to resume normal activities
Was there any weakness or speech difficulty
Systems enquiry after a fall
General Cardiovascular Respiratory Neurological Genitourinary GI MSK
General system enquiry after a fall
Fatigue
Wt loss
PMH - visual/ hearing impairment, DM, anaemia
Cardiovascular system enquiry after a fall
Chest pain
Palpitations
PMH - cardiovascular disease, arrhythmias
Respiratory system enquiry after a fall
SOB
Cough
PMH - COPD
Neurological system enquiry after a fall
Loss of consciousness
Seizures
Motor or sensory disturbance
PMH - Parkinson’s, peripheral neuropathy, stroke, dementia
GU system enquiry after a fall
Incontinence
Urgency
Dysuria
PMH - recurrent UTI, incontinence
GI system enquiry after a fall
Abdominal pain
Diarrhoea
Constipation
PMH - Diverticulitis, chronic diarrhoea, alcoholic liver disease
MSK system enquiry after a fall
Joint pain
Muscle weakness
PMH - arthritis, chronic pain, fractures
Home safety assessment
Assessment of commonly used areas inside and outside the home
Observation of the older person moving around the home environment
Fall risk and health status of the older person
Which types of problems are identified by home safety checklists
Hazards
Problem areas
Lack of supportive or safety features
Different locations care can be provided
Hospital Hospice Nursing home Residential home Home
Syncope
Fainting
What are syncopal episodes triggered by
A sudden, temporary drop in blood flow to the brain, which leads to loss of consciousness and muscle control
Falls and poor nutrition
Deficiencies in protein, vit D, calcium, vit B12 and folic acid
Dehydration
