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Geriatrics > Elderly - Immobility & Falls > Flashcards

Elderly - Immobility & Falls Flashcards

1
Q

Basic rules for looking after older people:

  • There will be more than ___ thing wrong
  • Most illness will present __________
  • One presenting complaint can lead to a ________ of diagnosis
  • (much more interesting than single organ-ology clinics)
  • Be an annoying toddler, keep asking ‘why?’

Usually present with one of the _________ syndromes

A

one

atypically

multitude

geriatric

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2
Q

what are the causes of falls?

A
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3
Q

what are the musculoskeletal causes of a fall?

A

Arthritis of weight bearing joints

Sarocopenia (syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength and it is strictly correlated with physical disability, poor quality of life and death)

Deformities of feet

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4
Q

what are the drugs causes of a fall?

A

Anti hypertensives

Sedatives, alcohol

And lots of others

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5
Q

what are the neurological causes of a fall?

A

Stroke, old or new

Parkinsonism

Dementia

Delirium, Ataxia (Seizure, TIA)
Other neurological conditions

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6
Q

what are the sensory causes of a fall?

A

Visual impairment

Inattention

(Hearing)

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7
Q

what are the cardiovascular causes of a fall?

A

Postural hypotension

Arrythmia

Heart failure (can make people to weak to stand up)

Aortic Stenosis

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8
Q

how doe sincontinence cause a fall?

A

Rushing to the toilet

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9
Q

how do drugs cause a fall? what do they decrease and what do they increase?

A
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10
Q

what are some culprit drugs that may cause a fall?

A
  • Antihypertensive (easy to stop)
  • Beta blocker
  • Sedatives
  • Anticholingerics
  • Opioids
  • Alcohol
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11
Q

Where are you seeing a perosn who has had a fall? and what are they likely to be presenting like?

A
  • Falls clinic - Likely to be well patients, difficult and multifactorial falls
  • A+E - More likely to be acutely unwell. May not be possible to do it all
  • Assessing a hospital inpatient who has fallen - Very likely to be acutely unwell. Significant injury possible
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12
Q

The falls clinic is a full MDT - who is involved and what is their role?

A
  • Nurse - Eye test, ECG, Lying and standing BP, incontinence questionarrie. MMSE
  • Physiotherapist - Full assessment of gait and balance
  • Doctor - Through history and examination, consider bone health and osteoporosis screening. (45 minutes +)
  • MDT discussion - Treatment plan made
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13
Q

History in falls is the same as any other medical history - what would be involved?

A
  • PC/HPC Detail of the fall. What were you doing. Who with? What happened? What happened next. How did you get up off the floor
  • Collapse with no memory ?syncope or cognition
  • Clear history of trip – think sensory (eyes, nerves)
  • Palpitations preceding fall and no trip - think cardiac
  • On turning – think postural instability
  • Any ‘near misses’- unsteady on standing
  • Syncope on exertion think aortic stenosis
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14
Q

systemic enquiry - Very important – in addition to usual things:

what informaiton should you get?

A
  • Memory – Ideally ask a relative too
  • Urinary symptoms (they won’t tell you if you don’t ask)
  • Has walking changed recently

Drugs:

  • Yes, I want to know everything. Especially over the counter antihistamines…
  • Especially alcohol
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15
Q

what would you do on examination?

A

top to toe:

  • Get patient on couch
  • Head and arms:
  • Cranial nerves, apart from smell. Check glasses
  • Check neglect,
  • Cerebellar signs
  • Bradykineasia, ridigidity – signs of PD (parkinsons)
  • Pulse, (BP) Heart sounds. Signs of heart failure and respiratory disease
  • Kyphosis
  • Abdominal examination (+PR if prostate)

see patient walking

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16
Q

what examination of the legs is required?

A
  • Look at feet (footware, toenails).
  • Check sensation, vibration sense, and proprioception – remember usually glove and stocking not dermatomal
  • Co-ordination

Put shoes and socks back on. (You may need a shoehorn) Stand patient up:

  • Romberg’s
  • Assess gait
17
Q

Match the gait to the pathology:

ataxic

A

Cerebellar damage

Ataxic is a wide gate, Cerebellar damage is caused by alcohol followed by stroke

18
Q

Match the gait to the pathology:

Arthralgia

A

arthritis

trying not to put weight on one leg

19
Q

Match the gait to the pathology:

Hemiplegic

A

stroke

stiff leg and not putting weight through it

20
Q

Match the gait to the pathology:

Small steps, shuffling

A

(Vascular) parkinsonism

Shuffling gate is very common

21
Q

Match the gait to the pathology:

high stepping

A

Peripheral neuropathy

22
Q

scenario 1:

  • It’s 2am in accident and emergency. You are the FY2. You have been asked to see Mabel. She is a 93 year old woman who has been waiting since 4pm.
  • She was brought to A+E by ambulance after she was found at home by her carers having fallen.
  • What do you do?
A
23
Q

The patient in A+E who has fallen - what do they present like?

A
  • Non-injured fallers are often left at home by paramedics and referred to community falls pathways- including falls clinic
  • Patients in A+E are usually:
  • Tired
  • Injured
  • In pain
  • Unable to stand due to injury (so can’t assess gait)
  • Systemically unwell
  • Will need MDT assessment later
24
Q

A falls assessment in A+E - History - what informaiton would you gather?

A
  • First do ABDCE assessment and assess and treat any injury
  • How did they fall? Did they trip over? What did they trip over?
  • Long lie – check CK for rhabdomyolysis. Pneumonia and skin injury common as well
  • Any other falls
  • Any cognitive impairment (may be dementia or deliruim)
  • Any incontinence
  • Any syncope
  • Any features of seizure (rare but happens)
  • Are they drunk
  • Look at ambulance sheet – about where they were, where they fell, what assessment at scene, they will normally of done a blood glucose
  • Talk to relative (even if they seem to have capacity)
25
Q

A falls assessment in A+E - examination
and investigations - what would you do?

A
  • Are they acutely unwell? – do bloods
  • Do a neurological examination as well as Chest/heart/abdomen (skip reflexes!)
  • Look at legs and try and get them to walk (if you can)
  • The best history you can get (include the ambulance sheet)
  • Ensure a full set of obs are done (do yourself if in ‘minors’) do L+S BP
  • ECG for all
  • Bloods for all* check B12, folate, CK, TFTs
  • Check for delirium using 4AT
  • Consider CT head if fall with head injury and neurological signs or anticoagulated

Have they got neglect, have they had a stroke

If you cant get them to walk then you cannot send them home

26
Q

what are some questions to ask yourself?

A
  • Is Mable injured?
  • Is she sick?
  • Are there any reversable causes of fall you can correct now?

(DRUGS DRUGS DRUGS)

•Is she safe to go home (+ community falls service)?

  • Can she go to the toilet on her own?
  • Can she get a cup of tea between carer visits?
  • Can she walk in A+E ?
  • Can she summon help (would she have a long lie)?
27
Q

when assessing a fallen patient, what are the 3 main things to do?

A
  • ABCDE approach
  • Check glucose
  • Top to toe survey
28
Q

Scenario 2 – In Hospital falls:

  • It’s 2am in ARI – are the FY1 who has been asked to see Jack who is 92 and has fallen on a ward.
  • What do you do?
  • Assess both cause and consequence of the fall?
  1. Immediately assess for serious injury
  2. Consider cause of fall
A
29
Q

when someone has fallen in hospital:

Name, fall date and time, description of fall, what happened, what was their observation, when was the doctor called and when did thy arrive

Medical assessment when they are on the floor – check for big injury, GCS

what consequences of a fall may there be?

A

Looking for the consequences of a fall shown by the red arrows, these are not the causes of falls

30
Q

Things not to miss after an inpatient falls - what are they?

A

Don’t want to miss a subdural, not every subdural is obvious, may only be a bit more confused after they fell

Don’t want to miss fractured hip – shortened and externally rotated hip, cant stand up, may not be obvious but may just not be able to weight bare or pain on weight bearing

31
Q

Do I need to CT a head injury?

A

Yes immediately if:

  • Low GCS <13
  • Still confused after 2 hours (or not back to baseline cognitive state)
  • Focal neurology
  • Signs of skull fracture
  • Basal skull fracture – CSF leak, bruising around eyes
  • Seizure
  • Vomiting
  • Anti-coagualtion
32
Q

Should I x ray that? (fractured hip)

A
  • If pain on moving a joint have low threshold of x ray
  • If no deformity but pain on weight bearing have low threshold to x ray
  • People can walk on fractured hips (I don’t know how either!)
33
Q

What caused the fall in inpatients?

A
  • All the same things as outpatients and….
  • Patient getting postural hypotension (or just hypotension) due to illness
  • Or new medication
  • Low blood glucose
  • Or getting sicker
  • DELIRIUM DELRIUM DERLIRUM
  • De-conditoning
  • Call bell out of reach, no appropriate footwear
34
Q

what acitons does a nurse do after a fall?

A
  • Repeat risk assessment
  • Datix
  • Call family
  • Try and prevent further fall

Main thing we are focussing on is can we prevent another fall

35
Q

__________ is better than cure

A

Prevention

36
Q

What caused this fall?

  • Mary 88
  • Lives alone, PMH, AF, hypothyroid, recent diagnosed mild dementia, hypertension,
  • Shopping in Marks and Spencer when she feels dizzy and collapses. Was looking at coats, not exerting herself.
  • No trip. Gives clear history herself
  • Friend with her agrees. No LOC
  • On Apixiban, levothyroxine, bisoprolol 10mg, Donepezil 10mg,
  • O/S Systolic murmur, BP 110/80 lying 90/70 standing, HR 55 irregular. No heart failure, neurologically intact. No injury FBC, CRP, U+E, LFTs Normal.
A

Which medication could it be?

  • Apixaban
  • Levothyroxine
  • Bisoprolol
  • Donezipezil
37
Q

What to do now?

what is the most likely diagnosis?

A
  • Postural hypotension due to Bisoprolol
  • Bradycardia due to Bisoprolol, Donepezil and possible undertreated hypothyroidism
  • Rarer but life threatening ones not to miss - Aortic stenosis

Geriatrics (12 decks)

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