Falls Flashcards
What makes someone more likely to have a fall?
Age due to natural ageing process
Long term health condition
What proportion of adults over 65 living at home will have a fall at least once a year?
1 in 3
Aside from clinical consequences what can a fall result in?
Loss of confidence
Become withdrawn
Loss of independence
What should you do if you fall?
Keep calm
Don’t get up too quickly
Roll on your hands and knees
Look for a stable piece of furniture e.g. chair or bed
Hold with both hands
Rest before carrying on with daily activities
What should you do if you are hurt and unable to get up?
Call out for help Bang on wall or floor Use aid call button Call 999 Try to reach something warm e.g. blanket/dressing gown to keep over you particularly legs and feet Keep as comfortable as possible
How often should you change your position if you have fallen?
Every half and hour roughly
Falls are the most common cause of injury related deaths in what population?
People over the age of 75
Why are older people more susceptible to falls?
Balance problems Muscle weakness Poor vision Long term health conditions e.g. hearing disease Can lead to dizziness and a brief loss of conciousness Reduced bone mineral density Bones deficient in elastic reserve Medications e.g. beta blockers Low blood pressure (postural/orthostatic hypotension)
What environmental factors make a fall more likely to happen?
Floors are wet e.g. bathroom or recently polished Dim lighting Not properly secured rugs or carpets Person is reaching for storage areas Wires Person is going down the stairs Person is rushing to go to the toilet Carrying out maintenance work on a ladder
Why may falls in older people be particularly problematic?
Osteoporosis
What makes you more susceptible to osteoporosis?
Smoking
Excessive alcohol consumption
Steroid medication
Family history of hip fractures
Why are older women more at risk of osteoporosis?
Often associated with hormonal changes during menopause
Give examples of measures that can help prevent falls
Using non-slip mats in the bathroom Mopping up spills Ensuring good lighting Removing clutter Getting help moving or lifting heavy items
What can a GP do to reduce the risk of falls?
Simple balance checks
Review of medication for side effects that may increase risk
What might a GP recommend to reduce the risk of falls?
Sight test ECG Blood pressure check Request a home hazard assessment Doing exercises to improve strength and balance
Define hip fracture
Bony injury of the proximal femur typically occurring in the elderly
How much do hip fractures cost the NHS a year?
£1 billion
What are the risk factors for hip fractures?
Increasing age Osteoporosis Low muscle mass Steroids Smoking Excess alcohol intake
What is the mean age for hip fractures?
80
How many hip fractures are there a year in the UK?
65,000
How many times more common are hip fractures in women?
4x
What is the 1 year mortality for hip fractures?
40%
What comprises the proximal femur?
Head Neck Greater trochanter Lesser trochanter Shaft
What is unique about the proximal femur?
Largest bone in the human body
What is the inter-trochanteric line?
Line that lies of the anterior surface of the femoral neck running between trochanters
Demarcates the inferior attachments of the hip capsule
Where the hip capsule attached?
Proximally to margins of acetabulum and transverse acetabular ligament
Distally to the inter-trochanteric line
Posteriorly to the bases of the trochanters and the femoral neck
What does the hip capsule contain?
Reticular vessels
What are the reticular vessels?
Main blood supply to the femoral head
Originates from the extra-capsular arterial ring
Supplied by the medial and lateral circumflex vessels
What is the foveal artery?
Supplies the epiphysis with a small amount of blood during skeletal development
What are the metaphyseal vessels?
After skeletal maturity the contribute blood to the femoral head
How can hip fractures be classified?
intra- or extra- capsular
What does intra-capsular mean?
Above the inter-trochanteric line
What does extra-capsular mean?
Below the inter-trochanteric line
What does the type of fracture determine?
Likelihood of disruption to the blood supply fo the femoral head
Intra = higher risk
How are intra-capsular fractures sub-classified?
According to garden’s classification
Type I-IV
What is type I?
Incomplete
Impacted in valgus
What is type II?
Complete
Undisplaced
What is type III?
Complete
Partially displaced
What is type IV?
Complete
Completely displaced
How might a hip fracture be caused in a younger person?
Trauma
Gait disturbance e.g. MS
Prolonger steroid use
How are hip fractures diagnosed?
Radiologically
May be suspected clinically
How do patients with hip fractures typically present?
Inability to bear weight
Pain in the affected side
Reduced range of movement
Bony tenderness
What bedside investigations can be carried out?
Observations
Urine dip
ECG
What bloods should be done?
FBC U&E CRP Clotting Group & Save x2
What imaging can be done?
CXR pre-op
Plain films
MRI/CT if plain films are inconclusive
Cardiac echo
What should you observe on an X-ray?
Shenton’s line should be continuous and smooth
What is shenton’s line?
Imaginary curved line drawn along the inferior border of the superior ramus
Along the inferomedial border of the proximal femur
How are most hip fractures treated?
Surgically
When might surgery not be an option?
Significant co-morbidities
Rarely what conservative measures could be used?
Traction
Bed rest
Restricted mobilisation
Outcomes are often very poor
What do NICE recommend?
Surgery to be performed on the day of or the day after admission
Aim to allow patients to fully weight bear in the immediate post-op period
What surgery is recommended for displaced intra-capsular fracture gardens III/IV?
THR
Total hip replacement for fit patients
Hemi-arthoplasty for patients with significant comorbidity
What surgery is recommended for minimally displaced intra-capsular fracture gardens I/II?
2-3 cannulated hip screws
What surgery is recommended for extra-capsular fractures?
Dynamic hip screw: Promotes bone healing
Intramedullary nail
How can you categorise risks of falls?
Neurological e.g. confusion, cognitive impairment
Unmodifiable e.g. age, female
Environmental
Chemical
Cardiovascular
Neuromuscular
Other e.g. fear of falling, incontinence, fragility
What are the neuromuscular risk factors for falls?
Muscle weakness
Gait disorder: Parkinson’s, hemiplegia, cerebellar disease, antalgic, normal pressure hydrocephalus eat.c
What is a fragility fracture?
Result from mechanical forces (low energy)
Equivalent to a fall from standing height or less
Can happen without a fall
What is a major risk factor for fragility fracture?
Reduced bone mineral density
How can a fragility factor occur without a fall?
Coughing
Heavy lifting
Banging into things
What scan do we use for diagnosis of osteoporosis?
DEXA Scan
T-score
What T-score represents osteoporosis?
Less than 2.5
What is osteoporosis characterised by?
Low bone mass
Micro architectural disruption
Skeletal fragility
Decreased bone strength and increased risk of fracture
What is the relationship between osteoporosis and hip fractures to age and gender?
Risk increases with age in men and women
More so in women
Why are elderly females at particular risk for osteoporosis?
Low oestrogen levels after menopause
What does oestrogen do in bones?
Inhibits osteoclasts activity
Increases osteoblasts activity
Why might an elderly person be vitamin D deficient?
Not going out as frequently
Diet
Poor kidney and liver function
Why is vitamin D important in bone health?
Involved in calcium absorption
What hormone level will rise in response to low calcium?
Parathyroid hormone
What does PTH do?
Increases calcium reabsorption
Action of osteoclasts
What role do stem cells in the bone marrow have in osteoporosis?
Stem cells become adipocytes rather than osteoblasts
What is the mechanostat theory?
Suggests that external forces influence the mass and architecture of the bone
Adapts strength to resist/cope with habitual loads
Regulatory mechanism in bone that senses changes in the mechanical demands placed on it and stimulates adjustment in its architecture
Below a certain threshold of mechanical use bone is reabsorbed
What is sarcopenia?
Progressive and generalised loss of skeletal muscle and strength
Risk factors: age, gender, levels of physical activity
What is sarcopenia correlated with?
Physical disability
Falls
Low BMD
Poor quality of life
What % of people with hip fractures die within in month?
10%
What % of them die within a year?
30%
Why might they die within a year?
Co-morbidities Infection Hospital acquired infections Heart failure Poor mobility- blood clots, bed sores
How would you treat Garden II, undisplaced,intra-articular, intra-capsular fracture?
Dynamic hip screw
Cannulated hip screw
How would you treat a extra-capsular, displaced, intertrochanteric fracture?
Intra-medullary nail
How would you treat intra-capsular, Garden IV, displaced fracture?
Hip replacement
Total- also replaces that acetabulum
Why would you only do a hemi-arthroplasty?
Lesser operation
Less risk of post-op complications
What medication should you start after a fragility fracture?
Alandronic acid
First line treatment of osteoporosis
Oral
What should you supplement after a fragility fracture?
Calcium and cholecalciferol
Where can you refer a patient after they suffer a fragility fracture?
Falls clinic
What is teriparatide?
Competitive inhibitor for PTH
Used to treat osteoporosis
How can bisphosphantes be used to treat osteoprosis?
Helps replenish minerals within bone
Inhibit osteoclasts
What are contraindications for alendronic acid?
Acid reflux
GI issues
What occurs in a falls clinic?
Rehabilitation Occupational therapy Physiotherapist MDT approach Medications review
What explains Mrs. Wilkins’ current mental state?
Acute confusional state- delirium
What factors might have contributed to Mrs Wilkins delirium?
Age Dehydration Change in environment Medications- change, new, not taking Painkillers Bladder and bowel problems Head trauma
What do you check for when a patient suffers delirium?
Infection
Electrolyte abnormalities
Metabolic abnormalities
Intracerebral pathology
How can delirium be combated in a hospital setting?
Familiar objects Continuity of care Relatives Rehydration Mealtime buddies Red tray- signals they need help when eating
How do you divide care for patients with neck of femur fractures?
Pre op
Op
Post op
What should you know about your patients?
Medical co-morbidities
How mobile there were before their fall
Social history
What drugs can cause bleeding?
Warfarin
Low molecular weight heparin
What should you look for on an X-ray?
Intra/extra capsular
Displaced/undisplaced
What can prolonged bed rest lead to?
Thromboembolism UTIs Pneumonia Pressure sores Loss of muscle
Who is involved in post-op management?
Orthopaedic surgeon Geriatric physician Nurses Occupational therapist Social workers Physiotherapists
What is key in ideal management of neck of femur fractures?
Early diagnosis
Early surgery within 36 hours of presentation
What are the effects of delirium?
Easily distracted More confused Changes in alertness Disorientation Rambling speech Disturbed patterns of sleep Prone to mood swings Hallucinations Abnormal/Paranoid beliefs
What is ‘hypoactive’ delirium?
Causes patients to become withdrawn and sleepy
What is hypoactive delirium often confused with?
Depression
What is ‘hyperactive’ delirium?
Abnormally alert
Restless
Agitated
Possibly aggressive
What is mixed delirium?
Alternating between hypo/hyper active delirium
What is the difference between dementia and delirium?
Delirium starts suddenly
Delirium symptoms will vary greatly during the day
Which type of dementia is delirium most similar to?
Lewy body
What percentage of older people in hospital have dementia?
20%
What can delirium result from?
Brains reaction to underlying medical problem: Chest infection UTI Severe illness Surgery Pain Dehydration Constipation Poor nutrition Change in medication
Who is at risk of delirium?
Dementia Over 65 Frailty Multiple co-morbidities Poor hearing/vision Multiple medications
In what % of people at risk can delirium be prevented?
30%
How can delirium be diagnosed?
Clinical history
Underlying health
Current mental state
Speaking to loved ones
How can people with delirium be supported?
Review medications Pain free Properly hydrated Well nourished Oxygenated
How can the environment be adapted?
24 hour clock
Hearing aids and glasses properly worn
Avoid unnecessary noise t night
Not moving person between wards
What effects can be seen post-delirium?
Distressing memories
Rapid worsening of a person’s mental abilities
Later diagnosis of dementia
Higher risk of death
What is an osteoporotic fracture?
Fragility fracture caused by osteoporosis
What are risk factors for fragility fractures?
Osteoporosis Advancing age Acromegaly Osteogenesis imperfecta Poor balance Poor muscle strength
How many fractures does osteoporosis cause?
200,000 annually
How much do they cost the NHS?
£1.7 Billion
What are the risks of fragility fractures?
Age Female Low body mass/ Anorexia nervosa Parental history Corticosteroid therapy Cushing's 3+ units a day Smoking Ethnicity- caucasian higher risk OI/Acromegaly Visual impairment Cognitive impairment Sedative meds
What are secondary causes of osteoporosis?
Rheumatoid arthritis Very sedentary lifestyle Hypogonadism Hyperparathyroidism Hyperthyroidism Post-transplantation Chronic kidney disease GI e.g. Crohn's, coeliac Premature menopause T1DM and T2DM Chronic liver disease COPD
What are common sites for fragility fractures?
Vertebrae
Proximal femur
Distal radius
What can compression fractures cause?
Pain Morbidity associated with high analgesia doses Loss of height Difficulty breathing Loss of mobility GI symptoms Difficulty sleeping Symptoms of depression
How are acute injuries managed?
Chest X-ray ECG FBC Renal function Glucose Assessment of cognitive function
What post op components can be used?
Pain control Antibiotic prophylaxis FBC monitoring Routine examinations Cognitive function assessment Prevention and management of pressure sores Nutritional status monitoring Monitoring of renal/bowel/bladder function Wound care Early mobilisation
How can low BMD be treated?
Adequate vit D and calcium intake
What is denosumab?
Monoclonal antibody that reduces osteoclast activity
What is strontium ranelate?
Only used for severe osteoporosis
or patients for whom other treatments are not possible due to increased risk of myocardial infarction
What is raloxifene?
Selective oestrogen receptor modulator
Inhibits bone reabsorption
Reduces vertebral fracture risk
What is teriparatide?
Recombinant fragment of parathyroid hormone
Why may HRT be used?
Option in younger perimenopausal women who also need treatment for symptoms of menopause
What does prognosis depend upon?
Age
Comorbidity
Fracture site
Personal circumstances
What % of people with hip fractures cannot live independently afterwards?
50%
