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CSI > Falls > Flashcards

Falls Flashcards

1
Q

What makes someone more likely to have a fall?

A

Age due to natural ageing process

Long term health condition

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2
Q

What proportion of adults over 65 living at home will have a fall at least once a year?

A

1 in 3

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3
Q

Aside from clinical consequences what can a fall result in?

A

Loss of confidence
Become withdrawn
Loss of independence

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4
Q

What should you do if you fall?

A

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

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5
Q

What should you do if you are hurt and unable to get up?

A 
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
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6
Q

How often should you change your position if you have fallen?

A

Every half and hour roughly

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7
Q

Falls are the most common cause of injury related deaths in what population?

A

People over the age of 75

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8
Q

Why are older people more susceptible to falls?

A 
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)
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9
Q

What environmental factors make a fall more likely to happen?

A 
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
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10
Q

Why may falls in older people be particularly problematic?

A

Osteoporosis

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11
Q

What makes you more susceptible to osteoporosis?

A

Smoking
Excessive alcohol consumption
Steroid medication
Family history of hip fractures

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12
Q

Why are older women more at risk of osteoporosis?

A

Often associated with hormonal changes during menopause

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13
Q

Give examples of measures that can help prevent falls

A 
Using non-slip mats in the bathroom
Mopping up spills 
Ensuring good lighting 
Removing clutter 
Getting help moving or lifting heavy items
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14
Q

What can a GP do to reduce the risk of falls?

A

Simple balance checks

Review of medication for side effects that may increase risk

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15
Q

What might a GP recommend to reduce the risk of falls?

A 
Sight test
ECG 
Blood pressure check
Request a home hazard assessment 
Doing exercises to improve strength and balance
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16
Q

Define hip fracture

A

Bony injury of the proximal femur typically occurring in the elderly

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17
Q

How much do hip fractures cost the NHS a year?

A

£1 billion

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18
Q

What are the risk factors for hip fractures?

A 
Increasing age
Osteoporosis 
Low muscle mass
Steroids
Smoking
Excess alcohol intake
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19
Q

What is the mean age for hip fractures?

A

80

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20
Q

How many hip fractures are there a year in the UK?

A

65,000

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21
Q

How many times more common are hip fractures in women?

A

4x

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22
Q

What is the 1 year mortality for hip fractures?

A

40%

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23
Q

What comprises the proximal femur?

A 
Head
Neck
Greater trochanter
Lesser trochanter
Shaft
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24
Q

What is unique about the proximal femur?

A

Largest bone in the human body

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25
Q

What is the inter-trochanteric line?

A

Line that lies of the anterior surface of the femoral neck running between trochanters
Demarcates the inferior attachments of the hip capsule

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26
Q

Where the hip capsule attached?

A

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

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27
Q

What does the hip capsule contain?

A

Reticular vessels

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28
Q

What are the reticular vessels?

A

Main blood supply to the femoral head
Originates from the extra-capsular arterial ring
Supplied by the medial and lateral circumflex vessels

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29
Q

What is the foveal artery?

A

Supplies the epiphysis with a small amount of blood during skeletal development

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30
Q

What are the metaphyseal vessels?

A

After skeletal maturity the contribute blood to the femoral head

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31
Q

How can hip fractures be classified?

A

intra- or extra- capsular

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32
Q

What does intra-capsular mean?

A

Above the inter-trochanteric line

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33
Q

What does extra-capsular mean?

A

Below the inter-trochanteric line

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34
Q

What does the type of fracture determine?

A

Likelihood of disruption to the blood supply fo the femoral head
Intra = higher risk

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35
Q

How are intra-capsular fractures sub-classified?

A

According to garden’s classification

Type I-IV

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36
Q

What is type I?

A

Incomplete

Impacted in valgus

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37
Q

What is type II?

A

Complete

Undisplaced

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38
Q

What is type III?

A

Complete

Partially displaced

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39
Q

What is type IV?

A

Complete

Completely displaced

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40
Q

How might a hip fracture be caused in a younger person?

A

Trauma
Gait disturbance e.g. MS
Prolonger steroid use

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41
Q

How are hip fractures diagnosed?

A

Radiologically

May be suspected clinically

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42
Q

How do patients with hip fractures typically present?

A

Inability to bear weight
Pain in the affected side
Reduced range of movement
Bony tenderness

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43
Q

What bedside investigations can be carried out?

A

Observations
Urine dip
ECG

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44
Q

What bloods should be done?

A 
FBC
U&E
CRP
Clotting
Group & Save x2
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45
Q

What imaging can be done?

A

CXR pre-op
Plain films
MRI/CT if plain films are inconclusive
Cardiac echo

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46
Q

What should you observe on an X-ray?

A

Shenton’s line should be continuous and smooth

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47
Q

What is shenton’s line?

A

Imaginary curved line drawn along the inferior border of the superior ramus
Along the inferomedial border of the proximal femur

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48
Q

How are most hip fractures treated?

A

Surgically

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49
Q

When might surgery not be an option?

A

Significant co-morbidities

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50
Q

Rarely what conservative measures could be used?

A

Traction
Bed rest
Restricted mobilisation
Outcomes are often very poor

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51
Q

What do NICE recommend?

A

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

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52
Q

What surgery is recommended for displaced intra-capsular fracture gardens III/IV?

A

THR
Total hip replacement for fit patients

Hemi-arthoplasty for patients with significant comorbidity

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53
Q

What surgery is recommended for minimally displaced intra-capsular fracture gardens I/II?

A

2-3 cannulated hip screws

54
Q

What surgery is recommended for extra-capsular fractures?

A

Dynamic hip screw: Promotes bone healing

Intramedullary nail

55
Q

How can you categorise risks of falls?

A

Neurological e.g. confusion, cognitive impairment
Unmodifiable e.g. age, female
Environmental
Chemical
Cardiovascular
Neuromuscular
Other e.g. fear of falling, incontinence, fragility

56
Q

What are the neuromuscular risk factors for falls?

A

Muscle weakness

Gait disorder: Parkinson’s, hemiplegia, cerebellar disease, antalgic, normal pressure hydrocephalus eat.c

57
Q

What is a fragility fracture?

A

Result from mechanical forces (low energy)
Equivalent to a fall from standing height or less
Can happen without a fall

58
Q

What is a major risk factor for fragility fracture?

A

Reduced bone mineral density

59
Q

How can a fragility factor occur without a fall?

A

Coughing
Heavy lifting
Banging into things

60
Q

What scan do we use for diagnosis of osteoporosis?

A

DEXA Scan

T-score

61
Q

What T-score represents osteoporosis?

A

Less than 2.5

62
Q

What is osteoporosis characterised by?

A

Low bone mass
Micro architectural disruption
Skeletal fragility
Decreased bone strength and increased risk of fracture

63
Q

What is the relationship between osteoporosis and hip fractures to age and gender?

A

Risk increases with age in men and women

More so in women

64
Q

Why are elderly females at particular risk for osteoporosis?

A

Low oestrogen levels after menopause

65
Q

What does oestrogen do in bones?

A

Inhibits osteoclasts activity

Increases osteoblasts activity

66
Q

Why might an elderly person be vitamin D deficient?

A

Not going out as frequently
Diet
Poor kidney and liver function

67
Q

Why is vitamin D important in bone health?

A

Involved in calcium absorption

68
Q

What hormone level will rise in response to low calcium?

A

Parathyroid hormone

69
Q

What does PTH do?

A

Increases calcium reabsorption

Action of osteoclasts

70
Q

What role do stem cells in the bone marrow have in osteoporosis?

A

Stem cells become adipocytes rather than osteoblasts

71
Q

What is the mechanostat theory?

A

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

72
Q

What is sarcopenia?

A

Progressive and generalised loss of skeletal muscle and strength
Risk factors: age, gender, levels of physical activity

73
Q

What is sarcopenia correlated with?

A

Physical disability
Falls
Low BMD
Poor quality of life

74
Q

What % of people with hip fractures die within in month?

A

10%

75
Q

What % of them die within a year?

A

30%

76
Q

Why might they die within a year?

A 
Co-morbidities 
Infection 
Hospital acquired infections
Heart failure 
Poor mobility- blood clots, bed sores
77
Q

How would you treat Garden II, undisplaced,intra-articular, intra-capsular fracture?

A

Dynamic hip screw

Cannulated hip screw

78
Q

How would you treat a extra-capsular, displaced, intertrochanteric fracture?

A

Intra-medullary nail

79
Q

How would you treat intra-capsular, Garden IV, displaced fracture?

A

Hip replacement

Total- also replaces that acetabulum

80
Q

Why would you only do a hemi-arthroplasty?

A

Lesser operation

Less risk of post-op complications

81
Q

What medication should you start after a fragility fracture?

A

Alandronic acid
First line treatment of osteoporosis
Oral

82
Q

What should you supplement after a fragility fracture?

A

Calcium and cholecalciferol

83
Q

Where can you refer a patient after they suffer a fragility fracture?

A

Falls clinic

84
Q

What is teriparatide?

A

Competitive inhibitor for PTH

Used to treat osteoporosis

85
Q

How can bisphosphantes be used to treat osteoprosis?

A

Helps replenish minerals within bone

Inhibit osteoclasts

86
Q

What are contraindications for alendronic acid?

A

Acid reflux

GI issues

87
Q

What occurs in a falls clinic?

A 
Rehabilitation 
Occupational therapy 
Physiotherapist 
MDT approach 
Medications review
88
Q

What explains Mrs. Wilkins’ current mental state?

A

Acute confusional state- delirium

89
Q

What factors might have contributed to Mrs Wilkins delirium?

A 
Age
Dehydration
Change in environment 
Medications- change, new, not taking 
Painkillers
Bladder and bowel problems
Head trauma
90
Q

What do you check for when a patient suffers delirium?

A

Infection
Electrolyte abnormalities
Metabolic abnormalities
Intracerebral pathology

91
Q

How can delirium be combated in a hospital setting?

A 
Familiar objects
Continuity of care
Relatives
Rehydration
Mealtime buddies
Red tray- signals they need help when eating
92
Q

How do you divide care for patients with neck of femur fractures?

A

Pre op
Op
Post op

93
Q

What should you know about your patients?

A

Medical co-morbidities
How mobile there were before their fall
Social history

94
Q

What drugs can cause bleeding?

A

Warfarin

Low molecular weight heparin

95
Q

What should you look for on an X-ray?

A

Intra/extra capsular

Displaced/undisplaced

96
Q

What can prolonged bed rest lead to?

A 
Thromboembolism
UTIs
Pneumonia
Pressure sores
Loss of muscle
97
Q

Who is involved in post-op management?

A 
Orthopaedic surgeon
Geriatric physician 
Nurses
Occupational therapist
Social workers
Physiotherapists
98
Q

What is key in ideal management of neck of femur fractures?

A

Early diagnosis

Early surgery within 36 hours of presentation

99
Q

What are the effects of delirium?

A 
Easily distracted
More confused 
Changes in alertness
Disorientation
Rambling speech
Disturbed patterns of sleep 
Prone to mood swings
Hallucinations
Abnormal/Paranoid beliefs
100
Q

What is ‘hypoactive’ delirium?

A

Causes patients to become withdrawn and sleepy

101
Q

What is hypoactive delirium often confused with?

A

Depression

102
Q

What is ‘hyperactive’ delirium?

A

Abnormally alert
Restless
Agitated
Possibly aggressive

103
Q

What is mixed delirium?

A

Alternating between hypo/hyper active delirium

104
Q

What is the difference between dementia and delirium?

A

Delirium starts suddenly

Delirium symptoms will vary greatly during the day

105
Q

Which type of dementia is delirium most similar to?

A

Lewy body

106
Q

What percentage of older people in hospital have dementia?

A

20%

107
Q

What can delirium result from?

A 
Brains reaction to underlying medical problem:
Chest infection
UTI
Severe illness
Surgery
Pain
Dehydration
Constipation
Poor nutrition
Change in medication
108
Q

Who is at risk of delirium?

A 
Dementia
Over 65
Frailty
Multiple co-morbidities 
Poor hearing/vision
Multiple medications
109
Q

In what % of people at risk can delirium be prevented?

A

30%

110
Q

How can delirium be diagnosed?

A

Clinical history
Underlying health
Current mental state
Speaking to loved ones

111
Q

How can people with delirium be supported?

A 
Review medications
Pain free
Properly hydrated
Well nourished
Oxygenated
112
Q

How can the environment be adapted?

A

24 hour clock
Hearing aids and glasses properly worn
Avoid unnecessary noise t night
Not moving person between wards

113
Q

What effects can be seen post-delirium?

A

Distressing memories
Rapid worsening of a person’s mental abilities
Later diagnosis of dementia
Higher risk of death

114
Q

What is an osteoporotic fracture?

A

Fragility fracture caused by osteoporosis

115
Q

What are risk factors for fragility fractures?

A 
Osteoporosis
Advancing age
Acromegaly
Osteogenesis imperfecta
Poor balance
Poor muscle strength
116
Q

How many fractures does osteoporosis cause?

A

200,000 annually

117
Q

How much do they cost the NHS?

A

£1.7 Billion

118
Q

What are the risks of fragility fractures?

A 
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
119
Q

What are secondary causes of osteoporosis?

A 
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
120
Q

What are common sites for fragility fractures?

A

Vertebrae
Proximal femur
Distal radius

121
Q

What can compression fractures cause?

A 
Pain 
Morbidity associated with high analgesia doses
Loss of height 
Difficulty breathing
Loss of mobility 
GI symptoms 
Difficulty sleeping 
Symptoms of depression
122
Q

How are acute injuries managed?

A 
Chest X-ray
ECG
FBC
Renal function
Glucose 
Assessment of cognitive function
123
Q

What post op components can be used?

A 
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
124
Q

How can low BMD be treated?

A

Adequate vit D and calcium intake

125
Q

What is denosumab?

A

Monoclonal antibody that reduces osteoclast activity

126
Q

What is strontium ranelate?

A

Only used for severe osteoporosis

or patients for whom other treatments are not possible due to increased risk of myocardial infarction

127
Q

What is raloxifene?

A

Selective oestrogen receptor modulator
Inhibits bone reabsorption
Reduces vertebral fracture risk

128
Q

What is teriparatide?

A

Recombinant fragment of parathyroid hormone

129
Q

Why may HRT be used?

A

Option in younger perimenopausal women who also need treatment for symptoms of menopause

130
Q

What does prognosis depend upon?

A

Age
Comorbidity
Fracture site
Personal circumstances

131
Q

What % of people with hip fractures cannot live independently afterwards?

A

50%

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