Falls Flashcards
How likely are falls in those 70+?
2x as likely as younger population
What increases the likelihood of falling?
Degredation of
- Vestibular system
- Proprioception
- Eyesight
- Muscle mass/ strength (sarcopenia)
- Reflexes
Presence of co-morbidities
What is important to ask about a fall?
Before: what were they doing, any warning, how did they feel, obvious cause?
During: LOC, seizure, balance, injuries?
After: able to get up, post-fall phase, amnesia, time on floor?
Long lie is considered 1hr+ although this varies
What is important to do when a patient has had a fall?
Assess their risk of future falls
Medical: eyesight, examination, ECG, bloods, x-ray, DEXA (if right age)
PT: mobility assessment, balance assessment, walking aids
OT: home environment, ability to perform ADLs
Why is polypharmacy more of a problem in the elderly?
Reduced renal clearance
- Reduced liver volume
- Reduced circulating albumin
- Reduced lean body mass
What are the mian problems with polypharmacy in the elderly?
Increased risk of drug interactions because of multiple drugs
Increased risk of adverse effects
Lack of evidence of drugs in the elderly
Multi-morbidity means polypharmacy is often necessary
Lack of resources to guide prescribing for the elderly
What is the STOPP START tool?
Tool to raitionalise medication use in those 65+
STOPP: screening tool of older people’s prescriptions
START: screening tool to alert right treatment
Gives a score to medications that should be given consideration to either start a patient on or stop prescribing depending on associated risks
Problems with anticholinergics
Anticholinergic burden
- Xerostomia, urinary retention, constipation, confusion/ falls, increased risk of hosp. admission, poor memory and executive function, increased risk of delirium
Postural hypotension
Common problem in the elderly and a common cause of falls
Diuretics cause hypovolemia and hyponatremia
Aim: BP of 140/80 but not at the risk of falling
Why are elderly people more at risk of AKI
50% renal function lost by 70yrs
Consider stoping siuretics/ anti HTN meds during acute admission because its better to prevent an AKI than control BP
Discuss asymptomatic bacteriuria
Very common
>50% women in care homes have it
Treatment can actually do more harm that good so the question is - do we treat? I don’t have the answer…)
Principles of good prescribing
Small selection of familiar drugs
Start low, go slow
Regular med review (every 6 months)
Stop medications that are not indicated
Patient-centred approach
Who does osteoporosis primarily affect?
Post-menopausal white women
What is osteopenia?
Low bone density
Classical presentation of patient with osteoporosis
Older woman, has had a fall resulting in a hip fracture
X-ray shows multiple asymptomatic vertebral fractures that will have occurred pre-fall
Asymptomatic spinal kyphosis and back pain due to pre-existing fractures
Spontaneous fracture of hip/ radial fracture after fall
Risk factors for osteoporosis
Older women
White
Long term corticosteroids
PM
Smoking
Low BMI
Vitamin D deficiency (causes PTH risk and bone resorption)
Glucocorticoid excess (Cushing’s)
Pathophysiology of osteoporosis
Key mechanisms
- Inadequate peak bone mass
- Excessive resorption due to lack of oestrogen
- Inadequate formation during remodelling due to lack of oestrogen
Investigations for osteoporosis
DEXA scan: gold star=ndard for measuring bone density
If patient is 75+ and has had a fracture we don’t scan them because it is assumed they have osteoporosis
<75: input score of DEXA in FRAX tool which gives the 10-year fracture risk
Management of osteoporosis
Lifestye: increase activity, stop smoking, reduce alcohol, healthy BMI
Consider calcium and vitamin D supplements if at risk
Medication:
- Oral bisphosphonates 1st line, denosumab if not tolerated
- HRT: reserved for younger PPM women and not used long term because of CV and other risks
Teriparatide: form of PTH, reserved for severe cases
How do bisphosphonates work?
Inhibit function of osetoclasts and therefore reduce bone resporption
Nitrogenous/ simple: inhibit FDS enzyme which prevents formation of proteins needed for survival and function of osteoclasts e.g. alendronate
Non-nitrogenous: death of osteoclasts, more negative effects are are rarely used e.g. etidronate
How is glucocotricoid-related osteoporosis managed?
- Consider osteoporosis prophylaxis in patients taking >7.5mg daily pred/ equivalent
- Oral bisphosphonates 1st line
- Denosumab, teriparatide are alternatives
How does denosumab work?
Reduced RANK–RANKL binding, osteoclast formation, function and survival are inhibited, bone resorption decreases and bone mass increases
Protects bone from degredation
Problems associated: hypocalcaemia and osteonecrosis of jaw
Why do we differentiate between intracapsular and extra capsular fractures?
Increased risk of AVN in intracapsular fractures because of a higher rate of non-union of bone and because the blood supply to the femoral neck is poor compared to the rest of the femur
Categories of hip fractures
Intracapsular: above the isertion of the hip joint
Extracapsular: below insertion of hip joint
Intracapsular hip fractures
Fracture within the capsule: the femoral head or neck
Likely to cause impaired blood supply - avascular necrosis
Extracapsular hip fractures
Further divided into
- Trochanteric
- Subtrochanteric
What test can be done if suspective the patient has BPPV?
BPPV: due to crystals floating around and causing signals that head is travelling in directions it is not
Dix-Hallpike: sit patient up, turn their head to the side, lie them down on bed with head hanging over edge and look for nystagmus
Grading pressure sores
- Skin intact, erythema and signs of pressure: discolouration, warmth, oedema, hardness
- Partial thickness skin loss involving epidermis/ dermis/ both
- Full thickness: skin loss and damage/ necrosis of subcut tissue - can extend to but does not involve fascia
- Extensive destruction: tissue necrosis/ damage to bone, muscle or supporting structures
