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
Epidemiology of femoral fractures
65,000 per year UK
£1billion/ year
10% die within 30 days
33% die within 12 months
*Most deaths due to co-morbidities rather than fracture itself
MDT assessment following hip fracture
Orthogeri assessment
Optimisation of fitness for surgery
Goals for rehab
Imaging: offer MRI if suspecting fracture but nothing showing on x-ray (CT is alternative)
When should surgery for a hip fracture be done?
On day of admission or day after
Analgesia following hip fracture
Assess pain at time of presentation, within 30 mins of giving pain relief and then hourly until settled on ward
- Analagesia must be sufficient to allow for examination
- Paracetamol every 6hrs after surgery
+ opioids if needed
+ nerve block if needed
*NSAIDs not recommended
Overview of surgery for hip fractures
Aim is to allow patient to fully weight bear
Replacement arthroplasty: total hip replacement
Hemi: only ball, not socket
Other options: dynamic hip screws (syable fracture) , gamma nail (instable fracture)
Why are patients with dementia more likely to fall?
8x more likely
- Inappropriate risk taking
- Abnormal gait due to impaired processing
- Medication
- Orthostatic hypotension e.g. in PD or Lewy body dementia
- Visuo-spatial impairment in vascular dementia
- Treatable cause may be missed because patient unable to give hx
What is a mechanical fall?
A cause of fall that would cause anyone to fall e.g. no difference between young and old
Only 15% of falls are mechanical
Epidemiology of falls
50% of those 80+
Increasing risk with age
F>M
Accounts for 10% fractures in the elderly
More common in care homes and hospital (unfamiliar)
Aetiology of falls
Syncope: transient LOC due to cerebral hypoperfusion, cardiogenic (arrhythmia, hypotension due to bleed), vasovagal (triggered by post-meal vasodilation, micturition, defecation), orthostatic hypotension (drugs, dehydration, autonomic failure e.g. PD)
Idiopathic trip: environmental, poor vision, poor vestibular function
Neurology: PD, peripheral neuropathy, stroke, seizure
Balance disorders: vestibular (BPPV, cerebellar syndrome, loss of proprioception with age), mechanical (poor joint mobility, sarcopenia, osteoporosis, poor neuro function on one side e.g. stroke)
DAME mnemonic of fall aetiology
Drugs: anti-HTN, opiates, benzos, anticholinergics, anti-arrhythmics, alcohol
Age related change: visual loss, loss of vestibular function, loss of mobility, poor gait, slowed reaction time, sensory impairment
Medical: stroke, heart disease, PD
Environment: obstacles, poor lighting, unfamailar surroundings
Drug causes of falls
Anti-HTN: hypotension and syncope
Anti-cholinergics: dizzy, blurred vision
Opiates: drowsy, reduced reaction time
Benzos: drowsy
Anti-arrhythmics: can promote arrhythmia
Questions to ask a patient who has had a fall
Cause: when , where, how, why
What happened before:
Any aura, any warning, weakness, palpitations, chest pain, just eaten (vasovagal syncope), just after turning head to one side (carotid sinus hypersensitivity)
Orthostatic hypotension? After standing up?
Vertigo?
What happened during:
LOC, did they hit the ground, did anyone witness fall, any injuries sustained, bitten tongue, incontinence, which part of body hit the floor first
What happened after:
Were they able to get up, long lie, rapid recovery, how did they feel after
Previous falls: in last 12 months
Specific symptoms: peripheral neuropathy, problem with vision, trouble with walking, confidence on feet, dizziness
Systems review: cardiac (palpitations, chest pain), neuro (LOC, seizures, motor/ sensory loss), genitourinary (dysuria, incontinence, urgency), MSK (joint pain, muscle weakness)
PMHx, drug hx, FHx
Investigations following a fall
Bedside
Obs: BP (lying and standing), HR, RR, sats, temp: infective or cardiogenic cause? Hypotension/ bradycardia
Urine dip: although not in 65+
ECG
Cognitive screen
BM: hypoglycaemia due to poor oral intake?
Bloods
FBC: anaemia/ infection
U&E: dehydration, electrolyte anomalies, rhabdomyolysis (CK)
Bone profile: raised calcium in malignancy
Imaging
Head CT, CXR, echo
Special tests
48hr cardiac monitoring, vertigo manoeuvres
When is a change in blood pressure on standing significant?
If the systolic drops 20mmHg+
If the diastolic drops 10mmHg+
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
Managing a patient following a fall
Medic: treat the cause, reduce pain, stop any unecessary drugs, consider treatment of osteoporosis
OT/PT
Optician review?
Podiatrist for shoes?
Acute consequences of falls
Rhabdomyloysis
Pressure sores
Hypothermia
Hypostatic pneumonia (long lie = fluid on lungs and infection)
Chronic consequences of falls
Fear of future falls: immobility and isolation
Burns: friction/ fell onto heat source
Anxirty/ depression
Spinal cord damage
33% die within 1yr
What is immobility?
Spectrum from not being able to drive to being housebound/ wheelchair dependent
Typical complaint: gone off legs, unable to stand, taken to bed
Epidemiology of immobility
>50% of >75s struggle to get around own home
Many use walking aids
Causes of immobility
Pain: joints, bones, muscles
Weakness: neuro, muscle damage, anaemia, infections, loss of fitness
Visual impairment
Psychological: anxiety, agoraphobia, depression, delirium
iatrogenic: sedation from medication
Physical consequences of immobility
Muscle wasting/ de-conditioning
Osteoporosis
Pressure sores
Pneumonia
Constipation
DVT
Psycho-social consequence of immobility
Depression, isolation, loss of confidence, reliance on others, risk of institutionalisation
Management of immobility
Treat reversible problems: OA, review medications, analgesia
PT: walking aids, wheelchair
Podiatry: foot care and proper shoes
OT: remove barriers/ make home suitable
Causes of faecal incontinence
Diarrhoea: infective, drug induced, inflammatory
Constipation overflow
Dementia: disinhibition
Obstetric trauma
Iatrogenic following surgery
Neurological: stroke, spinal cord injury
Immobility: cannot make it to toilet
Management of faecal incontinence
Treat any underlying cause
Try bulking preparations and regularly take patient to toilet (ispaghula husk - dietary fibre)
Anti-diarrhoeals (loperamide, codeine)
What is a pressure sore?
Breaking of epidermal layer due to patient remaining in one place for extended period of time
Causes of pressure sores
Pressure on skin overrides perfusion pressure
Illness
Paralysis
Advancing age
Epidemiology of pressure sores
70% occur in those 70+
Incidence rising due to ageing pop.
Where do presure sores usually develop?
Over bony prominences
- Sacrum
- Heel
- Ischial tuberosity
- Greater trochanter
Predisposing factors to pressure sores
Lack of mobility: spinal injury, stroke, reduced consciousness, pain
Malnourishment: poor healing
Sensory neuropathy
Low BMI
PVD: poor blood supply
Medications: sedation/ lack of pain awareness
What is the Waterlow score?
Used to screen for patients at risk of developing pressure sores
Score of 10-14 indicates ‘at risk’ a score of 15-19 indicates ‘high risk’, and. a score of 20 and above indicates very high risk
What scoring system can be used to assess patient’s risk of developing pressure sore/ pressure injury?
Waterlow
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
Management of pressure sores
Prevent: identify at risk, reduce immobility, regular turning, nutrition, keep skin dry
Can take months to heal, consider nutritional supplements, treat pain, antivbiotics if infected, refer to tissue viability nurse, surgical debridement
What does a tissue viability nurse do?
Assess and treat patients with complex wounds
