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Falls Flashcards

1
Q

How likely are falls in those 70+?

A

2x as likely as younger population

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2
Q

What increases the likelihood of falling?

A

Degredation of

  • Vestibular system
  • Proprioception
  • Eyesight
  • Muscle mass/ strength (sarcopenia)
  • Reflexes

Presence of co-morbidities

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3
Q

What is important to ask about a fall?

A

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

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4
Q

What is important to do when a patient has had a fall?

A

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

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5
Q

Why is polypharmacy more of a problem in the elderly?

A

Reduced renal clearance

  • Reduced liver volume
  • Reduced circulating albumin
  • Reduced lean body mass
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6
Q

What are the mian problems with polypharmacy in the elderly?

A

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

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7
Q

What is the STOPP START tool?

A

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

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8
Q

Problems with anticholinergics

A

Anticholinergic burden

  • Xerostomia, urinary retention, constipation, confusion/ falls, increased risk of hosp. admission, poor memory and executive function, increased risk of delirium
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9
Q

Postural hypotension

A

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

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10
Q

Why are elderly people more at risk of AKI

A

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

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11
Q

Discuss asymptomatic bacteriuria

A

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…)

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12
Q

Principles of good prescribing

A

Small selection of familiar drugs

Start low, go slow

Regular med review (every 6 months)

Stop medications that are not indicated

Patient-centred approach

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13
Q

Who does osteoporosis primarily affect?

A

Post-menopausal white women

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14
Q

What is osteopenia?

A

Low bone density

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15
Q

Classical presentation of patient with osteoporosis

A

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

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16
Q

Risk factors for osteoporosis

A

Older women

White

Long term corticosteroids

PM

Smoking

Low BMI

Vitamin D deficiency (causes PTH risk and bone resorption)

Glucocorticoid excess (Cushing’s)

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17
Q

Pathophysiology of osteoporosis

A

Key mechanisms

  1. Inadequate peak bone mass
  2. Excessive resorption due to lack of oestrogen
  3. Inadequate formation during remodelling due to lack of oestrogen
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18
Q

Investigations for osteoporosis

A

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

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19
Q

Management of osteoporosis

A

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

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20
Q

How do bisphosphonates work?

A

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

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21
Q

How is glucocotricoid-related osteoporosis managed?

A
  • Consider osteoporosis prophylaxis in patients taking >7.5mg daily pred/ equivalent
  • Oral bisphosphonates 1st line
  • Denosumab, teriparatide are alternatives
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22
Q

How does denosumab work?

A

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

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23
Q

Why do we differentiate between intracapsular and extra capsular fractures?

A

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

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24
Q

Categories of hip fractures

A

Intracapsular: above the isertion of the hip joint

Extracapsular: below insertion of hip joint

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25
Intracapsular hip fractures
Fracture within the capsule: **the femoral head or neck** Likely to cause impaired blood supply - avascular necrosis
26
Extracapsular hip fractures
Further divided into - Trochanteric - Subtrochanteric
27
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
28
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)
29
When should surgery for a hip fracture be done?
On day of admission or day after
30
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
31
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)
32
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
33
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
34
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)
35
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)
36
DAME mnemonic of fall aetiology
**D**rugs: anti-HTN, opiates, benzos, anticholinergics, anti-arrhythmics, alcohol **A**ge related change: visual loss, loss of vestibular function, loss of mobility, poor gait, slowed reaction time, sensory impairment **M**edical: stroke, heart disease, PD **E**nvironment: obstacles, poor lighting, unfamailar surroundings
37
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
38
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
39
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
40
When is a change in blood pressure on standing significant?
If the systolic drops 20mmHg+ If the diastolic drops 10mmHg+
41
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
42
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?
43
Acute consequences of falls
Rhabdomyloysis Pressure sores Hypothermia Hypostatic pneumonia (long lie = fluid on lungs and infection)
44
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
45
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
46
Epidemiology of immobility
\>50% of \>75s struggle to get around own home Many use walking aids
47
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
48
Physical consequences of immobility
Muscle wasting/ de-conditioning Osteoporosis Pressure sores Pneumonia Constipation DVT
49
Psycho-social consequence of immobility
Depression, isolation, loss of confidence, reliance on others, risk of institutionalisation
50
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
51
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
52
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)
53
What is a pressure sore?
Breaking of epidermal layer due to patient remaining in one place for extended period of time
54
Causes of pressure sores
Pressure on skin overrides perfusion pressure Illness Paralysis Advancing age
55
Epidemiology of pressure sores
70% occur in those 70+ Incidence rising due to ageing pop.
56
Where do presure sores usually develop?
Over bony prominences - Sacrum - Heel - Ischial tuberosity - Greater trochanter
57
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
58
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
59
What scoring system can be used to assess patient's risk of developing pressure sore/ pressure injury?
Waterlow
60
Grading pressure sores
1. Skin intact, erythema and signs of pressure: discolouration, warmth, oedema, hardness 2. Partial thickness skin loss involving epidermis/ dermis/ both 3. Full thickness: skin loss and damage/ necrosis of subcut tissue - can extend to but does not involve fascia 4. Extensive destruction: tissue necrosis/ damage to bone, muscle or supporting structures
61
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
62
What does a tissue viability nurse do?
Assess and treat patients with complex wounds

Elderly (4 decks)

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