Falls and mobility Flashcards
Optimizing high falls risk / or in the setting of recurrent fall and osteoporosis
I have identified following risk factors for. MR. X for mobility and falls risk
1. Polypharmacy- benzo, anti arrhythmics,
2. Cognition- patient not rehabilatable in severe cognitive impairment.—-> RACF
3. Poor vision
4.Musculoskeletal - prox myopathy, osteoporosis and arthritis
5 Neurological - stroke, PN,focal neurological deficits.
6. Vascular- PVD, postural hypotension ( Parkinson disease)
7. Footwear/ Podiatry
8.General adherence. and insight to fall and preventive measures
9. Pain
Assesment and management of RF
- In term of polypharmacy, I would like to look reduce his benzodiazepine, psychotropic/antiarrythmic/diuretics
- In term of cognition, I would like to get an full OT cognitive using a validated tool such as MOCA/RUDAS/KICA -max39 and functional
assessment and organise neuroimaging such as MRI, SPECT scan and if appropriate commence pt on cholinesterase
inhibitor such as Donepezil, galantamine, rivastigmine ( oral and patch ) and Memantine ( NMDA rec antag) in consult with
a geriartrician and memory clinic. ( AD and LBD cognitive impairment can be managed wth AChase inh) - In term of vision, I would get an optometrist assessment to identify any correctable ocular pathology and optimise glasses.
- In term of his RA/ Osteoporosis/Prox myopathy, neurological /stroke/PN/PVD/ autonomic dysfunction/pain, I would like to
address XXX in my next issue) - In term of footwear, I would advise patient full adherence to well fitted shoes at home/ outdoor with input from podiatry for foot wear and OT for specialised orthoses such as Ankle foot orthoses.
For optimization of mobility, I would consider MDT approach by…
- Get Physiotherapist to incorporate balance, reisstance and endurance training and I would refer to inpatient/ outpat rehab.
- I would ask for an OT to provide GAIT aid to improve stability and off load weight bearing leg to reduce pain and providing
home safety assessment for hazard reduction. - Provide pt with personal alarm to prevent long lie.
- I would refer to podiatry for appropriate foot wear and care.
Optimizing pain management- nature/quality of pain ( Nociceptive vs Neuropathic vs Noci plastic)
SOCRATES and pain type
Impact on quality of life - sleep
I would like to assess the quality and severity of the pain
I would clarify the possible causes of the pain by looking at Bloods, imaging
Regarding management, I would aim for better pain control and function / QOL.
Non pharmacologically,
-I would educate patient regarding realistic expectation for pain control and aiming for improving function/ mobility as opposed to complete pain elimination.
- I would refer pt for psychological intervention/ service ( grounding exercise, relaxation, distraction and CBT)
- I would encourage physical intervention ( RICE= rest, ice, compression and elevation)
Pharmacologically,
-I will utilise the WHO pain pharmacological treatment ladder. I would start stepwise initially regular paracetamol, then add NSAID then opiods +/- adjunct non-opioids therapy ( amitryptyline 10 mg nocte and duloxetine 30 mg daily/ Venlafaxine/ Pregabalin/ Gabapentin ) if mixed neuropathic pain in consult with pain specialist
- I would consider referal to invasive procedures for analgesia if appropriate e.g epidural block, spinal cord stimulation ( still experimental )
I have identified that this patient has a neuropathic / nociceptive pain with severity of 6/10 ( SOCRATES )
This is affecting Mr. XX sleep quality and ability to function at work ( as Occupation ) for the last few weeks ( acute < 3 months) (chronic > 3 months)
Assessment and management of Osteoarthritis
In the short term, I would like to optimise the pain management by non-pharmacological and pharmacological measure.
In non pharmacological measure,
1. I would like to provide counselling re: weight loss through diet and exercise +/- pharmacotherapy
2.I would consider MDT approach to improve mobility and pain
–by involving psychologist to address the negative pain coping strategies e.g CBT,
–then physiotherapy for to recommend graded exercise program, stretching and flexibility exercise to increase range of
motion. ( supervised vs individualised exercise, water based, aerobic exercise, group or home exercise)
–as well as OT to provide mobility aids and possible braces, orthoses to improve function.
–I would also involve the SW to organise support services for domestic activities of daily living.
In term of pharmacological measures,
1. I would consider
-warm/ cold compressor,
-topical or oral NSAID, +/- paracetamol, capsaicin cream for neuropathic pain,
-intraarticular steroid joint injections ( can be repeated in 3 monthly interval) and provide pain relief up to 3 months,
-intraarticular hyaluronan ( hyaluronic acid), Duloxetine, opiods ( very limited role- avoid if possible as very limited role and
prescribed for a short period of time)
- Surgical management- arthroscopic debridement /intervention and joint replacement.
Assessment and management of Autonomic dysfunction
Assessment and management of foot ulcers
Assessment and management of Osteoporosis-
- confirm dx, severity
-management- nonpharma and pharma with the AIM/ GOAL of therapy…
- follow up
I would confirm the diagnosis of osteoporosis looking at pt fasting MBS ( looking at bone turnover marker), Bone mineral density scan and lateral view of thoracolumbar spine.
Regarding management of OP, non-pharmacologically, I would address falls RF and management..
Pharmacologically, I would consider anti-resorptive therapy with bisphosphonate/ Denosumab/hormonal therapy/ Teriparatide/ Romusuzumab.
I would ensure patient is on Calcium enriched diet and has appropriate level of Vitamin D ( calcium and Vitamin is repleted)
and dental check is UTD, prior to commencing anti resorptive therapy.
In terms of follow up , I would review patient in 3 months to assess medication adherence, possible side effects and linked pat with GP for regular for BMD surveillance, renal function and Vitamin D and calcium.
What is Clinical frailty?
1- Very Fit- commonly exercise regularly
2- Well- no active disease, active occasionally
3-Managing well
4- Vulnerable- not dependent but symptoms limit activities
5- Mildly frailty- need help in higher order iADL
6- Moderately frail- need help with all outdoor activity
7- Severely frail-completely dependent for personal care
8- Very severely frail- completely dependent, approaching the end of life. typically not able to recover from minor illness
9- Terminally ill- approaching end of life, a life expectancy <6 months who are not otherwise evidently frail.
How do you optimise he falls risk?
Firstly, I would like to exclude
Patient factor-
-eyesight- visual acuity
-stroke- weakness
-peripheral neuropathy —> pin prick and proprioception in feet
-proximal myopathy whilst on steroid,
-medications that contribute e.g benzodiazepine
-Sarcopenia-
-Osteoporosis- BMD
-vestibular/balance issue—> examine romberg,
- Balance and strenghtening exercise with combination of weight bearing exercise, cardio and balance exercise such as pilates/tai Chi or yoga.
External factor-
-Weightloss- ask about weight
-Nutrition- bowel surgery that might affect absorption of micro and macronutrient. Ask for her food intake/chart
Environment
- House
- Aids
