Falls and old age - Clinical medicine Flashcards
Describe what mechanisms are involved in balance
- Sensory mechanism - vision, proprioception, tactile sense, vestibular system
- Central processing - the brain and spinal cord
- Effector mechanisms- muscle and joint
Describe the strategies involved in keeping your balance
- Ankle strategy
- Hip strategy
- Stepping
- Arm movements
What is involved in vision
- Distance
- Movement
- Orientation
- Standing/walking surface
What is the difference between stereoscopic and monocular distance
Stereoscopic - we have two slightly different view of the same things to our eye placement
Monocular - seeing two different things (animals with eyes on the side of head)
What is the role of proprioception
- Stretch receptors in muscles and tendons that detect change in muscle length
- Sense of position, movement, and force
- Mechanoreceptors in joints: cervical spine, hips, knees and ankles
Describe the vestibular system
The vestibular system is a sensory system composed of:
- Otolith organs - detect linear acceleration of head
- Semi-circular canals - detect angular acceleration of head due to endolymph
Describe the vestibulo-optic reflex
Maintains visual fixation (despite head movement)
Describe the role of the vestibulo-spinal reflex
Keeps head level but can overcome
What part of the brain is involved in central processing?
- Cerebral cortex
- Basal ganglia
- Cerebellum
Describe how does ageing effects vision
- Reduced acuity
- Reduced contrast sensitivity
- Reduced dark adaptation
Describe how ageing effects brain
- Fewer neurones
- Fewer nerve fibres
- Slow reaction times
- Impaired integration of sensory information - less able to cope with conficting information and less “reserve”
Describe the ageing effect of muscle
- Reduced muscle mass
- Reduced muscle strength
- Slower contraction
- “Active” muscle age less - vocal muscles and physically active elderly
Describe the causes of older people falling
- Accident
- Disease
- Vision impairment
- Hearing impairment
- Brain - dementia, parkinson’s disease, stroke
- Nerve and muscle - neuropathy (e.g., diabetes), myopathy (e.g., steroid treatment), joints (OA, foot deformity)
- Poison - medication and alcohol
- Psychotropics and sedatives e.g.,s dizepam/risperidone/haloperidol etc
- Anti-hypertensive drugs
- Sleeping tablets particularly long acting ones
- Analgesics e.g., opiods
- Diuretics
- Environmental factors - slippery surfaces, trailing wires, poor lighting, cluttered stairs, pets, risk-taking
Describe the risk factors of falls
- 2 or more falls
- Polypharmacy - on 4 or more medications
- Change in medications in last 2 weeks
- Muscle weakness
- History of falls
- Gait or balance abnormality
- Use of a walking aid
- Visual impairment
- Hearing impairment
- Arthritis
- Depression
- Cognitive impairment
- Age over 80 years
- Psychotropic medication
Describe the purpose of home assessment with people who fall
- Identify home hazards and recommend or arrange modifications
- Assess and modify performance and function
- Identify and agree strategies to reduce falls risk
Describe interventions to prevent falls
- Excercise (should include components of lower limb strength and balance training): multimodal group excercise and tai chi both effective
- Calcium and vitamin D supplementation: evidence of effectiveness only in patients in institutional care - large doses of Vit D may increase risk of falls and fractures
- Home environment assessment and modification
- Medication review: particularly medications with central actions such as hypnotics but also those with anticholinergic and hypotensive actions
- Cataract surgery: effective if for first cataracts
- Other vision interventions ineffective and may increase falls risk
- Cardiac pacemaker for carotid sinus hypersensitivty
Describe the role of social workers
- Care act 2014 - assessment and eligibility determination
- Risk assessment
- Mental capacity/best interest assessment
- Safeguard - including self-neglect
- Set up care and support
- Community work
- Involving older people, their carers, and families in their care
- Anti-discriminatory and anti-oppressive practice
- Review
Which patients should be offered home assessment?
High risk fallers
- Fallen before in previous 12 months
- Fall with injury
- Cognitive impairment
- Visual impairment
- Gait or balance impairment
- Fear of falling
- Leaving a rehab setting paticularly post neck fracture
Describe what is involved in a home visit
- Standardised assessment process
- Clinical reasoing
- Observation of funtion and behaviour
- Activity analysis
Provide an overview of current local pathways and practise
Primary care
- Supported care to home including occupational therapy home assessment
- Community occupational therapy
- Falls vehicle: paramedic and occupation therapy
Secondary care
- A&E
- OPED - older peoples emergency department, undergoes comprehensive geriatric assessment
- OPAC - older peoples assessment centre (nurse led discharge centre)
- Wards
- OPAS - older peoples assessment service (consultant - led outpatient service)
Older people could belong to 3 broad groups. Name the 3
- Entering old age
- Transitional phase – between a healthy active life and frailty
- Frail older people
This is the interaction of concepts. Use this to describe how the following health conditions can affect an elderly person:
a) Recurrent falls and subsequent injuries
b) Parkinson’s disease
c) Dementia
d) Person with past history of mental health problems
Name the common drugs that cause adverse drug reactions in old age and describe the adverse reactions
