Falls and old age - Clinical medicine Flashcards
1
Q
Describe what mechanisms are involved in balance
A
- Sensory mechanism - vision, proprioception, tactile sense, vestibular system
- Central processing - the brain and spinal cord
- Effector mechanisms- muscle and joint
2
Q
Describe the strategies involved in keeping your balance
A
- Ankle strategy
- Hip strategy
- Stepping
- Arm movements
3
Q
What is involved in vision
A
- Distance
- Movement
- Orientation
- Standing/walking surface
4
Q
What is the difference between stereoscopic and monocular distance
A
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)
5
Q
What is the role of proprioception
A
- 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
6
Q
Describe the vestibular system
A
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
7
Q
Describe the vestibulo-optic reflex
A
Maintains visual fixation (despite head movement)
8
Q
Describe the role of the vestibulo-spinal reflex
A
Keeps head level but can overcome
9
Q
What part of the brain is involved in central processing?
A
- Cerebral cortex
- Basal ganglia
- Cerebellum
10
Q
Describe how does ageing effects vision
A
- Reduced acuity
- Reduced contrast sensitivity
- Reduced dark adaptation
11
Q
Describe how ageing effects brain
A
- Fewer neurones
- Fewer nerve fibres
- Slow reaction times
- Impaired integration of sensory information - less able to cope with conficting information and less “reserve”
12
Q
Describe the ageing effect of muscle
A
- Reduced muscle mass
- Reduced muscle strength
- Slower contraction
- “Active” muscle age less - vocal muscles and physically active elderly
13
Q
Describe the causes of older people falling
A
- 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
14
Q
Describe the risk factors of falls
A
- 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
15
Q
Describe the purpose of home assessment with people who fall
A
- Identify home hazards and recommend or arrange modifications
- Assess and modify performance and function
- Identify and agree strategies to reduce falls risk
16
Q
Describe interventions to prevent falls
A
- 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
17
Q
Describe the role of social workers
A
- 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
18
Q
Which patients should be offered home assessment?
A
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
19
Q
Describe what is involved in a home visit
A
- Standardised assessment process
- Clinical reasoing
- Observation of funtion and behaviour
- Activity analysis
20
Q
Provide an overview of current local pathways and practise
A
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)
21
Q
Older people could belong to 3 broad groups. Name the 3
A
- Entering old age
- Transitional phase – between a healthy active life and frailty
- Frail older people
22
Q
a) Describe the consequences of hospital admission
b) What factors affect this
A
a) When admitted to hospital, frail, older people are at risk of deterioration
b) Factors affecting this are the environemnt,care delivery and risks
23
Q
Define frailty
A
It is not an illness, but a syndrome that combines that effects of natural ageing with the outcomes of multiple long-term conditions, a loss of fitness and reserves
24
Q
What are the warning symptoms and signs of frailty?
A
- Unintentional weight loss (always investigate)
- Fatigue
- Low physical activity
- Slow gait speed - taking more than 5s to walk 4m
- Weak grip strength
25
List the acute presentations of frailty
* Delirium
* Falls
* Adverse drug reactions/medicine management problems e.g., confusion with codeine and hypotension with antidepressants
* Immobility
* Continence problems
* Fluctuating disability
26
a) What is immobility?
b) Describe the symptoms
a) A state of having reduced ability to independantly get from one place to another
b)
* Sarcopenia and deconditioning
* Fear of falling
* Movement disorder
* Cerebrovascular disease
* Cognitive impairment
* Symptoms of other illness e.g., shortness of breath, pain, leg oedema and tremor may all limit ability to mobilise
27
Delirium is a common presenting condition in older patients and an acute presentation of frailty.
a) Describe the typeso f delirium
b) Why is early recognition of delirium important?
a)
1. Hyperactive delirium - the patient may have heightened arousal, agitation, aggression, restlessness
2. Hpoactive delirium - presents with a withdrawn patient, that is quiet, with reduced oral intake decreased responsiveness and slowed motor skills
b)
* Patients who develop delirium have worse outcomes
* Longer period of hospital stay
* Increased risk of falls
* Increased risk of pressure sores
28
Describe what is involved in a multi-disciplinary falls assessment
* Detailed history of falls (check no blackouts)
* Structured medication review
* Social history including alcohol intake
* Examination - weight and compare previous readings, gait andbalance, neurological assessment, peripheral neuropathy, visual assessment
* Cognitive assessment
* Osteoporosis risk assessment
* Consider continence issues
* ECG
* Home hazards assessement - by experience OT
* Assess psychological impact of fear falling, social isolation etc
29
Describe the falls prevention advice you would give an elderly person
* Stay active. Strength and balance training
* Eat well and keep hydrated
* Eye and hearing checks
* Attend medication reviwes
* Bone health - vit D and Ca intake, weight bearing excercie, osteoporosis risk assessments
* Good footwear
* Review hazards at home
* Bed/chair sensors
30
Describe the different locations care can be provided and the advantages and disadvantages of each
1. Hospital
Advanatges
* Good level of medical care - hospitals have resources, trained staff, medication, constant care/monitoring of condition
Disadvantages
* Uncomfortable place to die - confined to small area
* Must abide by visiting hours (may not get to say goodbye to everyone)
* Clinical environment
2. Hospice - palliative care; aim to reduce pain, suffering and improve comfort and QoL
Advantage
* Quiet location - able to find peace to be able to relax
* 24-hour care
* Visitors allowed
Disadvantage
* Unfamiliar and uncomfortable place to die
3. Nursing home - similar to nursing home but less frequent; GP manages healthcare
Advantage
* patients feel at home
* Patients can have visitors
* Patients get comfortable with the staff
* Visitors allowed
Disadvantage
* Not the same level of care compared to hospital
* Stigma associated with nursing home
4. Residential home
* Advantages - patients have some independance
* Disadvantages- less medical care compared to a hospital
5. Home - most requested place to die, care provided by relative, specialist nurses and managed by GP
Advantages
* Familiar and comfortable
* Can have relatives/friends visit whenever
Disadvantages
* Less medical support (less frequent)
* Family will have to deal with the aftermath of death
* Family may be uncomfortable staying at home of where someone has passed
31
Describe the managment after admission with a fall
* Treat underlying medical causes and delirium
* Treat postural hypotension e.g., with fludcortisone
* Medication review aiming precribing
* Ensure appropriate footwear
* Gait and balance training by a physiotherapist
* Environmental assessment by an occupation therapist
* Consider use of pendant alarms, bed, or chair sensors
32
When should we consider de-prescribing for a patient?
* Medication reviews - does the patient still need this medication?
* During hospital admission - vital it is made clear at the point of discharge that some medications have been stopped
* When we need to treat a new condition - potential drug interactions and polypharmacy can lead to potential for confusion increasing the risks of the wrong dose being taken or doses being missed
33
What are the 3 groups that NICE states should have a multifactoral falls assessment?
* People who have fallen 2 or more times in the past 12 months
* People who present for medical attention beacuse of a fall
* People with difficulties walking or balance
34
Describe the role of community services in elderly people
* Aim to prevent hospital admission - crisis mangement
* Integrated care teams of PTs,OTs, SLTs, nurses, S/W
* Supported discharge
* Staff skill mix - shared competences
* Linked referral routes
* 7/7 (each day of the week) care in some cases
35
What is a rapid response team and describe their role in preventing falls in older people
* Ring fenced team to promote a rapid response by the appropriate team member - usually OT/nurse/social worker who can provide same day assessment
* Aim is to prevent admission and set up immediate short term intervention plan
36
Describe the role of occupational therapists in preventing falls in older people
* Identifies occupation performance issues and implement plans
* Creation of 'safe enviroment'
* Appropriate adaptations/equipment/assistive technologies
* Use of reality orientation techniques and reminiscence activites to maintaIn a level of awareness
* Facilitates independence with everyday activities through occupation
* Signpost to other revelant services e.g., attendance at day hospital/support groups
37
Describe the assements and considerations OTs undertake when preventing falls in the elderly
* Impact of medical conditions on patients day to day life
* Self-care (toileting, nutrition, washing and dressing)
* Transfers and mobility
* Domestic activities
* Cognitive status
* Falls screening
* Support networks
* Leisure time
* Assessment & preparation for discharge
38
Describe the assessment PT's take to prevent falls in elderly people
* Subjective factors - identifies patiet concerns and expressed needs
* Objective factors - function of activities of faily living, mobility, strength
* Environmental factors - physical space
* Carer/relative factors - needs, beliefs and attitudes e.g., mental status, function, mobility and strength, space and risks, footware, carer
39
Decreibe the programs implented by PTs to prevent falls in the elderly
Activites
* Stengthen specific muscle groups
* Supervised transfers
* Supervise walking in different contexts -indoors, outdoors
* Teach relatives/caeres minimal safe handling
Environment
* Collaborate for safe arrangement of physical features
* Rugs,seating, furniture
Education and advice
* Footwear
* Lifestyle activites
40
Describe the assessment practices of speech and language therapists
* History of communication/swallowing difficulties
* Informal assessment e.g., observations, conversational skills, sensory or cognitive impairment; screening for swallowing difficulties
* Formal assessment of funtion e.g., components of speech production, language abilties, swallow function - video fluoroscopy
* Leading to profile of strengths and difficulties
41
Describe the role of SLT during the therpy process to prevent falls in the elderly
* Goal setting in negotiation with the client
* Direct therapy with client building strengths and addressing difficulties
* Indirect - working with significant others or adjusting communicative environment e.g., conversation partner training, reducing background noise, aphasia-friendly language
* MDT working
* Advise and education
* Advocacy
42
Describe the challenges as a PT, OT and SLT in preventing falls in elderly people
* Clinical assessment: complex and multifactoral
* History taking: sensory impairment, dementia, or delirium
* Often additional action is needed which may not be readily accessible
* Time pressures
43
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
44
What are the main variables that affect drug action in patients?
* Age
* Genetic factors
* Immunological factors
* Disease (especially when this influences elimination or metabolism e.g., kidney or liver disease
* Drug interactions
* Ethnicity
45
Why does age affect drug metabolism?
* Main reason is because drug eliminations is less efficient in older people. Therefore, many drugs produce a greater and prolonged effect
*
46
Describe how the changes in body composition during ageing affects drug action
There is a reduction in the relative percentage of fat and lean tissue which results in a change in the volume of distribution of the drug
47
Describe the effect of age on renal excretion of drugs
* Glomeular flitration rate (GRF) falls slowly from about 20 years of age
* This decrease is about 25% by age 50 and 50% by age 75, assuming that no renal disease is present
48
a) Why do we use eGFR (glomerular filtration) to estimate creatinine clearance in patients?
b) How is this impacted in elderly people?
a) This is because the plasma level of creatinine in the blood does not directly correlate with the clearance of creatinine by the kidneys
b) Creatinine synthesis is reduced in the elderly due to the reduction in the muscle mass so we need to take this into account when estimating the glomrular filtration rate
49
Describe the effect of age on drug metabolism
Drug metabolism depends on a range of enzymes in the liver. The activity of these hepatic microsomal enzymes declines slowly and variably with age
50
Name the common drugs that cause adverse drug reactions in old age and describe the adverse reactions
51
Chronic disease can co-exist. What is this known as?
Comorbidity/multimorbidity
52
Why does comorbiity in older people increase the potential for drug interactions?
Due to comorbidity in older people, we tend to to be prescribing a number of different drugs for one individual
53
What is deprescribing?
The process of withdrawal of an inapporpriate medication, supervised by a health care professional with the goal of managing polypharmacy and improving outcomes
54
Describe the factors leading to polypharmacy in old age
* Multiple pathology
* Poor patient education
* Lack of routine review of all medications
* Patient expectations of prescribing
* Over-use of drug interventions by doctors
* Attendance at multiple specialist clinics
* Poor communication between specialists
