Falls and pressure sores

Question 1

Pressure Sores - epidemiology

Answer 1

£1.4-2b NHS cost

40% staff, 29% opportunity cost, 18% dressing, 13% beds/mattresses

Question 2

Pressure sores - classification

Answer 2

stage I: non-blanching erythema
stage II: partial thickness
stage III: full thickness (subcut), slough
stage IV: exposure; slough/eschar - muscle/tendon/joint capsule reached / high risl of osteomyolitis
unclassified: obscured

pressure sores: bony, circ’d, circular, necrosis
suspected/unknown depth: discoloured intact skin
moisture lesion: folds/bony, diffuse spots, irreg, supf/partial, non-necrotic, maceration

Question 3

Pressure sores - RF/screening

Answer 3

Braden score: sensory, moisture, mobility, activity, nutrition, activity
Glamorgan (kids), Cubbin/Jackson (CritCare)
Assess

Question 4

Pressure sores - prevention

Answer 4

SSKIN:
support - cusions, mattress (gel, foam, air)
skin Ax and photos - skin tolerance finger test
keep moving: 2-3h
incontinence: moisture
nutrition (MUST): healing - keep hydrated

Question 5

Pressure sores - Mx

Answer 5

evaluate condition + RFs
interventions e.g. SSKIN
evaluation impact of interventions
report and refer

Question 6

Pressure sores - impact

Answer 6

employment/earning
sleep, appetite, mobility
dignity, privacy,
self-esteem, pain, anxiety, misery
infection, septicaemia, osteomyelitis

Question 7

Fall - definition

Answer 7

unintentional
resting at lower level
not against other structures
not secondary/no external force

Question 8

Falls - importance

Answer 8

hospital admission
non-specific presentation of underlying illness
cost (£1.8b; 1% of total spending)
repeat falls
morbidity and mortality

Question 9

Falls - physiology

Answer 9

balance system:

peripheral: vestibular, proprioception, vision
central: coordination

postural CVS reflexes:
carotid sinus

Question 10

Falls - RF

Answer 10

RF:
previous fall
intrinsic: balance, strength, activity, neuro, thyroid, DM, cataracts, CVD, MSK, female
extrinsic: environment, equipment, meds

medications:
beta blockers and nitrates
BZD and anti-H
diuretics
neuroleptics
TCAs

Question 11

Falls - consequences

Answer 11

fractures (20%) and injury (75%); 'long lie': hypothermia, pressure, dehydration/AKI, infection, SDH, rhabdomyalysis
social isolation
depression/anxiety
fear of falling, ADL/participation, QoL
carer strain
mortality
institutionalisation

Question 12

Falls - assessment

Answer 12

history: before during after; previous falls; cognition, DH, PMH/SR, SH (mobility, dependence, substances, support etc); RF, balance
collateral history

DDx: syncope, stroke/neuro, dementia, epilepsy, arrhythmia, delirium, ophthalmology/vision

examination: AtoE; gain/balance/MSK, neuro, vision, BP/CVS, feet/footwear

Ix: baselines, ECG, ?septic screen, UA; ?24h ECG, echo, TILT

Question 13

Falls - prevention

Answer 13

strength and balance training
environment
medical assessment: cause, co-morbidity management, bone health, meds r/v

Question 14

Falls - management

Answer 14

primary care: screening, referral
ED: AtoE, injuries, ?Ax + supervision
IP: prevention programme, fracture liaison, bone health
intitutions: high risk, modify RF e.g. exercise and hazards

Question 15

Falls - stats

Answer 15

after #hip, 33% fully dependent, 50% partial
1% of falls » hip fracture
#NOF 1y mortality is 20-35%
10% mortality within 12/12 after a fall

50% >80yo fall at least 1/y; 33% of >65yo
50% fall again within 1y
>75y = F>M, F (2x)
50% mobility issues

Question 16

falls - aetiology

Answer 16

brain: CVA/disease, dementia, BP/perfusion, heart disease
vision: cataracts, AMD, bifolcals, DR
vestibular: OM, ototoxic, meniere’s
proprioception: sensory neuropathy, joint replacement, ageing, MSK
effectors: atrophy, proximal myopathy, neuromuscular
other: continence, environment