Falls + Fractures Flashcards
What conditions with vision may affect the balance system? (4)
- Cataracts
- Age related macular degeneration
- Diabetic retinopathy
- Bifocal lenses
What conditions may affect proprioception (thus affecting the balance system) (3)
- Sensory neuropathy
- Joint replacements (lose proprioception)
- Ageing
What conditions of the vestibular system may affect balance? (3)
- Previous middle ear infections
- Meniere’s disease
- Ototoxic drugs (NSAIDs, aspirin, aminoglycosides)
What conditions of the brain/CV system may affect balance? (4)
- Cerebrovascular disease
- Dementia (affects judgement)
- Low BP
- Delirium (e.g. from infective cause)
What neuromuscular causes may affect balance? (3)
- Proximal myopathy (eg steroid exposure, vit D defc)
- Any neurological disease
- Disuse atrophy
What are intrinsic RFs for falls related to? (4)
- How well person can see
- How well they can walk or maintain their balance
- What kind of muscle strength they exhibit
- How well they can endure physical activity
List the main intrinsic RFs for falls (11)
Balance/gait problems: Stroke/Neuropathy/Parkinsons/Arthritis/Vestibular
Visual impairment (bifocal / glaucoma / ARMD / retinopath)
Cognitive problems: delirium/dementia
Urinary incontinence: urgency/frequency
List the main extrinsic RFs for falls (5)
Footwear Polypharm Sedatives/ CV med SEs Lighting/stairs/rug Lack of equipment
What are the short term complications of falls, due to trauma? (4)
o Soft tissue injury
o Fragility fractures (mortality and morbidity)
o Joint dislocations
o Subdural haemorrhage
What are the short term complications of falls, due to ‘long lie’? (4)
o Hypothermia
o Pressure sores
o Dehydration / AKI
o Infection (pneumonia)
What are the short term psychological (1) + social (2) complications of falls?
Psycho: loss of confidence / fear of falling
Social: Reduced mobility / Increased dependance
What are the long-term adverse complications of falls (7)
Fear of falling
Depression/Anxiety
Social Isolation
Injuries/Fractures
Death
Carer strain
Institutionalisation
What things should be included in the Hx in a falls pt (7)
- Sx, circumstances, eye witness account
- Any loss of consciousness
- 1st fall / Recurrent falls
- PMH → any falls RFs
- DH → any falls RFs / recent changes
- Alcohol
• Baseline cognition, function, mobility
What things should be included O/E in a falls pt? (5)
- Cognitive assessment
- Cardiovascular (pulse, L/S BP, murmurs, bruits)
- Neurological
- Feet, joints, eyes
- Gait (get up and go)
What Ix should be done in a falls pt? (2)
ECG
Postural BP
Possibly TILT assessment
What interventions may be done to reduce intrinsic factors of falls (3)
+ to reduce extrinsic factors (1)
Intrinsic - Physio:
Cardio training (bike)
Strength training (weights)
Balance training
Extrinsic - OT:
OT home assessment/adjustments
Outline the assessment (3) /management (2) for a falls patient
Dx reason for fall (eg visual disturbance)
Look for postural hypotension
Bone health assessment – past fractures, poss DEXA
Optomise management of contributing conditions
(eg cataracts, diabetes, overactive bladder)
Medication review
(minimise antihypertensives / start on Ca + VitD)
List certain types of drugs that are known to increase falls risk (+how) (8)
- Beta-blocker → hypotension
- Nitrates → hypotension
- Diuretics → hypotension
- BZDs → sedation
- Antihistamines → sedation
- TCAs → sedation
- Neuroleptics → sedation, muscle tremors/ spasms
- Steroids → proximal muscle weakness, osteoporosis
Define osteoporosis
A condition of skeletal fragility characterised by reduced bone mass and micro architectural deterioration predisposing to an increased risk of fractures
Describe the aetiology behind osteoporosis
Normal processes of bone formation/resorption become uncoupled or unbalanced → bone loss
List the clinical features of osteoporosis (3)
Asymp
Pain / loss of height with kyphosis development (due to spine fragility fractures)
Features of underlying disease (eg Cushing’s syndrome)
List some secondary causes of osteoporosis (16)
Genetic: Marfans/Turners/Osteogenesis imperfecta
Inflammatory: RA/Ank Spon/IBD
Iatrogenic: Steroids/Sex-steroid antags/Lithium/Heparin
Endocrine: Cushings/Acromegaly/Hypopituitary/Prolactinoma
Nutritional: Ca+VitD defc / Malabsorption
List the RFs for osteoporosis (12)
o Age o Women (men more likely 2o cause) o Previous fracture o FH o XS alcohol o Smoking
o Drugs (steroids/ heparin/ phenytoin) o Amenorrhoea for 6m (excl pregnancy) o Late menarche/ early menopause o Immobility/ physical inactivity o Inflammatory arthritis o Gastrectomy
What are the T score ranges (DEXA) for osteopenia/porosis?
Whats the diff b/wn T score + Z score
Osteopenia = T -1SD to -2.5SD Osteoporosis = T < -2.5SD
T score = compared to young healthy adult
Z = compares to similar age (used in <50s)
What Ix, other than DEXA, can be done in osteoporosis? (6)
Renal func (where Vit D metab) TFTs
Bone profile (Ca/Vit D; PTH; PO4-/alkaline PO4-) Bone turnover markers
Multiple myeloma screen (ESR, Serum Ig + protein electrophoresis, urinary Bence Jones protein)
Consider cortisol, testosterone, oestradiol, PSA, tTG
What are some long-term consequences of osteoporosis (3)
⇒ ↓QoL from pain/ kyphosis
⇒ ↓Independence
⇒ ↑Morbidity /↑Mortality (related to hip fractures)
What lifestyle modifications can be done to help osteoporosis (6)
- Improve Ca intake (1200-1500ml/day milk)
- Weight-bearing exercises
- Smoking cessation
- Reduce alcohol
- Exercises to promote bone density and reduce falls
- Hip protectors (poor compliance)
What medications can be used in osteoporosis (2+5)
Ca/VitD supplements**
Bisphosphonates**
HRT Selective oestrogen receptor modulators eg Raloxefine Testosterone treatment PTH hormone Strontium
How do bisphosphonates work? Give egs (4)
Delay action of osteoclasts
Allendronic acid (PO but GI SEs) Zolendronic acid (IV) Risedronate sodium (PO) Denosamab (SC)
