Falls / fragility / polypharmacy Flashcards
List some investigations to consider in a falls assessment
Bedside:
- Visible inspection for injuries (BEST SHOT or full inspection)
- Routine obs: HR, RR, O2 sats, temp
- Lying and standing BP
- ECG
- CBG
- Urinalysis
- Gait / functional assessment (MDT)
Labs:
- FBC, U&Es, LFTs, TFTs, clotting screen,
- Bone health bloods
Imaging:
- Consider CT head if any head trauma or unwitnessed fall with LOC
- Consider chest x-ray if symptoms
- Consider Echo
Procedures:
- Tilt table test
- Cardiac monitoring and 24 hr ECG
- Dix-Hallpike
State some general steps for prevent further falls in the elderly
Hollistic approach
Conservative:
- Non-slip mats
- Tidy home, remove trip hazards
- Good fitting footwear
- Keeping well hydrated + nutrition
- Strength and balance training e.g. Tai chi
- Reduce alcohol intake if necessary
Medical:
- Optimise medications (e.g. antihypertensives, sedatives)
- Ensure other conditions under control e.g. diabetes
- Up to date vision tests e.g. cataracts or hearing tests for balance
+ fall alarms or wristbands / sensors
Outline how to undertake a lying standing BP and what a positive result is for orthostatic hypotension
Measure BP as patient is lying down
Ask patient to stand up
- Measure BP after 1 min
- Measure BP after 3 mins
If BP is continuing to drop at 3 mins, continue measuring
Orthostatic hypotension:
- Drop of SBP > 20mmHg OR drop of DBP > 10mmHg
- AND symptomatic
Outline some components covered in the comprehensive geriatric assessment (CGA)
Overview:
- Medical
- Functional
- Mind
- Social
- Environmental
Medical assessment:
- PMH
- Medications
- MUST score
Functional assessment:
- ADLs (basic and instrumental)
- Gait / balance assessment
- Exercise / activity assessment
Psychological assessment:
- Cognitive status
- Mood
Social assessment:
- Social support
- Care resources / financial assessment
Environmental assessment:
- Home safety
- Access to transport (DRIVING)
Outline the main categories covered in the comprehensive geriatric assessment (CGA)
- Medical
- Functional
- Mind
- Social
- Environmental
Outline what is meant by ‘feed at risk’
Continue to eat and drink orally despite a significant risk of aspiration and choking
- Family need to be educated on risk of choking
- Now a form needs to be signed to confirm that family accepts risk
State some situations where ‘feeding at risk’ might be considered
- Later stages of terminal illness
- Safe swallow is unlikely to return
- Patient preference (in preference to artificial feeding / NG tube)
State the definition of postural hypotension
- Symptomatic
- Drop of 20mmHg (systolic) or 10mmHg (diastolic)
How do you differentiate between a fragility fracture and pathological fracture on an x-ray
Fragility fracture - caused by osteoporosis (will see reduced bone mass) but clear bone margin
Pathological fracture - fluffy margin
List some reasons why PEG feeding in advanced dementia is not advised
- Doesn’t prevent aspiration
- Procedure is associated with risks and discomfort
- Risk of patient dislodging tube
- No evidence that it increases life expectancy
Describe the 4 stages of pressure sores
Stage 1:
- Closed wound, superficial skin changes (non-blanching erythema)
Stage 2:
- Involvement of epidermis, dermis (NOT subcutaneous)
Stage 3:
- Involvement of all 3 layers (epidermis, dermis and subcutaneous layers) but do not reach muscle, tendon, or bone
Stage 4:
- Involvement of all layers, but also extending into fascia, muscle, bone, tendons etc.
List some discharge destinations
- Own home (with POC)
- Community hospital (mobility assessment)
- Specialist accommodation (with warden control)
- Discharge to Assessment (D2A) Bed
- Residential home
- Nursing home
- Fast track (end of life ~ 6 weeks)
List some medication classes that are associated with a high risk of falls
Analgesia / antidepressants:
- Opiates e.g. Codeine, Morphine, Tramadol
- Sedating antidepressants (tricyclics) e.g. Amitriptyline
- SNRIs e.g. Venlafaxine, Duloxetine
Psychotic drugs:
- Benzodiazepines
- Psychosis / agitation drugs e.g. Chlorpromazine, Haloperidol, Risperidone, Quetiapine, Olanzapine
- Sedatives ‘Z’s e.g. Zopiclone
Others:
- Anti-epileptics e.g. Phenytoin, Carbamazepine
- Parkinson’s disease e.g. dopamine agonists or MAOI-B inhibitors
Stat the definition of a fall
Coming to rest on a lower level surface, with or without loss of consciousness (LOC)
Not due to external force or medical problem
State the definition of frailty
State of increased vulnerability to poor resolution of homeostasis, after a stressor event
Occurs as a consequence fo age-related cumulative decline across multiple physiological systems
State some phenotypes of frailty
- Low activity level
- Slow walker
- Low energy
- Unintentional weight loss
- Low grip strength
List some consequences of frailty (geriatric giants)
- Immobility
- Instablity (falls)
- Incontience
- Impaired memory
- Iatrogenic
State the meaning of multimorbidity
2 or more co-existing long term medical conditions
What is meant by best interest (in the case that someone lacks capacity)
Decision of the clinician - with the input of those close to the patient as to what THEY think the patient would want
Looking at the welfare in the widest sense, considering the nature of the medical condition and likely prognosis, to put yourself in the place of the individual patient to appreciate what their attitude may be
Outline what is meant by polypharmacy
6 or more drugs, prescribed at one time
Roughly outline the Clinical Frailty Scores (1-9)
1 = VERY fit (fittest for their age)
2 = well (no symptoms of disease, active occasionally)
.
3 = managing well (well controlled disease, however routine walking is only activity)
4 = vulnerable (not dependent on others, but symptoms limit activites)
.
5 = mildly frail (difficulty with complex ADLs, generally slowing)
6 = moderately frail (need help with ALL outside activties and keeping house, assistance with bathing etc.)
.
7 = severely frail (COMPLETELY dependent on personal care, but stable and not at risk of dying in next 6 months)
8 = VERY severely frail (COMPLETELY dependent on everything, unlikely to survive even a minor illness)
.
9 = Terminally ill (end of life, likely to dye in next 6 months)
Roughly outline the Clinical Frailty Score - in relation to Dementia (how mild, moderate and severe present)
Frailty corresponds to the degree of dementia
Mild dementia = forgetting recent events, repetition, social withdrawal
Moderate dementia = recent memory is very impaired, personal care only if prompted
Severe dementia = completely dependent on personal care from others
