Falls / fragility / polypharmacy

Question 1

List some investigations to consider in a falls assessment

Answer 1

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

Question 2

State some general steps for prevent further falls in the elderly

Answer 2

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

Question 3

Outline how to undertake a lying standing BP and what a positive result is for orthostatic hypotension

Answer 3

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

Question 4

Outline some components covered in the comprehensive geriatric assessment (CGA)

Answer 4

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)

Question 5

Outline the main categories covered in the comprehensive geriatric assessment (CGA)

Answer 5

• Medical
• Functional
• Mind
• Social
• Environmental

Question 6

Outline what is meant by ‘feed at risk’

Answer 6

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

Question 7

State some situations where ‘feeding at risk’ might be considered

Answer 7

• Later stages of terminal illness
• Safe swallow is unlikely to return
• Patient preference (in preference to artificial feeding / NG tube)

Question 8

State the definition of postural hypotension

Answer 8

• Symptomatic
• Drop of 20mmHg (systolic) or 10mmHg (diastolic)

Question 9

How do you differentiate between a fragility fracture and pathological fracture on an x-ray

Answer 9

Fragility fracture - caused by osteoporosis (will see reduced bone mass) but clear bone margin

Pathological fracture - fluffy margin

Question 10

List some reasons why PEG feeding in advanced dementia is not advised

Answer 10

• Doesn’t prevent aspiration
• Procedure is associated with risks and discomfort
• Risk of patient dislodging tube
• No evidence that it increases life expectancy

Question 11

Describe the 4 stages of pressure sores

Answer 11

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.

Question 12

List some discharge destinations

Answer 12

• 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)

Question 13

List some medication classes that are associated with a high risk of falls

Answer 13

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

Question 14

Stat the definition of a fall

Answer 14

Coming to rest on a lower level surface, with or without loss of consciousness (LOC)
Not due to external force or medical problem

Question 15

State the definition of frailty

Answer 15

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

Question 16

State some phenotypes of frailty

Answer 16

• Low activity level
• Slow walker
• Low energy
• Unintentional weight loss
• Low grip strength

Question 17

List some consequences of frailty (geriatric giants)

Answer 17

• Immobility
• Instablity (falls)
• Incontience
• Impaired memory
• Iatrogenic

Question 18

State the meaning of multimorbidity

Answer 18

2 or more co-existing long term medical conditions

Question 19

What is meant by best interest (in the case that someone lacks capacity)

Answer 19

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

Question 20

Outline what is meant by polypharmacy

Answer 20

6 or more drugs, prescribed at one time

Question 21

Roughly outline the Clinical Frailty Scores (1-9)

Answer 21

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)

Question 22

Roughly outline the Clinical Frailty Score - in relation to Dementia (how mild, moderate and severe present)

Answer 22

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