Falls, Frailty Flashcards
What is the principle feature of a fall?
Instability
Epidemiology of falls
in community dwelling people, 30% of those over 65 years old and over 40% for those over 75 have had a fall in the past 12 months.
around 50% of the falls are seen in people with a history of falls (twice or more a year )
is the commonest cause of accidental deaths in elders over 75 years (1
Why are falls important to the NHS?
Falls have important implications both on the personal level and on the level of the cost to the NHS - a large burden of care is placed by people falling and needing inpatient treatment, not to mention the considerable morbidity and mortality suffered by this group.
RFs for falls
environmental risk factors
lack of assistive devices in the bathroom
loose throw rugs
low level lighting
obstacles on the walking path
slippery outdoor conditions
medical risk factors
anxiety and aggitation
arrrythmias
dehydration
depression
malnutrition
medications causing over sedation
orthostatic hypotension
poor vision and use of bifocals
previous falls
urgent urinary incontinence
neuro and muculoskeletal risk factors
kyphosis
poor balance
weak muscles
reduced proprioception
other risk factors
fear of falling
Aetiology of falls
Roughly 50% of falls in the elderly follow a trip or an accident, with a mere 5% caused by dizziness. 5% are accompanied by loss of consciousness, 10% are a result of the legs giving way for no reason. The remaining 30% are unexplained.
- history of falls
- gait deficit, balance deficit
- mobility impairment
- visual impairment
- cognitive impairment
- urinary incontinence
- home hazard - poor lighting, loose carpets
- number of medication
- muscle weakness
What are some cardiovascular causes of falls in the elderly
vasovagal (neurocardiogenic) syncope
carotid sinus syndrome
postural hypotension: - secondary to intercurrent illness aggravated by chronic venous insufficiency - age associated autonomic neuropathy - drugs (diuretics, nitrates, tricyclic antidepressants, sedatives hypnotics and neuroleptics)
Cardiac abnormalities
arrhythmias: - Age associated idiopathic fibrosis of conducting tissue may cause sino-atrial exit block, sick sinus syndrome, paroxysmal AF or heart block.
structural abnormalities – valvular stenosis, hypertrophic obstructive cardiomyopathy, aortic dissection
Miscellaneous
pulmonary embolism
TIA
subclavial steel syndrome (1)
Primary complications of Falls
- laceration, contusion
- head injury, possibly with subdural haematoma
- fractured limb, particularly fractured neck of femur
- fractured rib, which may result in pneumonia
- wrist fracture (common between the ages 65 and 75) and hip fracture (after 75) (1)
Secondary consequences of falls
inability to summon help, resulting in:
- pressure sores
- pneumonia
- hypothermia
- rhabdomyolysis
Interventions to prevent falls
- strength and balance training
- home hazard assessment and intervention
- vision assessment and referral
- medication review with modification or withdrawal
HPC - When did you fall?
What time of day?
What were they doing at the time?
Looking upwards (vertebrobasilar insufficiency)
Getting up from bed (postural hypotension)
HPC - Where did you fall?
In the house, or outside?
HPC - What happened before/during and after the fall?
Before
Was there any warning?
Was there any dizziness/chest pain or palpitations?
During
Was there any incontinence or tongue biting? (indicating seizure activity)
Was there any loss of consciousness?
Was the patient pale/flushed? (may indicate vasovagal attack)
Did the patient injure themselves?
What part of the body had the first contact with the floor?
After
What happened after the fall?
Was the patient able to get themselves up off the floor?
How long did it take them?
Was the patient able to resume normal activities afterwards?
Was there any confusion after the event? (head injury)
Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)
HPC - How many times have you fallen over the last 6 months? What does this question show?
Allows you to gauge the severity of the problem
Systems enquiry - General, CV, Resp
Gen - fatigue, weight loss
CV - Chest pain, palpitations
Resp - SOB, cough
Systems enquiry - Neuro, GU, GI, MSK
Neuro - Loss of consciousness, Seizures, Motor or sensory disturbances
GU - incontinence, urgency, Dysuria
GI - Abdominal pain, Diarrhoea, Constipation
MSK - Joint pain, muscle weakness
General examination for falls
Is the patient alert and orientated?
Are they able to perform the timed “up and go” test?: Ask the patient to get up from the chair/bed and walk three metres then turn around and sit down again. The patient should be permitted to use their walking aid.
Cardiovascular examination for falls
Pulse: may have irregularities such as AF or bradycardia
Blood pressure – hypotension
Bruits over carotid arteries (e.g. aortic stenosis, carotid stenosis)
Murmurs: aortic stenosis/regurgitation, mitral stenosis
Resp examination for falls
Inspection: increased work of breathing
Auscultation: coarse crackles (e.g. pneumonia)
Percussion: dullness (e.g. pleural effusion)
Neurological examination for falls
Cranial nerve examination: stroke or visual impairment
Power: weakness (e.g. stroke, disuse atrophy)
Tone: increased in stroke
Reflexes: absent (e.g. diabetic neuropathy), hyperreflexia (e.g. upper motor neuron pathology)
Sensation: may be reduced secondary to upper or lower motor neuron pathology
Co-ordination: may be impaired (e.g. chronic alcohol misuse leading to cerebellar degeneration)
GI exams for falls
Abdominal tenderness
Organomegaly
MSK exams for falls
Check for injuries associated with falls and examine carefully the point of contact with the floor
ENT exams for falls
Is there any evidence of ear wax?
Are the tympanic membranes intact?
Investigations for falls
- Bedside-Vital signs (BP/HR/RR/SpO2/Temperature)
Sepsis
Bradycardia- - Lying and standing blood pressure
Orthostatic hypotension - Urine dipstick
Infection
Rhabdomyolysis (+++ blood) - ECG
Bradycardia
Arrhythmias - Cognitive screening (e.g. AMT)
Cognitive impairment - Blood glucose
Hypoglycaemia secondary to poor oral intake - Bloods Full blood count
Anaemia
Infection (raised white cells) - Urea and electrolytes
Dehydration
Electrolyte abnormalities
Rhabdomyolysis - Liver function tests
Chronic alcohol use
Bone profile
Calcium abnormalities in malignancy
Over-supplementation of calcium
Imaging Chest X-ray
Pneumonia - CT head
Chronic or acute subdural
Stroke
Echo
Valvular heart disease (e.g aortic stenosis)
Specialist Tilt table test
Dix-Hallpike test
Benign paroxysmal positional vertigo
Cardiac monitoring (e.g. 48hr tape)
If no symptoms during monitoring episode in hospital
DDs of Falls
Polypharmacy
Arrhythmias
Orthostatic HT
Bradycardia
Stroke
Peripheral neuropathy
Incontinence
UTI
Hypoglycaemia
Arthritis
BPPV
Medication that can cause falls
Beta-blockers (bradycardia)
Diabetic medications (hypoglycaemia)
Antihypertensives (hypotension)
Benzodiazepines (sedation)
Antibiotics (intercurrent infection)
Management of falls
Gait - Physiotherapy
Visual problems - Eye test and ensure wears glasses
Hearing difficulties - Remove earwax, hearing assessment
Medication review
Alcohol cessation
Psychiatric team if cognitively impaired
Good fitting footwear
Turn on lights
Take up rugs
What is osteoporosis?
complex skeletal disease characterised by low bone density and micro-architectural defects in bone tissue, resulting in increased bone fragility and susceptibility to fracture.
What is osteopenia
Osteopenia refers to a less severe reduction in bone density than osteoporosis.
Epidemiology of osteoporosis
- Osteoporosis affects over 3.2 million people in the UK.
- Prevalence is higher in women and increases following menopause as oestrogen levels fall. Women also lose trabeculae with age.
- An ageing population is contributing to a rise in fragility fractures
- Caucasians and asians more at risk
- 1/2 women and 1/5 men over 50
- NHS cost £2.3 billion
Aetiology of osteoporosis
Primary disease (e.g. with older age)
Secondary disease, may be due to: malignancy, diabetes, Cushing, IBD, CKD, COPD, SSRis, PPIs
Pneumonic for RFs for osteoporosis
SHATTERED
SHATTERED
- Steroid use (long term corticosteroids)
- Hyperthyroidism, hyperparathyroidism, hypercalciuria
- Alcohol and tobacco use
- Thin - Low BMI (<18.5 kg/m2)
- Testosterone decrease
- Early menopause
- Renal or liver failure
- Erosive/ inflammatory bone disease e.g. myeloma or RA
- Dietary (reduced Ca2+, malabsorption, diabetes)
Other RFs for osteoporosis
- Older age
- Female (especially post-menopausal, as oestrogen is protective)
- Caucasian/ asian
- Family history
- Previous fragility fracture
- Reduced mobility and activity
Which genes are involved in getting to your peak bone mass?
Multiple genes are involved, including
- collagen type 1A1,
- vitamin D receptor
- oestrogen receptor genes.
What other factors are involved in peak bone mass?
- Nutritional factors
- sex hormone status
- physical activity
also affect peak bone mass.
Oestrogen
Oestrogen deficiency leads to an increased rate of bone loss. Oestrogen is key to the activity of bone cells with receptors found on osteoblasts, osteocytes, and osteoclasts.
osteoclasts survive longer in the absence of oestrogen, and there is arrest of osteoblastic synthetic architecture.
What do Glucocorticoids cause
increased turnover of bone and osteoporosis. Prolonged use can result in reduced turnover state - though even here synthesis is affected more leading to a loss of bone mass.
Basic pathophysiology of osteoporosis
Osteoclast are primarily responsible for bone breakdown whilst osteoblasts are responsible for bone formation. As we age, the activity of osteoclasts increases and is not matched by osteoblasts.As such bone mass decreases.
Clinical manifestation for osteoporosis
Asymptomatic condition with the exception of fractures
Common fragility fractures include vertebral crush fracture and those of the distal wrist (Colles’ fracture) and proximal femur.
Investigations for osteoporosis
FRAX Tool
DEXA Scan
Vertebral fracture assessment
FRAX tool
- Predicts the risk of a fragility fracture over the next 10 years. Usually the first step of assessment and is done on patients at risk of osteoporosis
- Women >65 years, men >75 years, younger patients with risk factors
involves inputting information such as their age, BMI, co-morbidities, smoking, alcohol and family history +/- bone mineral density
- Women >65 years, men >75 years, younger patients with risk factors
What does the DEXA scan do
Measures bone mineral density by measuring how much radiation is absorbed by the bones.
DEXA scan (dual-energy xray absorptiometry) method
- Can be measured anywhere on the skeleton but reading at the hip is KEY.
- 2 scores are obtained:
- Z score - represent the number of standard deviations the patients bone density falls below the mean for their age.
- T score - represent the number of standard deviations below the mean for a healthy young adult their bone density is.
What is management based on?
Management based on NOGG guidelines, using the FRAX score
FRAX without bone mineral density
- Low risk – reassure
- **Intermediate risk – offer DEXA scan and recalculate the risk with the results
- High risk – offer treatment*
FRAX with bone mineral density
- Treat
- Lifestyle advice and reassure*
1st line treatment
Bisphosphonates
- Interfere with osteoclasts and reducing their activity, preventing the reabsorption of bone.
- Examples of bisphosphonates are:
- Alendronate 70mg once weekly (oral)
- Risedronate35mg once weekly (oral)
- Zolendronic acid 5 mg once yearly (intravenous)
Other management
- Lifestyle changes -
exercise, weight, vit D, smoking, alcohol - NICE - recommend calcium + vit D supplementation
- Denosumab: monoclonal antibody that blocks the activity of osteoclasts.
- HRT- for early menopause
- Raloxifeneis used as secondary prevention only.
What does raloxifene do
It is a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus.
Monitoring
Patients on bisphosphonates should have a repeat FRAX and DEXA scan after 3-5 years and a treatment holiday should be considered if their BMD has improved and they have not suffered any fragility fractures. This involves a break from treatment of 18 months to 3 years before repeating the assessment.
Complications
- Fractures
-
Side effects of bisphosphonates:
- Reflux and oesophageal erosions. Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent this.
- Atypical fractures (e.g. atypical femoral fractures)
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
What is Bone strength determined by?
-
BMD:
- How much mineral in bone
- Determine by the amount gained during growth and amount lost during ageing
-
Bone size:
- Short and fat is stronger than long and thin
- Distribution of cortical bone
-
Bone quality:
- Bone turnover, the architecture of it and the mineralisation (if there is not enough mineralisation then bone break, if too much then bones are stiff and shatter)
Morbidity in the first year post hip fracture
Death within one year - 20%
Permanent disability - 30%
