Falls - Frailty, osteoporosis, fragility fractures Flashcards
What is the Physiological definition of frailty?
“Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event as a consequence of ageing related cumulative decline across multiple physiological systems”
- Loss of physiological reserve
In terms of frailty what is a minor stressor?
stressor event = challenges your homeostasis
Minor stressor is often iatrogenic (e.g. drug induced) or environmental (e.g. place of care) as well as acute illness
Think about physiological factors of frailty can lead to:
1) Delirium
2) Falls / reduced mobility
1) vulnerable brain + minor stressor –> delirium
2) Vulnerable brain, vision, balance, muscles + minor stressor –> falls or reduced mobility
What is Phenotypic frailty ?
Phenotypic= syndrome / something can see on examination
Fried et al:
- Low grip strength
- Low energy
- Slow walking speed
- Low physical activity
- Unintentional weight loss
What are the geriatric giants?
- Immobility
- Instability (falls)
- Incontinence
- Impaired memory (dementia, delirium)
- Iatrogenic
What is frailty? How many older people have frailty? (Dr lakkappa lecture)
Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves.
- 10% of people aged over 65 years have frailty
- 25-50% over 85 years
What the characteristics of frailty? (Dr lakkappa lecture)
- Shrinking : weight loss (unintentional)
: Sarcopenia (loss of muscle
mass) - Weakness
- Poor endurance; exhaustion
- Slowness
- Low activity
pre-frail = 1 or 2
frail = 3
Why is identifying frailty so important?
- To improve outcomes
- To avoid unnecessary harm
The central problem with frailty is the potential for serious adverse outcomes after a seemingly minor stressor event or change, such as an infection or new medication.
In terms of a pts functional abilities how does a frail vs non frail person respond to a minor illness?
What are some tests / tools to identify and recognise frailty?
Timed up and go test:
- (taking more than 10 sec to stand from a
standard chair, walk a distance of 3m, turn and
walk back to the chair and sit down)
Walking speed (gait speed)
- taking > 5 sec to walk 4 m
PRISMA 7 questionnair
- 7 items a score of > 3 = frailty
What are the 5 frailty syndromes? ( if you encounter should raise suspicion of frailty)
Falls (instability)
Immobility
Delirium (impaired memory)
Incontinence
Susceptibility to side effects from medication (iatrogenic)
basically same as geriatric giants
How does hospitalisation affect an elderly pts function?
Functional decline in ADL is common after a hospital stay
10 days of bedrest can = 12% loss of aerobic capacity (equivalent to a decade of physiologic decline)
When you review a frail patient in A&E what are the possible outcomes? (flow diagram - think where pt will go next / what help they get)
You are a Dr in A&E / Assessment unit about to discharge a frail older person. What questions do you need to ask to see if discharge is appropriate?
How common is falls in the older population ?
30% those > 65 each year
40% those > 80 in community each year
60% those >80 in nursing home each year
What is the clinical importance of falls in elderly? (complications that result from falls)
Morbidity and mortality:
- soft tissue injury / head injury e.g. subdural haematoma
- fear of falling - decreased activity / isolation / functional decline
- 5% result in fracture (1% = hip)
- 25% die in 6 months
- 25% remain functionally more dependant
- nursing home placements and loss of independence
What is involved in the physiology of standing upright ?
In age, how does physiology change which could affect ability to maintain upright position?
- Slower gait
- muscle strength / mass decreases
- Reaction times slower
- Postural sway increases
- Vision : Acuity / contrast / depth perception
- Disease
- Decreased sensation and proprioception
What are some identifiable RF for falling ?
What are some Intrinsic RF for falling?
What are some extrinsic RF for falling?
What are key topics to cover in evaluating a fall pt? (Dr Lakkappa lec)
What questions to ask in the Hx of presenting complaint should you ask with a fall?
WHO
WHEN
WHERE
WHAT
WHY
HOW
What should you cover in a systems review of a pt with a falls Hx?
What should you cover in the PMHx of a pt with a falls Hx?
What should you cover in the Social Hx of a pt with falls ?
- House/flat/bungalow
- Stairs and associated equipment (e.g. stair rails, stair lift)
- mobility aids? when do they use them?
- Sofa surfing?
- Upstairs/downstairs toilet/commode
- Who else is at home with the patient
- Any pre-existing package of care (POC)
- Level of independence for activities of daily living (ADLs)
- Alcohol history:
- Potential associated alcohol neuropathy
- Intoxication-related falls
- If hx of dependence, offer support to quit - Smoking history
- offer support to help quit
-Who does cooking/shopping/cleaning of house? - Gas hob (safety)
- Do they have a pendant alarm?
- Do they have a key safe?
When doing a medication review of a pt with falls what are some side effects of commonly prescribed drugs should you be looking for?
Side effects as well as poylpharmacy:
Beta-blockers (bradycardia)
Diabetic medications (hypoglycaemia)
Antihypertensives (hypotension)
Benzodiazepines (sedation)
Antibiotics (intercurrent infection)
What should you include in a physical examination of a pt with falls?
-General
- CVS
- Resp
- Neuro
- GI
- MSK
- ENT
When performing a General clinical examination for a pt with falls - what are you looking for?
- Is pt alert and orientated?
-`Timed “up and go” test? (using their walking aid)
(Ask the patient to get up from the chair/bed and walk three metres then turn around and sit down again)
When performing a cardiac clinical examination for a pt with falls - what are you looking for?
-Pulse - irregularities e.g. AF, bradycardia
- BP– hypotension (do 3 lying to standing readings)
- Bruits over carotid arteries (e.g. aortic stenosis, carotid stenosis)
- Murmurs- aortic stenosis/regurgitation, mitral stenosis
When performing a Resp clinical examination for a pt with falls - what are you looking for?
Inspection: increased work of breathing
-Equal, pain-free air entry? (Inspiration can be limited by the pain from fractured ribs from the fall)
Auscultation: coarse crackles (e.g. pneumonia)
Percussion: dullness (e.g. pleural effusion)
-Evidence of LRTI/pneumonia as an underlying infection
- Evidence of chronic respiratory problems leading to SOB and increased frailty?
-Hypoventilation (and associated atelectasis) due to pain is a risk factor for pneumonia
When performing a Neuro clinical examination for a pt with falls - what are you looking for?
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)
When performing a GI clinical examination for a pt with falls - what are you looking for?
Abdominal tenderness e.g. constipation
Organomegaly e..g enlarged bladder - urinary retention
When performing a MSK clinical examination for a pt with falls - what are you looking for?
Check for injuries associated with falls and examine carefully the point of contact with the floor
When performing a ENT clinical examination for a pt with falls - what are you looking for?
Is there any evidence of ear wax?
Are the tympanic membranes intact?
Any evidence of vertigo?
What bedside investigations would you order for a pt with falls ?
What blood / lab investigations for a pt with falls?
What imaging might you order for a pt with falls?
maybe add ECG?
Any specialist investigations / tests to do for a pt with falls?
What are some differentials for the causes of falls? Think based on systems
General:
- Mechanical (e.g. poor footwear/visual impairment)
- Polypharmacy
CVS:
- Arrhythmias
- Orthostatic hypotension
- Bradycardia
- Valvular heart disease
Neuro:
-Stroke
- Peripheral neuropathy
- TIA
GI / Urinary:
- Incontinence
- Urinary tract infection
Endocrine:
- Hypoglycaemia
MSK:
- Arthritis
- Disuse atrophy
ENT:
- Benign paroxysmal positional vertigo
- Ear wax
Psychological:
- psychogenic syncope
For a pt with a hx of falls, what is it essential to complete?
A falls risk assessment
NICE:
A multifactorial risk assessment by an appropriately skilled and experienced clinician (usually in a specialist falls service) should be offered to older people who have had one or more falls in the past year or demonstrate abnormalities of gait and/or balance. This assessment should be part of an individualized, multifactorial intervention.
A multifactorial risk assessment may include assessing for home hazards, visual impairment, and drug treatments.
Interventions commonly offered by specialist falls services include strength and balance training, home hazard assessment and intervention, vision assessment and referral, and medication review (with modification or withdrawal).
What are some practical issues a falls risk assessment might bring up? What are some interventions?
e.g. Medication review - reduce unnecessary meds
Pass med: what does NICE recommend to do for those who have fallen in the last 12 months?
- Identify all individuals who have fallen in the last 12 months.
- As per above identify why they are at risk.
- For those with a falls history or at risk complete the ‘Turn 180° test’ or the ‘Timed up and Go test’.
Pass med: what does NICE recommend to do for those who are >65 and have fallen > 2 times in the last 12 months?
- Offer a multidisciplinary assessment by a qualified clinician to all patients over 65 with:
- > 2 falls in the last 12 months
- A fall that requires medical treatment
- Poor performance or failure to complete the ‘Turn 180° test’ or the ‘Timed up and Go test’
Individuals who fall but do not meet these criteria should be reviewed annually and given written information on falls.
What is osteoporosis? (quesbook)
Osteoporosis is an osteopaenic disease characterised by fragility fractures.
CKS definition - a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.
What are RF for osteoporosis?
Age (>50 for women and >65 for men)
Female sex
SHATTERED FAMILY:
S – Steroid use
H – Hyperthyroidism, hyperparathyroidism
A – Alcohol and smoking
T – Thin (BMI<22)
T – Testosterone deficiency
E – Early menopause
R – Renal/liver failure
E – Erosive/inflammatory bone disease
D – Diabetes
FAMILY HISTORY
Who should be investigated for osteoporosis?
Calculate the 10 year fracture risk using a tool such as FRAX or Qfracture for:
- All men >75
- All women >65
All men and women >50 if they have:
- Family history of hip fracture
- Falls history
- Previous fragility fracture
- Low BMI
- Drink >4U per day of alcohol
- Are/were on steroids
- Disease associated with osteoporosis (e.g. -
- Coeliac disease, inflammatory bowel disease, hyperparathyroidism)
If 10 yr fracture risk is high then investigate further —> confirm osteoporosis and exclude metabolic bone disease
What tests / investigations can you do to confirm osteoporosis?
- DEXA scan (Gold standard) (asses bone mineral density)
- X-rays (wrist, heel, spine, hip) if fractures suspected
- MRI spine (to look for vertebral fracture)
What investigations to exclude metabolic bone disease?
Bone profile (calcium, phosphate, albumin, total protein, ALP)
Vitamin D level
TFTs
Urinary free cortisol
Testosterone
Bence-Jones protein (paraproteins made by myeloma cells -urine protein electrophoresis)
DEXA scan interpretation. What score is diagnositic of osteoporosis?
T score
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
T score: based on bone mass of young reference population
T score of -1.0 means bone mass of one standard deviation below that of young reference population
Z score is adjusted for age, gender and ethnic factors
What does FRAX tool loook at?
estimates 10-year risk of fragility fracture for pts 40-90 yrs
Factors: age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol intake
bone mineral density (BMD) is optional, but improves accuracy.
NICE recommend arranging a DEXA scan if FRAX (without BMD) shows an intermediate result
How to manage osteoporosis ? (see Passbook, quesbook as alot)
Who gets treatment?
1. postmenopausal women w/ fragility fractures + a T-score of - 2.5 SD or below
2. women > 75 years (can treat w/o DEXA first assumed osteoperosis)
- vitamin D and calcium supplementation should be offered to all women unless replete
1) alendronate is first-line (weekly)
(25% of patients cannot tolerate - upper GI SE),
Many other options e.g. Raloxifene (oestrogen receptor modulator or Denosumab (monoclonal antibodies stops maturation of osteoclasts)
How do you advise a pt to take bisphoshphonates?
Bisphosphonates should be taken alone on an empty stomach first thing in the morning with at least 240 mL (8 oz) of water sat upright in a chair.
After taking, do not have food, drink, medications, or supplements for at least one half-hour (alendronate, risedronate) or one hour (ibandronate).
Lifestyle changes for osteoporosis?
Reduce risk factors - eg. stop smoking, better diabetic control
Diet - adequate vitamin D, calcium, protein
Regular weight bearing exercise
Hip protectors in nursing home patients
Side effects of bisphosphonates?
advice for how to take to avoid oesophageal ulcer
other side effects: atrial fibrillation, osteonecrosis of the jaw, atypical stress fractures
What is CGA (comprehensive geriatric assessment)?
from BB
- A multidimensional interdisciplinary diagnostic process
- which is focused on determining a frail elderly person’s medical, psychological and functional capability
- in order to develop a coordinated and integrated plan for treatment and long term follow up.
Advantages and disadvantages to CGA (BB)
ADV:
* NNT (number needed to treat) 17 to avoid 1 death in 6 months
* people more likely to remain active
* lower levels of dependency compared to standard treatment of presenting complaint
DISADV:
* only effective when whole MDT is involved
What would be in Hx of pt who had fall due to vasovagal syncope
(BB)
Onset in seconds
Precipitated by fear, stress or standing
Ex findings in pt with fall due to vasovagal syncope
(BB)
Possible postural drop, otherwise normal
What would be in Hx of pt who had fall due to cardiac syncope
(BB)
Sudden onset and recovery
Chest pain
Palpatations
And/or SOB
Ex findings for patient who had fall due to cardiac syncope (BB)
Fast, slow or irregular pulse
Investigation results for pt who had fall due to cardiac syncope?
(BB)
Arrythmia or MI on ECG
Rasied cardiac markers
What would be in Hx of pt who had fall that was neurological in origin?
(BB
Rapid onset
headache
reduced GCS
weakness
altered sensation
Ex findings for pt who presented with fall of neurological origin (BB)?
Focal neurology
Persistently abnormal GCS
Investigation results for pt who had fall of neurological origin (BB)?
CVA or intracranial haemorrhage on CT
Check glucose - as could be mimic
What would be in Hx of pt who had fall due to seizure?
(BB)
Possible aura
no memory of fall
abnormal limb movements
tongue biting
incontinence
post-ictal phase
Ex findings for pt who had fall due to seizure? (BB)
Drowsy
Injuries possible
Todd’s paralysis
Also could have normal examination
Describe approach to assessment of someone who presents with recurrent falls (BB)
- Hx and Ex
- Drug review - involve GP and pharmacist
- Specific review of meical risk factors: vision, syncope, CNS, CVS, DM
- Functional and mobility assessment
- Psychological effects of fall (pt may reduce mobility to reduce fall risk - but this causes muscle weakness and joint stiffness)
What are causes of dizziness?
group into vestibular and non-vestibular
What are your differentials for a collapsed patient?
Define transient loss of consciousness
- short duration (max 5 mins)
- abnormal motor control (loss of postural muscle tone, stiff or flaccid, may have abnormal movements)
- loss of responsiveness
- amnesia
What five components must be fulfilled to be true syncope?
Note: syncope is a symptom
- TLOC (only one cause)
- Loss of voluntary muscle tone
- Rapid onset, spontaneous & prompt recovery
- Full recovery
- Transient global cerebral hypo-perfusion
True syncope: must fulfil 5 components
What are the causes of syncope?
- reflex syncopal syndromes = situational syncope, vasovagal, carotid sinus syndrome
- orthostatic hypotension
- cardiac syncope
What features in a history may suggest a reflex syncopal syndrome (situational syncope, vasovagal syncope, carotid sinus syndrome)?
- after sudden, unexpected unpleasent sight, sound or smell
- prolonged standing in crowded warm places
- nausea and vomiting
- within an hour of a meal - post prandial
- after exertion
- with head rotation (puts pressure on carotid sinus = carotid sinus syndrome)
For syncope, what questions should you ask in a Hx?
What are red flags or high risk features of cardiac syncope?
- New onset Chest pain or SOB
- Sudden onset palpitations immediately prior
- Collapse during exercise/supine/ (seated)
- Personal PMH:
significant arrhythmias
LVSD
IHD
Valvular heart disease
Family History SCD (< 50)
What are cardiac causes for cardiac syncope?
-
Arrhythmia:
Brady-
Tachy- -
Structural Heart Disease
Valvular
Chamber
Pericardial -
Vascular
PE
Acute volume loss
Dissection
MI (arrhythmia)
A patient has a collapse. On taking a history, these features were noted:
Vagueness/absences
Abnormal movements
Stereotyped movements
Tonic-clonic jerks
Myoclonus
LOC (> transient)
Tongue biting
Incontinence
Post-ictal phase
Grunting/snoring
What is your main diagnosis?
seizures
A patient is dizzy and light headed. On taking a history, these features were noted:
Postural change
Rolling in bed
Lying down/getting up from lying
Diplopia
Tinnitus
Nausea/Vomiting
Room spinning
Motion-sickness-like feeling
Episodic
No relationship to sit-to-stand
No TLOC but falls
What is your main DDx?
BPPV
A patient has a falls associated with the following features:
Weak legs
Fatigue
General unwellness
Weight gain
Swollen ankles/legs
SOB
Off-balance
Trips
Falls whilst not using aids
What are your differentials for this illness script?
Consider:
Accidental falls
Swollen leg-associated
Walking aid non-compliance
Neurological disorders (CVA, Foot drop, proprioception loss,
peripheral neuropathy, proximal myopathy,
Vit D Deficiency)
Define orthostatic hypotension
Definition Early OH:
Systolic BP fall > 20 mmHg or Diastolic BP fall > 10 mmHg
In first 3 min of standing
OR:
Systolic BP < 90mmHg from baseline
What are causes of orthostatic hypotension (which causes syncope)?
- Hypovolaemia: Dehydration, Haemorrhage (Addison’s)
- DRUGS: Antihypertensives, anti-anginals, antidepressants,
- Alcohol
- Prolonged bed rest
- Autonomic failure - primary (eg MSA, PD) - secondary (DM)
- Idiopathic
What preventative measures could be put in place to treat orthostatic hypotension?
Preventative:
Recognise & avoid predisposing factors
* warmth, alcohol/food
* drugs
* speed of position change
* Prolonged recumbent position (HUT sleeping 100)
* stop anti-hypertensives, vasodilators, diuretics.
Elastic support stockings
Increase intravascular volume
- increase fluid & salt intake
What is the pathophysiology of vasovagal syncope?
What is the tilt table test?
1. describe it
2. what are indications ?
3. when should it be considered?
Supine –> Upright:
Gravitational shift of 300-800 ml of blood to venous capacitance system
In first 10 seconds reduced venous return and cardiac filling pressure
reduced SV
Compensatory increase in HR: not enough
Key is SNS mediated increased TPR.
= failure of the compensatory mechanisms causes VVS and forms the basis of tilt table testing.
What is management for vasovagal syncope?
Define falls
Definition
Inadvertently coming to rest on the ground or other lower level with or without LOC and other than as a consequence of overwhelming external force, sudden onset paralysis, epileptic seizure, excess alcohol intake
All age groups affected but more
commonly in the elderly
What assessments would you do in a patient presenting after a fall?
Remember most falls = ‘Multi-factorial’ > CGA
Assessments include:
- Falls & Syncope, Neurological, Musculoskeletal, Cardiac & Vestibular History & directed examination
- Drug/Poly-pharmacy review
- Appropriate Investigations including:
Blood tests, ECGs, Xrays /CT scans/MRI scans/Tilt Table/DEXA Scan - Bone Health/Osteoporosis Review
(Falls: Ca2+ & Vit D; fragility# : Bisphosphonates as well; refer to Metabolic bone clinic )
What ECG findings would be suggestive or arrhythmic syncope?
- Bifascicular block
- Alternating LBBB & RBBB
- Other ICVD (QRS >0.12 s)
- Mobitz 1 second degree
- First degree with marked increase PR
- Asymptomatic Mild sinus brady or slow AF (40-50) (day time)
- Non-sustained VT
- Pre-excitation QRS
- QTc >460ms
- Sig LVH
