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 practical issues a falls risk assessment might bring up? What are some interventions?
e.g. Medication review - reduce unnecessary meds
What are causes of dizziness?
group into vestibular and non-vestibular
What are your differentials for a collapsed patient?
For syncope, what questions should you ask in a Hx?
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?
