FALLS & osteoporosis Flashcards
Causes of FALLS
DAME
- Drugs (polypharmacy, alcohol).
- Age-related changes (gait, vision, balance, sarcopaenia, sensory impairment).
- Medical (stroke disease, CVS disease, Hypoglycemia).
- Environmental (obstacles, trailing wires, poor lighting)
Estimated Fragility Fracture Cost in the UK
£5 BILLION
History
Investigation of falls
BIB
dont forget B12 and thyroid
DEXA>osteoporosis
EEG if suspect seizure
CT> if head injury
Risk factors for falls
- Lower limb muscle weakness
- Vision problems
- Balance/gait disturbances (diabetes, rheumatoid arthritis and parkinson’s disease etc)
- Polypharmacy (4+ medications)
- Incontinence
- >65
- Have a fear of falling
- Depression
- Postural hypotension
- Arthritis in lower limbs
- Psychoactive drugs
- Cognitive impairment
Causes of SYNCOPE
Drugs causing falls
Who should receive a multifactorial risk assessment for falls? (3)
The following patients should receive a multifactorial risk assessment:
- 2 or more falls in the past YEAR
- Presentation for medical attention with a fall.
- did shit on the “Get Up & Go test” and/or the “Turn 180° test”
What should be covered in a mulitfactorial risk assessment and management plan?
- History of falls
- Consider the impact of co-morbidities
- Polypharmacy
- Osteoporosis risk
- Urinary incontinence.
- Perform a lying and standing BP
- Perform a “Get up and Go Test”
- home hazards–> OT
Examination
A functional assessment of their mobility – how do they mobilise, what with and what is their gait like
Vision–> snellen, visual acuity, fundoscopy
CVS examination – HR, ECG , lying and standing BP (at immediate, 3 and 5 minutes)
Neurological -
Musculoskeletal – assess their joints
what is a postitive postural BP test?
A drop in systolic BP of 20mmHg or more (with or without symptoms).
A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without
symptoms).
A drop in diastolic BP of 10mmHg w/ symptoms (although clinically less significant than a
drop in systolic BP).
Tx postural hypotension
non-pharmacological
- Withdraw offending medication
- Rise slowly from supine to sitting to standing position
- Avoid straining, coughing, and prolonged standing
- Cross legs while standing
- Raise head of bed 10 to 20 degrees
- Small meals and coffee in the morning
- Elastic waist high stocking
- Increase salt and water intake
- Exercise, eg, swimming, recumbent biking, and rowing
Pharmacological
1st line–>Fludrocortisone :expands BV and reduces salt loss.
Last line: Midodrine
How can you assess for mobility?
GAIT examination
- Timed “get up and go test”
- 180 degree turn test
- Gait speed
List 3 Fall Risk Assessment tools
- Falls Risk Assessment Tool (FRAT): helps u uncover any health issues that might make you more likely to fall, which you can discuss with your GP
Falls prevention & MDT (4)
MDT
- PT–> strength and balance training
- OT–>home hazards
- DR–>medication review (stopstart) co-morbidities, Bone health assessment (DXA scan)
- Psycology–> fear of falling leads to social isolation, reduce mobiltiy (CBT, refer to AgeUK for social support)
- Orthotics–> vision assessment and referral
what medications cause osteoporosis?
- PPI
- Steroids
- Antiepileptics
- SSRI
- Aromatase inhibitors
- Gonadotropin-releasing hormone agonists, such as goserelin.
how do you perform a bone health assessment? (3)
what is the T score? (1)
1st —> FRAX tool estimates the 10-year risk of fragility fracture
2nd–> Offer a DEXA scan (dual-energy X-ray absorptiometry) to measure BMD (femoral neck and lumbar sacral)
Bloods: vitamin D, Ca+, TFT, PTH
- TSH inhibits bopne resorption (hypo or hyper)
- anybody who falls from nonstanding postition is a “fragility fracure”
- Bone density can be represented as a Z score or T score
- T score: based on bone mass of YOUNG reference population
What is the cut off T-score for osteoporosis?
A T-score of -2.5 and below confirms osteoporosis and is diagnostic.
if T score is -1 to -2.5 they have osteopenia
Management of Osteoporosis
Conservative: Lose weight, healthy lifestyle/Diet, stop smoking, reduce falls, reduce alchohol
Calcium and VitD (colecalciferol)
Medical
1st line–> Bisphosphonates (reduces osteoclast activity, preventing the reabsorption of bone)
- Alendronate 70mg once weekly (oral)
- Risedronate 35 mg once weekly (oral)
- Zolendronic acid 5 mg once yearly (intravenous)
2nd line–>
Denoxumab (blocks activity of osteoclasts)
Strontium ranelate is a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction.
Raloxifene is used as secondary prevention only. It is a SERM it stimulates oestrogen receptors on bone but blocks them in the breasts and uterus.
HRT considered in women who have early menopause
instructions on taking Bisphosphinates? SE? (4)
- Oral bisphosphonates are taken on an empty stomach sitting upright for 30 minutes before moving or eating to prevent Reflux and oesophageal erosions.
- Atypical fractures (e.g. atypical femoral fractures)
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
Follow up for Osteoporosis
Low risk patients not on Tx: should be given lifestyle advice and followed up within 5 years for a repeat assessment.
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.
Primary hyperparathyroidism causes bone loss in the distal fore arms, so we dexa scan the distal for arm in this case ok?
Dangers of a long lie
- pressure ulcers
- incontinence
- AKI
- incr risk mortality
