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MBBS VI - SpC - Family Medicine > Geriatrics: Fall, motor function and gait assessment, Osteoporosis > Flashcards

Geriatrics: Fall, motor function and gait assessment, Osteoporosis Flashcards

1
Q

, Immobility

Fall

WHO definition

A
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2
Q

Types of fall

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3
Q

Causes of syncopal fall

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4
Q

Causes of non-syncopal falls (intrinsic, not due to environment or behavior)

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5
Q

Causes of non syncopal falls - extrinsic factors

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6
Q

Fall

Risk factor

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7
Q

Falls

Complications

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8
Q

Approach to fall

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9
Q

Fall

Important P/E

A
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10
Q

List gait and balance assessment tests

A

Gait and balance:
- Functional reach: assess postural instability
- Performance - orientated assessment of mobility
- Berg balance scale: 14 activities of everyday life
- Time up and go test
- Morse fall assessment scale: inpatient use
- FRAIL scale for frailty: Fatigue, Resistance, Ambulation, Illness, Loss of weight
- Other tests: Dynamic gait index, Four Square Step Test

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11
Q

Functional reach test

Assessment
Scoring

A
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12
Q

Performance Orientated assessment of mobility

Task
Score

A
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13
Q

Berg balance scale

Task
Score

A
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14
Q

Time up and go test

Task
Score

A
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15
Q

FRAIL

Items
Interpretation

A
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16
Q

Prevention of fall and fall-related injury

Non-pharmacological management

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17
Q

Fall and fall-related injury

Medical management

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18
Q

Time up and go test

Setup
Patient instructions

A
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19
Q

Time up and go test

Interpretation

A
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20
Q

Time up and go test

False positive result

A
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21
Q

Gait assessment

Metrics for assessment

A
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22
Q

Common pathological gaits

A
23
Q

Hemiplegic gait
Diplegic gait

Features

A
24
Q

Cerebellar ataxic gait

Features

A
25
Q

Sensory ataxic

Feature

A
26
Q

Parkinsonian gait

Features

A
27
Q

Hyperkinetic gait

Feature

A
28
Q

Waddling gait

Feature

A
29
Q

Steppage gait

Features

A
30
Q

Trenedelenburg gait

Feature

A
31
Q

Antalgic gait

Features

A
32
Q
A
33
Q

Pathophysiology of age-related bone loss

A

Increased rate of bone remodeling in both cancellous and cortical bone
> Increase number of remodeling units
> Resorbed cavities too large and newly formed pocket of bone too small
> Increased bone loss and negative remodeling balance

34
Q

Recommended Ca intake

A

800mg/d in adults

1000mg/d for >50y (F) or >70y (M)

35
Q

Normal changes in bone density over lifetime

A

Peak bone mass attained in age 20-40y

Gradual age-related bone loss after 40y (~1%/y)

36
Q

Causes and RF of primary osteoporosis

A

Race: Asians, White
Body habitus: short stature, ↓BMI
Family history of OP or fragility fracture
Low oestrogen states: post-menopausal, amenorrhoea >6mo, multiparity
Dietary: low dietary calcium or vitamin D
Lifestyle: smoking, drinking, sedentary lifestyle

37
Q

Causes and RF of secondary osteoporosis

A

Endocrine: hyperthyroidism, hyperparathyroidism, hypogonadism, Cushing’s syndrome, prolactinoma

Drugs: glucocorticoids, anticonvulsants, PPI, heparin, aromatase inhibitor

Malignancy: multiple myeloma, leukaemia

Inflammatory: IBD, RA

GI: gastrectomy, malabsorption, Primary biliary cirrhosis

Renal: renal osteodystrophy

Others: prolonged immobilization, osteogenesis imperfecta, homocystinuria, Turner syndrome, scurvy

38
Q

Clinical presentation of Osteoporosis

A

Asymptomatic: presented with incidental finding of XR osteopenia or by screening

Fragility fractures: fractures occurring with low energy trauma (eg. fall from level ground)
□ Vertebral collapse: acute mechanical LBP ± radiation with height loss and kyphosis
□ Trochanter/neck of femur, usually upon fall landing on buttock
□ Distal forearm: distal radius/ulna
□ Neck of humerus, pelvic (pubis, sacrum), rib

39
Q

Diagnosis of Osteoporosis

A

□ Previous Low-trauma/ Low-energy fracture in postmenopausal/ elderly patient
□ T-score ≤-2.5 based on BMD measurement by DXA

Device: dual energy X-ray absorptiometry (DEXA) at spine and hip (best predictor of fracture risk)
Interpretation (WHO 1994):
→ Normal = T score ≥ -1
→ Osteopenia = T score <1 and >-2.5
→ Osteoporosis = T score ≤-2.584
→ Established osteoporosis = T score ≤-2.5 with fracture

Note that by 60y, ~1/2 of women will have low bone mass or osteoporosis

40
Q

Outline history-taking for OP

A 
Aim:
□ Identify risk factors
□ Evidence for secondary osteoporosis
□ Medications/illnesses that ↑risk of fall and OP 
□ Family Hx

Past health:

  • History of fractures
  • Fall risk
  • Low estrogen state: age of menopause, multiparity… etc
  • GI disease/ Malabsorption syndromes
  • Anorexia nervosa
  • Type I DM

Drug history:

  • OP: glucocorticoids, PPI, anticonvulsants, TZDs
  • Fall risk: hypnotics, sedatives…etc

Social:

  • Smoking and alcohol (RFs)
  • Sedentary lifestyle

Family Hx:
- OP or fragility fractures

41
Q

Outline specific physical exams for OP

A

Height and weight, any recent acute changes (vertebral fracture, Cushing’s syndrome)

Dental exam for loss of teeth and dentures (early signs of osteoporosis, risk of osteonecrosis of jaw)

Evidence of secondary osteoporosis:
→ Signs of endocrine diseases, eg. hyperthyroidism, Cushing’s disease
→ Signs of myeloma, eg. anaemia, hypercalcemia
→ Signs of hypogonadism

Clinical effects of osteoporosis:
→ Observe posture and estimate degree of kyphosis
→ Examine for site of tenderness

Fall assessment: critical in elderly
→ Agility, hearing, eyesight, postural sway
→ Gait
→ Mobility muscle strength

42
Q

List panel of lab investigations for OP

A
43
Q

Non-pharmacological treatment of OP

A

Adequate dietary Ca, vitamin D intake:
→ Recommended intake: 1000mg Ca, 600IU vit D (M or premenopausal F); 1200mg Ca, 800IU vit D (post-M F)
→ Role of supplementation: not much evidence, only in inadequate dietary intake (esp vegans, lactose intolerance)
→ Note that PPI use can ↓calcium absorption

Regular weight bearing exercise

Smoking cessation and moderate alcohol consumption

Regular exposure to sunlight esp in institutionalized patients

44
Q

Calcium intake
1) Example of food with high Ca

2) Calcium supplements
- Examples
- S/E

A

Cheese, Sardine, Almond, Yogurt, Tofu

Ca supplements (Calcium carbonate, Calcium citrate)

  • Taken with food, gastric acidity promote calcium absorption
  • S/E: Dyspepsia and constipation (increase fluid and fiber intake to mitigate)
45
Q

Vitamin D intake

  • Recommended level
  • Source of Vit. D
A

Requirement: target 25 hydroxyvitamin D level at 30ng/mL

  • Mean Vit. D requirement: 1000IU/day
  • 2000IU /day for obese, limited sun exposure, malabsorption

Sources:
- Synthesis of cholecalciferol (Vit. D3) in the skin under UV light
10-15 minutes sunlight exposure every day over face, hands, arms
- Food/ supplements

46
Q

Weight bearing exercises

  • Examples
  • Benefits
A

Examples:
- Brisk walking, jogging, stair climbing, Tai Chi, Dancing

Benefits:

  • Retard bone loss
  • Increase muscle mass and strength
  • Improve balance, reduce fall risk
  • Improve QoL
47
Q

2 classes of pharmacological agents for OP with examples

A

□ Antiresorptives:
oestrogen (HRT), SERM, bisphosphonate, RANKL inhibitor

□ Anabolic agent:
teriparatide/ Abloparatide (PTH), romosozumab (anti-sclerostin Ab)

48
Q

Standard treatment regiment for OP

A

1st line: oral bisphosphonate (+ raloxifene or HRT if under 65 without hip fracture)
→ Raloxifene: generally less effective, more for lower risk pt who prefer to ↓CA breast risk
→ HRT: NO longer indicated for osteoporosis ALONE, can be used if vasomotor symptoms

Add-on therapy:
→ IV bisphosphonate: if refractory to GI S/E of oral form
→ Denosumab: refractory to bisphosphonate, poor compliance or CKD
→ Anabolic agent: severe osteoporosis, fractures or unresponsive to other Tx

49
Q

Management of osteoporotic fractures

A

Non-operative:

  • Manipulation and cast application for 4-6 weeks
  • Conservative wait for symptom improvement in 6 weeks

Operative:

  • Vertebral body augmentation procedures
  • Open surgery if significant neurological deficit/ kyphotic deformity/ pain
50
Q

PTH for OP

  • Examples
  • MoA
  • Effect
  • S/E
  • C/O
A

PTH, eg. teriparatide (SC low-dose PTH analogue). Abaloparatide

Biphasic action of PTH on bone:
→ Low dose, intermittent → anabolic action eg. daily IMI can ↑BMD and ↓vertebral fracture risk by 70%
→ High dose, continuous → catabolic action with resorption of cortical > trabecular bone

Effect: ↓vertebral fracture by 70%, ↓non-vertebral fracture by 30%

S/E:
Mild leg cramps
Injection site pain and bruising
Hypercalcaemia

C/O

  • Long-term use (osteosarcoma risk)
  • History of skeletal malignancies/ metastases
  • History of radiation to bone
51
Q

RANKL Antibody

  • Example
  • MoA
  • Effect
  • S/E
A

RANKL Ab, eg. denosumab

MoA: human mAb vs RANKL → interferes with RANKL → ↓osteoclast differentiation and activation

Effect: ↓vertebral fracture by 50%, ↓non-vertebral fracture by 30%

S/E: rash, atypical femoral fracture (very rare), hypocalcemia, osteonecrosis of jaw (very rare), sudden vertebral collapse if abrupt withdrawal

Can use for poor renal function, unlike bisphosphonate

52
Q

Bisphosphonates **

  • Examples
  • MoA
  • Effect
  • Precautions
  • S/E
A

Examples: Etidronate, alendronate, risedronate, Zoledronate (IV)

MoA: Anti-resorptive
Pyrophosphate derivative
→ binds to bone surface and absorbed by Osteoclasts
→ competitive inhibitor of PPi-requiring farnesyl pyrophosphate synthase (FPPS) reaction
→ inhibition of mevalonate pathway (i.e. steroidogenesis pathway)
→ specific inhibition of bone resorption + induce apoptosis of osteoclasts

Effect:
↓fracture risk by 50% in both vertebral and non-vertebral fractures (incl. hip)

Precautions:

  • Poor intestinal absorption, take 30min before meal
  • C/O Poor renal function (eGFR<30)
  • Avoid Ca or Vit D supplements >1h before bisphosphate (affect absorption)

S/E
→ Upper GI disturbance (~5%), eg. oesophagitis
→ Flu-like illness (fever, malaise, generalized myalgia) esp at 1st exposure
→ Oversuppression of bone turnover due to persistent action
→ Require drug holidays if undergo dental work (remind pt to ensure good dental hygiene)
→ Atypical femoral fracture due to excessive bone formation
→ Osteonecrosis of jaw due to limited bone healing following trauma (eg. dental work)

53
Q

SERM

  • Example
  • Indication
  • MoA
  • Effect
  • S/E
A

Selective estrogen receptor modulators (SERMs), eg. raloxifene

Indication: Young post-menopausal women with low risk of hip fracture

MoA:
Estrogen-agonist effect in bone: Decrease bone resorption
Estrogen-antagonist effect on breast and endometrium: ↓ER+ breast cancer, no risk of endometrial CA

Effect:
↓vertebral fracture risk by 50% but not non-vertebral fracture

S/E:
Venous thromboembolism
Hot flushes
Leg cramps

** Discontinue if prolong immobilization**

54
Q

HRT for OP

  • Indication
  • MoA
  • S/E
A
  • Indication: Young woman with Early menopause, concurrent decrease menopausal symptoms, reduce cholesterol
  • MoA:
    ↓bone resorption, ↓urinary Ca excretion, ↓stromal cell cytokine production → ↓osteoclastogenesis
  • S/E:
    ↑risk of CA endometrium → must add progestogen if uterus intact
    ↑risk of CA breast and CA cervix
    Venothrombolic disease

MBBS VI - SpC - Family Medicine (42 decks)

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