Geriatrics: Fall, motor function and gait assessment, Osteoporosis Flashcards
, Immobility
Fall
WHO definition
Types of fall
Causes of syncopal fall
Causes of non-syncopal falls (intrinsic, not due to environment or behavior)
Causes of non syncopal falls - extrinsic factors
Fall
Risk factor
Falls
Complications
Approach to fall
Fall
Important P/E
List gait and balance assessment tests
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
Functional reach test
Assessment
Scoring
Performance Orientated assessment of mobility
Task
Score
Berg balance scale
Task
Score
Time up and go test
Task
Score
FRAIL
Items
Interpretation
Prevention of fall and fall-related injury
Non-pharmacological management
Fall and fall-related injury
Medical management
Time up and go test
Setup
Patient instructions
Time up and go test
Interpretation
Time up and go test
False positive result
Gait assessment
Metrics for assessment
Common pathological gaits
Hemiplegic gait
Diplegic gait
Features
Cerebellar ataxic gait
Features
Sensory ataxic
Feature
Parkinsonian gait
Features
Hyperkinetic gait
Feature
Waddling gait
Feature
Steppage gait
Features
Trenedelenburg gait
Feature
Antalgic gait
Features
Pathophysiology of age-related bone loss
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
Recommended Ca intake
800mg/d in adults
1000mg/d for >50y (F) or >70y (M)
Normal changes in bone density over lifetime
Peak bone mass attained in age 20-40y
Gradual age-related bone loss after 40y (~1%/y)
Causes and RF of primary osteoporosis
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
Causes and RF of secondary osteoporosis
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
Clinical presentation of Osteoporosis
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
Diagnosis of Osteoporosis
□ 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
Outline history-taking for OP
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
Outline specific physical exams for OP
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
List panel of lab investigations for OP
Non-pharmacological treatment of OP
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
Calcium intake
1) Example of food with high Ca
2) Calcium supplements
- Examples
- S/E
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)
Vitamin D intake
- Recommended level
- Source of Vit. D
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
Weight bearing exercises
- Examples
- Benefits
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
2 classes of pharmacological agents for OP with examples
□ Antiresorptives:
oestrogen (HRT), SERM, bisphosphonate, RANKL inhibitor
□ Anabolic agent:
teriparatide/ Abloparatide (PTH), romosozumab (anti-sclerostin Ab)
Standard treatment regiment for OP
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
Management of osteoporotic fractures
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
PTH for OP
- Examples
- MoA
- Effect
- S/E
- C/O
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
RANKL Antibody
- Example
- MoA
- Effect
- S/E
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
Bisphosphonates **
- Examples
- MoA
- Effect
- Precautions
- S/E
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)
SERM
- Example
- Indication
- MoA
- Effect
- S/E
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**
HRT for OP
- Indication
- MoA
- S/E
- 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
