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OPIC > GP Tutorial 2 - falls, MDT and ACP > Flashcards

GP Tutorial 2 - falls, MDT and ACP Flashcards

1
Q

What is postural hypotension?

A

20mmHg or more of systolic drop on standing BP or 10mmHg diastolic

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2
Q

Measuring postural drop

A

Lie down 5 mins
Stand up
Measure shortly after, at 1 minute and at 3 minutes

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3
Q

Causes of postural drop

A

Acute:
* Dehydration
* Medications

Chronic
* Autonomic dysfunction
* Poor vascular tone
* Baroreceptor insensitivity

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4
Q

Does everyone get postural drop despite symptoms?

A

No - some get symptoms and have delayed postural drop

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5
Q

Risk factors for osteoporosis

A
  • Premature menopause
  • Long term steroids
  • Older age
  • Smoking
  • Alcohol >3 units perd day
  • FH fracture
  • PMH fracture
  • Rheumatoid arthiritis
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6
Q

RF for secondary OP

A
  • Type 1 diabetes
  • Untreated hyperthyroidism
  • Hypogonadism
  • Premature menopause
  • Chronic malabsorption
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7
Q

Calculating osteoporotic fracture risk

A

FRAX score - risk of OP fracture over next 10 years
* Green = lifestyle advice
* Amber = measure BMD
* Red - bisphosphonates

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8
Q

Management of OP

A
  1. Bisphosphate - alendronic acid 70mg OW/risedronate 5mg OD
  2. Calcium replacement/vitamin D
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9
Q

Polypharmacy - why is it a problem in adults

A
  • Treat symptoms
  • Numbers needed to treat say benefit>risk - this changes as people get older when life expectancy is no longer as long
  • Polypharmacy is at least 4 or 5 meds
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10
Q

Tools for polypharmacy

A
  • STOPP/START
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11
Q

What is the definition of a fall?

A
  • An event which causes a person to unintentionally rest on the ground or other lower level
  • Can be simple fall - due to chronic impairment of cognition, vision, balance or mobility
  • Or a collapse - neurogenic/cardiac
  • Syncopal or non-syncopal
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12
Q

Risk factors for falls and 3 domains

A

Activity:
* What was the person doing?

Environment:
* Where was the person?
* Any safety risks? eg cluttered

Person:
* History of falls
* Older age
* Visual problems
* Muscle weakness
* Abnormal gait eg Parkinsons
* Impaired balance
* Medications

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13
Q

Splitting a falls history up

A
  • Before fall
  • During fall
  • After fall
  • Now
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13
Q

What to ask re before fall?

A
  • Pre-syncopal symptoms - dizzy? lightheaded? palps?
  • Had they just stood up - postural drop?
  • In middle of walking –> arrhythmia?
  • Turning head - carotid sinus hypersensitivity
  • General health - infection?
  • How do they usually mobilise?
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14
Q

During fall - what to ask

A
  • Do they remember hitting the floor/falling? - if no –> LOC ?cardiac/seizure/stroke
  • Was it witnessed? - if yes, take a collateral
  • Can they describe how they fell?
  • Did they put their hands out to try and protect themselves? - no ?LOC –> worry re head injury
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15
Q

Questions to ask re after fall

A
  • Any limb jerking/urinary/faecal incontinence - seizure?
  • Were they well orientated after fall?
  • Able to mobilise independently after fall?
  • How long on the floor - rhabdo?
  • How did they feel after
  • How did they get up?
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16
Q

Questions to ask re now?

A
  • How they feel now?
  • Any pain? Bruising or swelling?
  • ICE
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17
Q

RF in PMH for fall

A
  • Diabetes - hypoglycaemia? peripheral neuropathy?
  • HTN - antihypertensives –> pos drop
  • Epilepsy
  • Previous falls
  • Arrhytmias
  • Parkinsons
  • Stroke/neuro problem
  • Incontinence/OAB - wake up at night –> fall
  • Vision
  • Cognition impairment
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17
Q

DH RF for fall

A
  • Antihypertensives
  • Alpha blockers –> pos drop
  • Hypoglycaemic agents eg gliclazide/insulin
  • Analgesia –> drowsy, frail, poor mobility
  • Bone protection
  • Steroids - proximal myopathy? fragility fracture
  • Diuretics
  • Anti-epileptics
  • Anti-cholinesterase inhibitors
  • Anticoags - subdural?
18
Q

SH to ask re fall

A
  • Type of building they live in - house/flat/bungalow
  • Stairs?
  • Upstairs/downstairs toilet
  • Clutter
  • Live with anyone
  • What ADLs do they do on their own?
  • Alcohol intake
  • Smoking history
19
Q

How to assess fracture risk

A

FRAX score - 10 yr probability of major OP fracture

20
Q

RF for OP fracture in FRAX

A
  • Older age
  • Female
  • Low BMI
  • Any previous fractures
  • FH of fractured hip
  • Smoking
  • Steroids
  • RA
  • Alcohol
  • T1DM
  • Hyperthyroidism
  • Premature menopause
  • Chronic malnutrition/malabsoprtion
20
Q

Examination for fall and what you would look for

A

CVS:
* Pulse, BP (lying and standing) murmurs (aortic stenosis –> syncope, MR ?CCF/AF)

Resp:
* LRTI, chronic respiratory problems –> SOB and frailty, painful inspiration ?rib fracture

Abdo:
* Constipation
* Urinary retention
* = delirium

Neurological:
* Signs of stroke
* Cerebellar signs
* Peripheral neuropathy

MSK:
* Check for fractures eg hip

20
Q

Differentials for fall causes based on system

A

CVS:
* Arrthymias
* Postural hypotension
* Bradycardia
* Valvular heart disease

Neurological:
* Stroke
* Peripheral neuropathy

Genitourinary:
* Incontinence
* UTI

Endocrine:
* Hypoglycaemia

MSK:
* Arthiritis

ENT:
* BPPPV

21
Q

Bedside inv for fall

A
  • Baseline obs - ?sepsis ?bradycardia
  • Lying and standing BP - postural drop
  • ECG - bradycardia? arrhythmia?
  • Blood glucose - hypoglycaemia
21
Q

Blood inv for fall

A
  • FBC - anaemia, infection
  • U&E - electrolyte disturbance, dehydration (isolated urea rise), rhabdomyolysis
  • LFTs - chronic alcohol use?
  • Bone profile - hypercalcaemia, bloods normal in OP
21
Q

Imaging for fall

A
  • XR of MSK regions where there is pain/bruising/impaired movement
  • CT head if head trauma - acute/chronic subdural, stroke
  • Echocardiogram - valvular heart disease
21
Q

Special inv for falls

A
  • 24hr ECG if nothing found and suspect
  • Dix hallpike
22
Q

Acute management for fall

A
  • Management pain - eg analgesia, WHO ladder, consider iliofascial block if hip fracture
  • NBM if surgery
  • VTE prophylaxis
  • IV fluids if dehydrated
  • Medication review - could this be cause
23
Q

Longer management when patient admitted following fall

A
  • Gait and mobility assessment - PT/OT input
  • Postural hypotension - improve hydration and review meds
  • Continence - treat infections, assess
  • Vision - arrange testing
  • Footwear - ensure appropriate
  • Environment hazards
  • Cognitive decline - assess, f/u in memory clinic, LPOP
  • Social factors - Age UK services, digital inclusion and technology support
  • Alcohol intake - if excessive give advice, refer to turning point
24
Q

Where does someone with a fall next go in the hospital often?

A
  • Orthopaedics/trauma unit if fracture hip etc - urgent surgery
  • Geriatric ward - CGA, address multifactorial causes for fall
  • Discharge planning (starts from admission) - home assessment, f/u in falls clinic, refer to memory clinic and vision testing, arrange community services
25
Q

What do ICT team do?

A
  • Intermediate care team
  • Try and prevent admissions to hospital and will assess patients within 72hrs of admission to try and facilitate early d/c
  • Offer services such as IV abx, quick OT/PT assessment
  • Receive referrals from GPs, ambulance, A&E, social services, patient and their families
26
Q

Why do we try and prevent hospital admissions?

A
  • Risk of complications - delirium, infections, deconditoning, pressure ulcers
  • Impact on independence - loss mobility, ADLs –> reduced QOL
  • Emotional and psychological - stress/anxiety/social isolation
  • Avoid overmedicalisation - stop invasive tests/treatments that are not wanted
  • Costs and resource implications - reduce strain
  • Better outcomes - recover faster, better physical and mental health in familiar environments
  • Risk of readmission/prolonged stay
  • Align with patient preference - most people do not want to be in hospital
27
Q

What do social services do?

A

Safeguarding, promote welfare of vulnerable adults and children eg:
* Child protection
* Support for families
* Assistance
* Advocacy for social justice
* Co-ordination with healthcare services

28
Q

Common responsibilities for social worker

A
  • Counsel individuals
  • Maintain care histories
  • Liase between hospitals and government agencies and families
  • Advocate for patients
  • Develop and review plans
  • Investigate issues and provide plan
  • Supervise other social worker
29
Q

Social prescriber - what do they do

A
  • AKA link worker
  • Connects individuals referred by healthcare professions to non-medical support services
  • Assess the needs, create personalised plan
  • Signpost to community services eg exercise groups, counselling, housing support
  • Collaborate with the wider team, reduce NHS pressures
  • Help with isolation, MH challenges, financial difficulties
30
Q

What is an advanced care plan?

A
  • Document that states persons preferences, values and wishes for future medical care
  • Incase their healthough declines and they become unable to make/communicate decisions for themselves - lack capacity
31
Q

How are advanced decisions completed?

A
  • Think - what is important, what you want/don’t want
  • Talk - with family and friends
  • Record this
  • Discuss with doctor/healthcare professional
  • Share - these preferences are then shared with permission
32
Q

How to identify patients who need advanced care planning?

A
  • At risk of losing mental capacity - progressive illness
  • Mental capacity varies - eg from mental illness
  • Reaching end of life - on GSF or supportive and palliative care indicators tool (SPICT)
  • Clinical frailty scale - frail patients
33
Q

ReSPECT form vs DNACPR

A
34
Q

Advanced statements vs decisions to refuse treatments

A
35
Q

What is LPA?

A
  • Legal document allowing someone to make decisions for a person if they lose their capacity (is not used if someone has capacity)
  • Under MCA 2005
  • Health and welfare LPA vs Property and Finance LPA
  • EPA does not inclide health and welfare - they stop being made in 2007 but are still valid for property and finance
36
Q

What is DOLs?

A
  • Deprivation of liberty safeguards
  • Ensures people who cannot make decisions regarding care are not inappropriately deprived of liberty
  • Lasts maximum of 12 months - but should be stopped ASAP
  • Safeguards vulnerable
  • Lengthy assessment ensures people cannot take rights away unlawfully
37
Q

When are you deprived of liberty - what does this mean?

A
  • Under supervision/controlled all the time
  • Not free to leave care setting (care home or hospital, any other settings require Court of protection involvement)
  • Lack capacity to consent to said arrangements
38
Q

Who does DOLs apply to?

A

Only to people in care home/hospital. Need to be:
* 18+
* Mental disorder
* Lack capacity
* No valid advanced decision to refuse treatment
* No refusals from LPA

39
Q

What is set to replace DOLS?

A
  • Replaced by liberty protection safeguards
  • Aims to apply across all settings and cover 16 years and above
40
Q
A

OPIC (17 decks)

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