MFE Flashcards
Where are the electronic Fraility Index (eFI) and Clinical Frailty Score (CFS) best used?
eFI - useful in general practice when you have a lot of data about a patient available via computer. Very useful for charting trends over time, but less useful in a hospital setting
CFS - useful all the time and widely applicable across all specialties dealing with elderly patients
Which of the following is NOT one of the most important risk factors for assessing falls risk in an elderly patient?
- Impaired gait or balance
- Polypharmacy (being on 6 or more medications)
- Being on any psychotropic medicines e.g. sleeping pills, sedatives
- History of previous falls
- Age >80
- Visual and cognitive impairments
- Urinary urgency/frequency
- Being female
Polypharmacy (being on 6 or more medications) - while this is definitely a risk factor, this is deemed a risk if being on 4 or more medications
Modifying falls risks requires a multifactorial approach, which healthcare professionals might be involved?
Physiotherapists - strength and balance training
Doctors and pharmacists - medication review
Doctors - medical review of cardiovascular, neurological and MSK systems
What % of over 65s fall each year?
How many falls a year is considered to increase the risk of death?
33%
3 or more falls a year
What % of frequent fallers are dead within 12 months?
Why is this the case?
Up to 25%
Due to underlying acute medical issues causing repeated falls
Falls History - what questions might you ask?
- Number of falls
- Location
- Preceeding symptoms
- LoC
- Urinary incontinence/tongue biting
- Use of walking aids
- Outdoor mobility
- Availability of community alarm/living situation and others present (collateral history may be needed)
- Underlying medical problems and medications
Going top to toe, what might you include in a full physical examination of a patient presenting with falls?
(List and review medications)
Visual acuity
Neurological examination including gait assessment and Tinetti/Berg scores with physiotherapist (related to balance)
Cardiovascular examination - listen for murmurs, bruits, record standing and lying BP, record and report ECG
(Does standing reproduce any feelings of dizziness?)
Examination of the feet
Consider fracture risk and need for bone protection
A patient presents with recurrent falls. During the history and examination, you learn that the patient is taking the following medications - which could be contributing to the increased falls?
- Escitalopram
- Quetiapine
- Tramadol
- Ropinirole
- Oxybutinin
- Tamsulosin
- Bendroflumethiazide
- Ramipril
- Atenolol
- Salbutamol
- Amlodipine
- Digoxine
ALL of the above!
Escitalopram (SSRI) - antidepressants are associated with increased falls. Especially true of tricyclics, SNRIs and MAOIs, but also SSRIs
Quetiapine (atypical antipsychotic) - cause sedation, slow reflexes and loss of balance due to some alpha-blockade and orthostatic hypotension
Tramadol (opiate analgesic) - sedation, slow reflexes, loss of balance, delirium
Ropinirole (Parksinson medication) - may cause delirium and orthostatic hypotension
Oxybutinin (anticholinergic acting on bladder)
Tamsulosin (alpha blocker) - commonly causes OH, and cessation may cause urinary retention. Also Doxazosin, Indoramin, Prazosin etc.
Bendroflumethiazide (thiazide diuretic) - causes OH and weakness due to low potassium (hypokalaemia). Note, loop diuretics such as furosemide are also a risk due to causing OH and dehydration resulting in hyponatraemia and hypokalaemia, but are less of a risk than thiazides
Ramipril (ACEI) - all ACE inhibitors require adequate kidney function for their removal, and if accumulating can result in dehydraiton or renal failure
Atenolol (beta blocker) - renally excreted and may accumulate, causing hypotension
Amlodipine (CCB) and Digoxin (antiarrhythmic) - both families of drug may cause hypotension, bradycardia and in Digoxin’s case arrhythmias
Lots of medications increase risk of falls - https://www.bgs.org.uk/sites/default/files/content/attachment/2018-05-22/Falls_drug_guide.pdf
The Comprehensive Geriatric Assessment covers Medical, Functioning, Psychological and Social components.
What is covered under ‘Medical’?
Problem list for the patient
Comorbidities and disease severity
Medication review
Nutritional Status
The Comprehensive Geriatric Assessment covers Medical, Functioning, Psychological and Social components.
What is covered under ‘Psychological’?
Mental status and cognitive function
Mood/depression testing
The Comprehensive Geriatric Assessment covers Medical, Functioning, Psychological and Social components.
What is covered under ‘Functioning’?
Basic and extended ADLs
Activity and exercise status
Gait and balance
The Comprehensive Geriatric Assessment covers Medical, Functioning, Psychological and Social components.
What is covered under ‘Social’?
Informal needs and assets
Care resource eligibility
Create a problem list based on the following…
Dear Receiving Doctor,
Re: Mrs Connie Fused 0101320125
Thank for admitting this elderly old lady with confusion. She has a history of vascular dementia, TIAs, OA of her hips, depression and AF. She has recently been treated for recurrent UTIs. She normally lives alone with a carer once daily. Over the last few days her carers have noticed that she has become more confused and is incontinent of urine.
Her medication consists of aspirin, simvastatin, bendroflumethazide, co-codamol 30/500, citalopram, levothyroxine and tolterodine.
Thank you for assessing her.
Yours sincerely,
GP
Is this delirium or dementia? History (including collateral) is VITAL - what is the patient’s normal and is this a change? Baseline cognitive assessment is essential for monitoring
1) delirium due to the following…
2) dehydration
3) constipation
4) possible urinary retention
5) possible UTI
6) polypharmacy
When determining if a patient has delirium, the Confusion Assessment Method is useful. What is included in the CAM? (3)
Does the patient…
- have inattention? AND
- have symptoms which are acute and fluctuating? AND
- have disorganised thinking or an altered conscious level
The Single Question in Delirium (SQiD) described by Sans et al in 2010 has an 80% sensitivity for delirium - what is it?
Do you think (name of patient) has been more confusd lately?
What are the components for the 4AT?
Alertness
AMT4 - abbreviated mental test (age, DoB, place, current year)
Attention (months of the year backwards, starting at December)
Acute change or fluctuating course
