Taking a tumble

Question 1

What is atrial fibrillation?

Answer 1

A heart condition that causes an irregular and often abnormally fast heart rate due to chaotic electrical signals.
Electrical signals from the SA node are chaotic, causing the atria to quiver. The AV node is bombarded with electrical impulses trying to cause the ventricles to constrict.

Question 2

What are the symptoms of atrial fibrillation?

Answer 2

Heart palpitations, tiredness, breathlessness, chest pain, dizziness

Question 3

What are the types of atrial fibrillation?

Answer 3

Paroxysmal: returns to normal rhythm after 7 days, symptoms are episodic and unpredictable. Can become permanent.
Persistent: irregular for over 7 days, requires intervention
Long-standing: irregular for over 12 months
Permanent: lasts indefinitely, no efforts to return to normal
Nonvalvular: not caused by heart valve issue

Question 4

What are the potential causes of atrial fibrillation?

Answer 4

Coronary artery disease, myocardial infarction, hypertension, abnormal heart valves, congenital heart defects, overactive thyroid gland, sick sinus syndrome.

Question 5

What are the risk factors for atrial fibrillation?

Answer 5

Old age, heart disease, other chronic conditions, drinking alcohol, family history, obesity, blood clots, cognitive impairment and dementia, stroke, heart failure, myocardial infarction.

Question 6

What diagnostic tools are used in atrial fibrillation?

Answer 6

ECG to assess structure and function of the heart and valves, chest x-ray to identify lung issues, blood tests to assess anaemia, thyroid and kidney function.

Question 7

What is the treatment for atrial fibrillation?

Answer 7

Anticoagulants to reduce the risk of stroke (Warfarin), Beta blockers or Cardioversion to restore normal heart rate, Catheter ablation to destroy diseased area, artificial pacemaker.

Question 8

What is patient centred care?

Answer 8

Treats the patient as an equal partner in planning, developing and monitoring their care. HCP is flexible, respectful and responsive to consider and incorporate patient’s own views, needs, expectations and priorities as care plans are developed.

Question 9

What is shared decision making?

Answer 9

HCP should give all the information needed to make an informed decision, discussing the risks and benefits of the options. Patients should have the opportunity to ask questions and reach a decision they are comfortable with.

Question 10

What is a CHA2DS2VASC score?

Answer 10

A clinical prediction tool that gives an estimated risk of stroke in patients with Atrial Fibrillation. A higher score indicates a higher risk. Score of 2 and above means oral anticoagulation therapy with a Vitamin K Antagonist (VKA, e.g. warfarin with target INR of 2-3) or one of the non-VKA oral anticoagulant drugs (NOACs, e.g. dabigatran, rivaroxaban, edoxaban, or apixaban) is recommended.

Question 11

What is a HASBLED score?

Answer 11

Scoring system that allows you to assess the 1-year risk of major bleeding in patients taking anticoagulants for atrial fibrillation. A score of ≥3 indicates “high risk” and some caution and regular review of the patient is needed.

Question 12

What is the ABCD2?

Answer 12

A clinical tool used to assess the risk of a stroke following the days after a transient ischaemic attack. Based on age, blood pressure, clinical features, duration of TIA, and presence of diabetes. Maximum of 7.

Question 13

What is QRISK2?

Answer 13

Prediction algorithm for the estimated risk of a person developing cardiovascular disease (CVD) over the next 10 years. Dependent on a number of factors and can be calculated online.

Question 14

What preventative measures are in place to prevent falls in older people?

Answer 14

Department of Health published a National service framework for older people which aims to reduce the number of falls which result in serious injury, and ensure effective treatment and rehabilitation for those who do fall.
Public health strategies, identifying and implementing measures for those at risk, improving care and treatment for those who have fallen and providing rehabilitation and long term support to increase mobility, confidence, independence.
National Falls Prevention Coordination Group (NFPCG) coordinates all fall prevention activities through many different organisations. Priorities include fall prevention, detecting and managing osteoporosis, and optimal support after fragility fracture.

Question 15

What are the guidelines for prevention of falls?

Answer 15

Older people should be asked about falls during routine appointments, risk assessments should be carried out for adults with fracture/history of falls/taking systemic glucocorticoids, general risk screening for older people (gait, balance, home hazard, vision), DEXA scan for osteoporosis, referral to osteoporosis service.

Question 16

What are the limitations of the fall prevention strategies?

Answer 16

Limitations in resources and funding, some individuals don’t have the money to access all the programmes available, some individuals are unaware of the risk or are resistant to change, discharge plans don’t include long-term prevention strategies.

Question 17

What can cause recurrent falls?

Answer 17

Recurrent falls can be caused by intrinsic predisposing conditions (due to the subject) and extrinsic predisposing conditions (due to the environment)

Question 18

What are the intrinsic causes of falls?

Answer 18

Age-related: reduction in visual ability, reduction in hearing ability, reduced muscle strength and movement, reduced stability, reaction times and sensitivity.

Pathological: cardiovascular, endocrine, neurological, musculoskeletal, gastrointestinal, physciatric, genitourinary and iatrogenic factors.

Question 19

What are the extrinsic causes of falls?

Answer 19

Obstacles, inadequate ambient lighting, inadequate footwear and clothing, slipping and uneven flooring, presence of steps, lack of handrails, inadequate height of beds, inadequate chairs, inadequate bathroom, unfamiliar environments.

Question 20

How do you manage falls?

Answer 20

Prevent extrinsic causes, treat acute and chronic diseases, carefully evaluate prescriptions, rehabilitation to improve basic motor skills, postural control, recovery of strength and mobility of lower limbs.

Question 21

What are fits/seizures?

Answer 21

When sudden bursts of electrical activity occur in the brain, temporarily affecting its function. Few seconds or minutes. Jerking/shaking can occur along with a loss of awareness and unusual sensations.

Question 22

What are the different types of seizures?

Answer 22

Focal seizures: abnormal electrical action in one area of the brain, can occur with (not responding, repetitive movements) or without loss of consciousness (changes to emotions/senses).
General seizures: Absence (staring into space, brief loss of awareness), Tonic (muscle stiffening, Atonic (loss of muscle control), Clonic (rhythmic jerking of muscles), Myoclonic (sudden brief jerks of arms or legs)
Tonic-clonic seizures: abrupt loss of consciousness, body stiffening and shaking and sometimes loss of bladder control or tongue biting.

Question 23

What are the potential causes of seizures?

Answer 23

Epilepsy (most common), lack of sleep, high fever, low blood sodium, medication, stroke, brain tumour, alcohol abuse.

Question 24

What is the treatment for seizures?

Answer 24

Anti-epileptic drugs (AEDs) or treatment to remove small part of the brain (pharma) or ketogenic diet (non-pharma).

Question 25

What is syncope?

Answer 25

A sudden loss of consciousness, usually associated with the lack of ability to maintain postural tone and follows with immediate or spontaneous recovery without the need for electrical or chemical cardioversion.

Question 26

What is vasovagal syncope?

Answer 26

Caused by prolonged periods of sitting or standing, emotional stress, pain, heat, venous puncture and alcohol use. Nausea, abdo pain, palpitations and dizziness. Due to the Bezold – Jarisch reflex: a decrease in venous return causing inadequate ventricular filling and vigorous cardiac contractions. This increases activity of the inhibitory receptors, causes hypotension and paradoxical bradycardia and therefore leads to parasympathetic hyperactivity. Remove trigger, increase exercise or treat with fludrocortisone.

Question 27

What is cardiac syncope?

Answer 27

Caused by structural heart diseases or conditions resulting in decreased cardiac output such as hypertrophic cardiomyopathy, ischemic heart disease, heart failure, cardiac tamponade and pulmonary embolism. Also caused by bradyarrhythmias and tachyarrhythmias. Treat underlying cause.

Question 28

What is Orthostatic hypotension?

Answer 28

A drop of 20mmHg in systolic and/or 10mmHg in diastolic blood pressure within 3 minutes of standing up. Can lead to falls, dizziness or syncope causing functional impairment, common in the elderly, . Treated with fludrocortisone and midodrine (pharma) or abdominal compression and elevation of the head of the bed (non-pharma).

Question 29

What is Carotid sinus sensitivity?

Answer 29

Extrinsic sinus node disease that is characterized by pre-syncope or syncope. Treated using a pacemaker or use of volumetric expansion.

Question 30

What are the neurological causes of syncope?

Answer 30

Cerebrovascular disease, autonomic dysfunction and subclavian steal syndrome. Neurological deficits in stroke, vertebrobasilar transient ischemic stroke, migraine can present as syncope.

Question 31

How to differentiate between different causes of collapse?

Answer 31

Difficult due to the huge overlap in symptoms.
Important to take a careful history on the events that happened before, during and after the collapse and look for symptoms that be exclusive to syncope or seizure.

Question 32

What are the different fall risk factors for the elderly?

Answer 32

Intrinsic: Deterioration in health, impaired balance, clinical conditions, cognitive impairment, alcohol misuse, polypharmacy.
Extrinsic: Poor fitting footwear, uneven or slippery surfaces, poor lighting, trailing cables, cluttered environment, pets.
Behavioural: Getting up at night, rushing for toilet, overstretching and overreaching.

Question 33

What is the impact of falls on the elderly?

Answer 33

Distress and detrimental impact on confidence: often due to sustaining injuries from fall and fear of recurrence, less likely to leave the house, increasingly isolated, prematurely enter long-term care.

Question 34

How to plan for discharge?

Answer 34

On admission: prepare detailed and accurate patient record, review assessment information, estimate date of discharge
During admission: undertake regular multidisciplinary assessments and assess opportunity for discharge
48 hours prior to discharge: inform MDT, initiate referrals, contact agencies to order patient equipment, order take home medicines, arrange transport
Day of discharge: contact family and carers to confirm follow-up care arrangements, check the documentation, send letter to GP, reinforce patient behaviour recommendations
Follow-up: initiate care package in consultation with GP

Question 35

What are some of the possible reasons for readmission of the elderly?

Answer 35

Complications or infections directly linked to initial hospital stay, due to poorly managed transitions during discharge (poor instructions given), recurrence of chronic condition e.g. Asthma, COPD, diabetes, depression, myocardial infarction and heart failure (same diagnosis or closely related condition)

Question 36

What is appropriate poly-pharmacy?

Answer 36

All drugs are prescribed for the purpose of achieving specific therapeutic objectives, process is being made towards these objectives, risk of adverse drug reactions (ADRs) has been minimised, patient is able to take all the medications.

Question 37

What is inappropriate poly-pharmacy?

Answer 37

One or more drugs are prescribed that are not or no longer needed because there is no evidence-based indication, dose is unnecessarily high, failing to achieve therapeutic objectives, causing unacceptable ADRs, patient is unable to take the medications.

Question 38

What is the prescribing cascade?

Answer 38

When signs and symptoms (multiple and nonspecific) of an ADR is misinterpreted as a disease and a new treatment/drug therapy is further added to the earlier prescribed treatment to treat the new condition.

Question 39

What are the symptoms of polypharmacy?

Answer 39

Tiredness, diarrhoea, incontinence, loss of appetite, sleepiness, tremors, confusion, decreased alertness, lack of interest in usual activities, anxiety or excitability, constipation, visual or auditory hallucinations, falls, depression.

Question 40

Why is there a greater risk of ADRs in the elderly?

Answer 40

Metabolic changes and reduced drug clearance associated with ageing.

Question 41

What are the health impacts of polypharmacy?

Answer 41

Non-adherence: potential disease progression, treatment failure, hospitalisation, adverse drug events
Functional status: diminished ability to perform daily activities and decreased physical functioning
Cognitive impairment: 54% patients taking 10+ medications
Falls: Associated with increased morbidity and mortality in elders and precipitated by certain medications
Urinary incompetence and increased risk of lower urinary tract infection
Nutrition: 50% of those taking 10+ medications were malnourished or at risk of being malnourished. Particularly associated with reduced fibre, fat-soluble and B vitamins, minerals, increased glucose, cholesterol and sodium intake