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Falls Flashcards

1
Q

What is ‘hyperactive’ delirium?

A

Abnormally alert
Restless
Agitated
Possibly aggressive

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2
Q

Define hip fracture

A

Bony injury of the proximal femur typically occurring in the elderly

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3
Q

How can people with delirium be supported?

A 
Review medications
Pain free
Properly hydrated
Well nourished
Oxygenated
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4
Q

How much do hip fractures cost the NHS a year?

A

£1 billion

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5
Q

What % of people with hip fractures cannot live independently afterwards?

A

50%

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6
Q

How would you treat Garden II, undisplaced,intra-articular, intra-capsular fracture?

A

Dynamic hip screw

Cannulated hip screw

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7
Q

What surgery is recommended for minimally displaced intra-capsular fracture gardens I/II?

A

2-3 cannulated hip screws

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8
Q

What are the risks of fragility fractures?

A 
Age
Female
Low body mass/ Anorexia nervosa
Parental history 
Corticosteroid therapy
Cushing's
3+ units a day
Smoking
Ethnicity- caucasian higher risk
 OI/Acromegaly
Visual impairment 
Cognitive impairment
Sedative meds
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9
Q

What effects can be seen post-delirium?

A

Distressing memories
Rapid worsening of a person’s mental abilities
Later diagnosis of dementia
Higher risk of death

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10
Q

What % of them die within a year?

A

30%

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11
Q

What is sarcopenia?

A

Progressive and generalised loss of skeletal muscle and strength
Risk factors: age, gender, levels of physical activity

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12
Q

Why is vitamin D important in bone health?

A

Involved in calcium absorption

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13
Q

What is unique about the proximal femur?

A

Largest bone in the human body

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14
Q

What is the mechanostat theory?

A

Suggests that external forces influence the mass and architecture of the bone
Adapts strength to resist/cope with habitual loads

Regulatory mechanism in bone that senses changes in the mechanical demands placed on it and stimulates adjustment in its architecture

Below a certain threshold of mechanical use bone is reabsorbed

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15
Q

What does intra-capsular mean?

A

Above the inter-trochanteric line

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16
Q

What is teriparatide?

A

Recombinant fragment of parathyroid hormone

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17
Q

How can a fragility factor occur without a fall?

A

Coughing
Heavy lifting
Banging into things

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18
Q

Aside from clinical consequences what can a fall result in?

A

Loss of confidence
Become withdrawn
Loss of independence

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19
Q

What percentage of older people in hospital have dementia?

A

20%

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20
Q

What does PTH do?

A

Increases calcium reabsorption

Action of osteoclasts

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21
Q

What is ‘hypoactive’ delirium?

A

Causes patients to become withdrawn and sleepy

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22
Q

How might a hip fracture be caused in a younger person?

A

Trauma
Gait disturbance e.g. MS
Prolonger steroid use

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23
Q

What is type I?

A

Incomplete

Impacted in valgus

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24
Q

What role do stem cells in the bone marrow have in osteoporosis?

A

Stem cells become adipocytes rather than osteoblasts

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25
What should you observe on an X-ray?
Shenton's line should be continuous and smooth
26
What hormone level will rise in response to low calcium?
Parathyroid hormone
27
How many fractures does osteoporosis cause?
200,000 annually
28
What is type II?
Complete | Undisplaced
29
What are secondary causes of osteoporosis?
``` Rheumatoid arthritis Very sedentary lifestyle Hypogonadism Hyperparathyroidism Hyperthyroidism Post-transplantation Chronic kidney disease GI e.g. Crohn's, coeliac Premature menopause T1DM and T2DM Chronic liver disease COPD ```
30
What do you check for when a patient suffers delirium?
Infection Electrolyte abnormalities Metabolic abnormalities Intracerebral pathology
31
Why might an elderly person be vitamin D deficient?
Not going out as frequently Diet Poor kidney and liver function
32
What is the inter-trochanteric line?
Line that lies of the anterior surface of the femoral neck running between trochanters Demarcates the inferior attachments of the hip capsule
33
What can compression fractures cause?
``` Pain Morbidity associated with high analgesia doses Loss of height Difficulty breathing Loss of mobility GI symptoms Difficulty sleeping Symptoms of depression ```
34
Why might they die within a year?
``` Co-morbidities Infection Hospital acquired infections Heart failure Poor mobility- blood clots, bed sores ```
35
What factors might have contributed to Mrs Wilkins delirium?
``` Age Dehydration Change in environment Medications- change, new, not taking Painkillers Bladder and bowel problems Head trauma ```
36
Why are older people more susceptible to falls?
``` Balance problems Muscle weakness Poor vision Long term health conditions e.g. hearing disease Can lead to dizziness and a brief loss of conciousness Reduced bone mineral density Bones deficient in elastic reserve Medications e.g. beta blockers Low blood pressure (postural/orthostatic hypotension) ```
37
What makes you more susceptible to osteoporosis?
Smoking Excessive alcohol consumption Steroid medication Family history of hip fractures
38
What T-score represents osteoporosis?
Less than 2.5
39
What should you do if you fall?
Keep calm Don't get up too quickly Roll on your hands and knees Look for a stable piece of furniture e.g. chair or bed Hold with both hands Rest before carrying on with daily activities
40
What is osteoporosis characterised by?
Low bone mass Micro architectural disruption Skeletal fragility Decreased bone strength and increased risk of fracture
41
What are the effects of delirium?
``` Easily distracted More confused Changes in alertness Disorientation Rambling speech Disturbed patterns of sleep Prone to mood swings Hallucinations Abnormal/Paranoid beliefs ```
42
How do you divide care for patients with neck of femur fractures?
Pre op Op Post op
43
What is raloxifene?
Selective oestrogen receptor modulator Inhibits bone reabsorption Reduces vertebral fracture risk
44
How can hip fractures be classified?
intra- or extra- capsular
45
What post op components can be used?
``` Pain control Antibiotic prophylaxis FBC monitoring Routine examinations Cognitive function assessment Prevention and management of pressure sores Nutritional status monitoring Monitoring of renal/bowel/bladder function Wound care Early mobilisation ```
46
How can low BMD be treated?
Adequate vit D and calcium intake
47
What % of people with hip fractures die within in month?
10%
48
What are risk factors for fragility fractures?
``` Osteoporosis Advancing age Acromegaly Osteogenesis imperfecta Poor balance Poor muscle strength ```
49
Which type of dementia is delirium most similar to?
Lewy body
50
Why may HRT be used?
Option in younger perimenopausal women who also need treatment for symptoms of menopause
51
What are common sites for fragility fractures?
Vertebrae Proximal femur Distal radius
52
What is strontium ranelate?
Only used for severe osteoporosis | or patients for whom other treatments are not possible due to increased risk of myocardial infarction
53
Why are elderly females at particular risk for osteoporosis?
Low oestrogen levels after menopause
54
What should you know about your patients?
Medical co-morbidities How mobile there were before their fall Social history
55
What explains Mrs. Wilkins’ current mental state?
Acute confusional state- delirium
56
What is teriparatide?
Competitive inhibitor for PTH | Used to treat osteoporosis
57
What imaging can be done?
CXR pre-op Plain films MRI/CT if plain films are inconclusive Cardiac echo
58
What is a fragility fracture?
Result from mechanical forces (low energy) Equivalent to a fall from standing height or less Can happen without a fall
59
When might surgery not be an option?
Significant co-morbidities
60
In what % of people at risk can delirium be prevented?
30%
61
Rarely what conservative measures could be used?
Traction Bed rest Restricted mobilisation Outcomes are often very poor
62
Give examples of measures that can help prevent falls
``` Using non-slip mats in the bathroom Mopping up spills Ensuring good lighting Removing clutter Getting help moving or lifting heavy items ```
63
What should you supplement after a fragility fracture?
Calcium and cholecalciferol
64
What bedside investigations can be carried out?
Observations Urine dip ECG
65
How can the environment be adapted?
24 hour clock Hearing aids and glasses properly worn Avoid unnecessary noise t night Not moving person between wards
66
What might a GP recommend to reduce the risk of falls?
``` Sight test ECG Blood pressure check Request a home hazard assessment Doing exercises to improve strength and balance ```
67
What is the 1 year mortality for hip fractures?
40%
68
What is type III?
Complete | Partially displaced
69
What surgery is recommended for displaced intra-capsular fracture gardens III/IV?
THR Total hip replacement for fit patients Hemi-arthoplasty for patients with significant comorbidity
70
What does the type of fracture determine?
Likelihood of disruption to the blood supply fo the femoral head Intra = higher risk
71
What does prognosis depend upon?
Age Comorbidity Fracture site Personal circumstances
72
What is type IV?
Complete | Completely displaced
73
Who is involved in post-op management?
``` Orthopaedic surgeon Geriatric physician Nurses Occupational therapist Social workers Physiotherapists ```
74
What is a major risk factor for fragility fracture?
Reduced bone mineral density
75
What are the metaphyseal vessels?
After skeletal maturity the contribute blood to the femoral head
76
What can prolonged bed rest lead to?
``` Thromboembolism UTIs Pneumonia Pressure sores Loss of muscle ```
77
How many hip fractures are there a year in the UK?
65,000
78
How do patients with hip fractures typically present?
Inability to bear weight Pain in the affected side Reduced range of movement Bony tenderness
79
How can bisphosphantes be used to treat osteoprosis?
Helps replenish minerals within bone | Inhibit osteoclasts
80
What comprises the proximal femur?
``` Head Neck Greater trochanter Lesser trochanter Shaft ```
81
What is the mean age for hip fractures?
80
82
How would you treat intra-capsular, Garden IV, displaced fracture?
Hip replacement | Total- also replaces that acetabulum
83
What can a GP do to reduce the risk of falls?
Simple balance checks | Review of medication for side effects that may increase risk
84
What are the risk factors for hip fractures?
``` Increasing age Osteoporosis Low muscle mass Steroids Smoking Excess alcohol intake ```
85
What is the difference between dementia and delirium?
Delirium starts suddenly | Delirium symptoms will vary greatly during the day
86
What environmental factors make a fall more likely to happen?
``` Floors are wet e.g. bathroom or recently polished Dim lighting Not properly secured rugs or carpets Person is reaching for storage areas Wires Person is going down the stairs Person is rushing to go to the toilet Carrying out maintenance work on a ladder ```
87
What do NICE recommend?
Surgery to be performed on the day of or the day after admission Aim to allow patients to fully weight bear in the immediate post-op period
88
What makes someone more likely to have a fall?
Age due to natural ageing process | Long term health condition
89
What is hypoactive delirium often confused with?
Depression
90
What does extra-capsular mean?
Below the inter-trochanteric line
91
What does the hip capsule contain?
Reticular vessels
92
What scan do we use for diagnosis of osteoporosis?
DEXA Scan | T-score
93
What drugs can cause bleeding?
Warfarin | Low molecular weight heparin
94
How are acute injuries managed?
``` Chest X-ray ECG FBC Renal function Glucose Assessment of cognitive function ```
95
What does oestrogen do in bones?
Inhibits osteoclasts activity | Increases osteoblasts activity
96
Where can you refer a patient after they suffer a fragility fracture?
Falls clinic
97
What is key in ideal management of neck of femur fractures?
Early diagnosis | Early surgery within 36 hours of presentation
98
What is the relationship between osteoporosis and hip fractures to age and gender?
Risk increases with age in men and women | More so in women
99
How much do they cost the NHS?
£1.7 Billion
100
What proportion of adults over 65 living at home will have a fall at least once a year?
1 in 3
101
Why are older women more at risk of osteoporosis?
Often associated with hormonal changes during menopause
102
What is denosumab?
Monoclonal antibody that reduces osteoclast activity
103
What should you look for on an X-ray?
Intra/extra capsular | Displaced/undisplaced
104
How are hip fractures diagnosed?
Radiologically | May be suspected clinically
105
How are intra-capsular fractures sub-classified?
According to garden's classification | Type I-IV
106
What should you do if you are hurt and unable to get up?
``` Call out for help Bang on wall or floor Use aid call button Call 999 Try to reach something warm e.g. blanket/dressing gown to keep over you particularly legs and feet Keep as comfortable as possible ```
107
How can delirium be combated in a hospital setting?
``` Familiar objects Continuity of care Relatives Rehydration Mealtime buddies Red tray- signals they need help when eating ```
108
What is mixed delirium?
Alternating between hypo/hyper active delirium
109
What is shenton's line?
Imaginary curved line drawn along the inferior border of the superior ramus Along the inferomedial border of the proximal femur
110
What medication should you start after a fragility fracture?
Alandronic acid First line treatment of osteoporosis Oral
111
How can you categorise risks of falls?
Neurological e.g. confusion, cognitive impairment Unmodifiable e.g. age, female Environmental Chemical Cardiovascular Neuromuscular Other e.g. fear of falling, incontinence, fragility
112
What occurs in a falls clinic?
``` Rehabilitation Occupational therapy Physiotherapist MDT approach Medications review ```
113
How often should you change your position if you have fallen?
Every half and hour roughly
114
Why would you only do a hemi-arthroplasty?
Lesser operation | Less risk of post-op complications
115
How can delirium be diagnosed?
Clinical history Underlying health Current mental state Speaking to loved ones
116
How are most hip fractures treated?
Surgically
117
How many times more common are hip fractures in women?
4x
118
How would you treat a extra-capsular, displaced, intertrochanteric fracture?
Intra-medullary nail
119
What is sarcopenia correlated with?
Physical disability Falls Low BMD Poor quality of life
120
Why may falls in older people be particularly problematic?
Osteoporosis
121
What bloods should be done?
``` FBC U&E CRP Clotting Group & Save x2 ```
122
What is the foveal artery?
Supplies the epiphysis with a small amount of blood during skeletal development
123
What are the neuromuscular risk factors for falls?
Muscle weakness | Gait disorder: Parkinson’s, hemiplegia, cerebellar disease, antalgic, normal pressure hydrocephalus eat.c
124
What are the reticular vessels?
Main blood supply to the femoral head Originates from the extra-capsular arterial ring Supplied by the medial and lateral circumflex vessels
125
What can delirium result from?
``` Brains reaction to underlying medical problem: Chest infection UTI Severe illness Surgery Pain Dehydration Constipation Poor nutrition Change in medication ```
126
What surgery is recommended for extra-capsular fractures?
Dynamic hip screw: Promotes bone healing | Intramedullary nail
127
Who is at risk of delirium?
``` Dementia Over 65 Frailty Multiple co-morbidities Poor hearing/vision Multiple medications ```
128
Falls are the most common cause of injury related deaths in what population?
People over the age of 75
129
What is an osteoporotic fracture?
Fragility fracture caused by osteoporosis
130
Where the hip capsule attached?
Proximally to margins of acetabulum and transverse acetabular ligament Distally to the inter-trochanteric line Posteriorly to the bases of the trochanters and the femoral neck
131
What are contraindications for alendronic acid?
Acid reflux | GI issues

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