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Falls Flashcards

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1
Q

What makes someone more likely to have a fall?

A

Age due to natural ageing process

Long term health condition

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2
Q

What proportion of adults over 65 living at home will have a fall at least once a year?

A

1 in 3

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3
Q

Aside from clinical consequences what can a fall result in?

A

Loss of confidence
Become withdrawn
Loss of independence

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4
Q

What should you do if you fall?

A

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

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5
Q

What should you do if you are hurt and unable to get up?

A 
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
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6
Q

How often should you change your position if you have fallen?

A

Every half and hour roughly

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7
Q

Falls are the most common cause of injury related deaths in what population?

A

People over the age of 75

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8
Q

Why are older people more susceptible to falls?

A 
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)
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9
Q

What environmental factors make a fall more likely to happen?

A 
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
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10
Q

Why may falls in older people be particularly problematic?

A

Osteoporosis

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11
Q

What makes you more susceptible to osteoporosis?

A

Smoking
Excessive alcohol consumption
Steroid medication
Family history of hip fractures

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12
Q

Why are older women more at risk of osteoporosis?

A

Often associated with hormonal changes during menopause

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13
Q

Give examples of measures that can help prevent falls

A 
Using non-slip mats in the bathroom
Mopping up spills 
Ensuring good lighting 
Removing clutter 
Getting help moving or lifting heavy items
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14
Q

What can a GP do to reduce the risk of falls?

A

Simple balance checks

Review of medication for side effects that may increase risk

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15
Q

What might a GP recommend to reduce the risk of falls?

A 
Sight test
ECG 
Blood pressure check
Request a home hazard assessment 
Doing exercises to improve strength and balance
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16
Q

Define hip fracture

A

Bony injury of the proximal femur typically occurring in the elderly

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17
Q

How much do hip fractures cost the NHS a year?

A

£1 billion

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18
Q

What are the risk factors for hip fractures?

A 
Increasing age
Osteoporosis 
Low muscle mass
Steroids
Smoking
Excess alcohol intake
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19
Q

What is the mean age for hip fractures?

A

80

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20
Q

How many hip fractures are there a year in the UK?

A

65,000

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21
Q

How many times more common are hip fractures in women?

A

4x

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22
Q

What is the 1 year mortality for hip fractures?

A

40%

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23
Q

What comprises the proximal femur?

A 
Head
Neck
Greater trochanter
Lesser trochanter
Shaft
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24
Q

What is unique about the proximal femur?

A

Largest bone in the human body

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25
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
26
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
27
What does the hip capsule contain?
Reticular vessels
28
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
29
What is the foveal artery?
Supplies the epiphysis with a small amount of blood during skeletal development
30
What are the metaphyseal vessels?
After skeletal maturity the contribute blood to the femoral head
31
How can hip fractures be classified?
intra- or extra- capsular
32
What does intra-capsular mean?
Above the inter-trochanteric line
33
What does extra-capsular mean?
Below the inter-trochanteric line
34
What does the type of fracture determine?
Likelihood of disruption to the blood supply fo the femoral head Intra = higher risk
35
How are intra-capsular fractures sub-classified?
According to garden's classification | Type I-IV
36
What is type I?
Incomplete | Impacted in valgus
37
What is type II?
Complete | Undisplaced
38
What is type III?
Complete | Partially displaced
39
What is type IV?
Complete | Completely displaced
40
How might a hip fracture be caused in a younger person?
Trauma Gait disturbance e.g. MS Prolonger steroid use
41
How are hip fractures diagnosed?
Radiologically | May be suspected clinically
42
How do patients with hip fractures typically present?
Inability to bear weight Pain in the affected side Reduced range of movement Bony tenderness
43
What bedside investigations can be carried out?
Observations Urine dip ECG
44
What bloods should be done?
``` FBC U&E CRP Clotting Group & Save x2 ```
45
What imaging can be done?
CXR pre-op Plain films MRI/CT if plain films are inconclusive Cardiac echo
46
What should you observe on an X-ray?
Shenton's line should be continuous and smooth
47
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
48
How are most hip fractures treated?
Surgically
49
When might surgery not be an option?
Significant co-morbidities
50
Rarely what conservative measures could be used?
Traction Bed rest Restricted mobilisation Outcomes are often very poor
51
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
52
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
53
What surgery is recommended for minimally displaced intra-capsular fracture gardens I/II?
2-3 cannulated hip screws
54
What surgery is recommended for extra-capsular fractures?
Dynamic hip screw: Promotes bone healing | Intramedullary nail
55
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
56
What are the neuromuscular risk factors for falls?
Muscle weakness | Gait disorder: Parkinson’s, hemiplegia, cerebellar disease, antalgic, normal pressure hydrocephalus eat.c
57
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
58
What is a major risk factor for fragility fracture?
Reduced bone mineral density
59
How can a fragility factor occur without a fall?
Coughing Heavy lifting Banging into things
60
What scan do we use for diagnosis of osteoporosis?
DEXA Scan | T-score
61
What T-score represents osteoporosis?
Less than 2.5
62
What is osteoporosis characterised by?
Low bone mass Micro architectural disruption Skeletal fragility Decreased bone strength and increased risk of fracture
63
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
64
Why are elderly females at particular risk for osteoporosis?
Low oestrogen levels after menopause
65
What does oestrogen do in bones?
Inhibits osteoclasts activity | Increases osteoblasts activity
66
Why might an elderly person be vitamin D deficient?
Not going out as frequently Diet Poor kidney and liver function
67
Why is vitamin D important in bone health?
Involved in calcium absorption
68
What hormone level will rise in response to low calcium?
Parathyroid hormone
69
What does PTH do?
Increases calcium reabsorption | Action of osteoclasts
70
What role do stem cells in the bone marrow have in osteoporosis?
Stem cells become adipocytes rather than osteoblasts
71
What is the mechanostat theory?
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
72
What is sarcopenia?
Progressive and generalised loss of skeletal muscle and strength Risk factors: age, gender, levels of physical activity
73
What is sarcopenia correlated with?
Physical disability Falls Low BMD Poor quality of life
74
What % of people with hip fractures die within in month?
10%
75
What % of them die within a year?
30%
76
Why might they die within a year?
``` Co-morbidities Infection Hospital acquired infections Heart failure Poor mobility- blood clots, bed sores ```
77
How would you treat Garden II, undisplaced,intra-articular, intra-capsular fracture?
Dynamic hip screw | Cannulated hip screw
78
How would you treat a extra-capsular, displaced, intertrochanteric fracture?
Intra-medullary nail
79
How would you treat intra-capsular, Garden IV, displaced fracture?
Hip replacement | Total- also replaces that acetabulum
80
Why would you only do a hemi-arthroplasty?
Lesser operation | Less risk of post-op complications
81
What medication should you start after a fragility fracture?
Alandronic acid First line treatment of osteoporosis Oral
82
What should you supplement after a fragility fracture?
Calcium and cholecalciferol
83
Where can you refer a patient after they suffer a fragility fracture?
Falls clinic
84
What is teriparatide?
Competitive inhibitor for PTH | Used to treat osteoporosis
85
How can bisphosphantes be used to treat osteoprosis?
Helps replenish minerals within bone | Inhibit osteoclasts
86
What are contraindications for alendronic acid?
Acid reflux | GI issues
87
What occurs in a falls clinic?
``` Rehabilitation Occupational therapy Physiotherapist MDT approach Medications review ```
88
What explains Mrs. Wilkins’ current mental state?
Acute confusional state- delirium
89
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 ```
90
What do you check for when a patient suffers delirium?
Infection Electrolyte abnormalities Metabolic abnormalities Intracerebral pathology
91
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 ```
92
How do you divide care for patients with neck of femur fractures?
Pre op Op Post op
93
What should you know about your patients?
Medical co-morbidities How mobile there were before their fall Social history
94
What drugs can cause bleeding?
Warfarin | Low molecular weight heparin
95
What should you look for on an X-ray?
Intra/extra capsular | Displaced/undisplaced
96
What can prolonged bed rest lead to?
``` Thromboembolism UTIs Pneumonia Pressure sores Loss of muscle ```
97
Who is involved in post-op management?
``` Orthopaedic surgeon Geriatric physician Nurses Occupational therapist Social workers Physiotherapists ```
98
What is key in ideal management of neck of femur fractures?
Early diagnosis | Early surgery within 36 hours of presentation
99
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 ```
100
What is 'hypoactive' delirium?
Causes patients to become withdrawn and sleepy
101
What is hypoactive delirium often confused with?
Depression
102
What is 'hyperactive' delirium?
Abnormally alert Restless Agitated Possibly aggressive
103
What is mixed delirium?
Alternating between hypo/hyper active delirium
104
What is the difference between dementia and delirium?
Delirium starts suddenly | Delirium symptoms will vary greatly during the day
105
Which type of dementia is delirium most similar to?
Lewy body
106
What percentage of older people in hospital have dementia?
20%
107
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 ```
108
Who is at risk of delirium?
``` Dementia Over 65 Frailty Multiple co-morbidities Poor hearing/vision Multiple medications ```
109
In what % of people at risk can delirium be prevented?
30%
110
How can delirium be diagnosed?
Clinical history Underlying health Current mental state Speaking to loved ones
111
How can people with delirium be supported?
``` Review medications Pain free Properly hydrated Well nourished Oxygenated ```
112
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
113
What effects can be seen post-delirium?
Distressing memories Rapid worsening of a person's mental abilities Later diagnosis of dementia Higher risk of death
114
What is an osteoporotic fracture?
Fragility fracture caused by osteoporosis
115
What are risk factors for fragility fractures?
``` Osteoporosis Advancing age Acromegaly Osteogenesis imperfecta Poor balance Poor muscle strength ```
116
How many fractures does osteoporosis cause?
200,000 annually
117
How much do they cost the NHS?
£1.7 Billion
118
What are the risks of fragility fractures?
``` 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 ```
119
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 ```
120
What are common sites for fragility fractures?
Vertebrae Proximal femur Distal radius
121
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 ```
122
How are acute injuries managed?
``` Chest X-ray ECG FBC Renal function Glucose Assessment of cognitive function ```
123
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 ```
124
How can low BMD be treated?
Adequate vit D and calcium intake
125
What is denosumab?
Monoclonal antibody that reduces osteoclast activity
126
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
127
What is raloxifene?
Selective oestrogen receptor modulator Inhibits bone reabsorption Reduces vertebral fracture risk
128
What is teriparatide?
Recombinant fragment of parathyroid hormone
129
Why may HRT be used?
Option in younger perimenopausal women who also need treatment for symptoms of menopause
130
What does prognosis depend upon?
Age Comorbidity Fracture site Personal circumstances
131
What % of people with hip fractures cannot live independently afterwards?
50%

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