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Flashcards in Falls Deck (30)
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1

Why do older people fall?

Why do older people fall?
In elderly people falls are usually caused by trips and slips
In frail elderly people 15% have acute illness and about 15% have a black out or faint, the rest have multiple factors that are contributing to the fall. Frail older people have much less capacity to adjust to intermetal or external changes and so an illness can overwhelm this resulting in falls, delirium, and immobility.

2

What systems should be assessed after a fall?

Assess cardiovascular, neurological, urinary, MSK, senses and social problems when assessing a falls patient.

3

How should you go about assessing someone who has had a fall?

Is this syncopal or non-syncopal
Is the patient confused or delirious?
How is their gait, balance and falls risk?
Vertigo and vision?
Neurological assessment
Cognition
Other factors – weight, environment etc.

CGA including a risk assessment examining the risk factors for falls, the Hx of falls, a drug review, ADL assessment and psychological effects.

4

What are the risk factors for a fall?

Age > 80
Polypharmacy
Frail
Alcohol
Female
Environmental hazards
Previous History of falls
Hypotension
Non-independent
Cognitive impairment
Visual/balance disorder
Peripheral neuropathy

5

What investigations should/can be done for someone who has had a fall?

Check for injuries
ECG
Lying/standing BP – interpret with caution, should only be done when euvolemic
Medication review - both hypotensive drugs and sedatives
Gait/functional assessment
Bone health review
Assessment for fear of falling/loss of confidence
Vision

Timed up and go test – Including 180-degree turn
Rise from chair without using arms, walk 3m, turn around, walk back, and sit down again
When assessing the turn – should not take more than 4 steps
When watching assess number of steps, gait speed and chair stand.

<10s normal
11s-20s normal for frail elderly or disabled
>20s intervention required or needing help

6

How can falls be prevented?

Exercise programmes – these both reduce the number of falls and the injuries sustained from falls if they do occur.
OT assessment and modification of house to prevent falls
Assess balance – Timed up and go test - >12 seconds = increased risk
Vitamin D supplementation

7

How is postural hypotension diagnosed?

Measure BP in the morning lying and standing. Should be done manually and at 1 and 3 minutes post standing up. Drop of more than 20/10 with symptoms is diagnostic or a drop below 90 systolic.

8

Are postural and positional hypotension the same thing?

Differentiate between postural (changing your posture e.g. lying to standing) and positional (changing head position) symptoms. Postural hypotension is very common in hospital due to being dehydrated, on drugs etc. so be wary of diagnosing it whilst ill.

9

What causes postural hypotension?

Acute – dehydration
Medication – heart rate controlling drugs or HTN drugs or diuretics
Autonomic dysfunction e.g. in diabetes and parkinson’s

10

What pharmacological management can be offered for postural hypotension

Fludrocortisone – increase blood pressure by returning fluid
Fluid retention and weight gain are the common side effects – contraindicated in HF
Also watch out for hyponatraemia and hypokalaemia

Midodrine – peripheral arterial vasoconstrictor (caution in those with IHD or peripheral artery disease) Takes an hour to work and don’t lie down within 6 hours – trial for 2 weeks the review.

11

Describe the 4 different groups of falls?

1. Group 1 – mainly locomotor, low grade balance problems, fear of falling. Very limited need for medical investigation
2. Group 2 – syncope and postural hypotension
3. Group 3 – neurological conditions including, PD, cerebrovascular, MSA, PSP, isolated gat apraxia, NPH and chronic subdural
4. Group 4 – dementia with high risk of falls

12

Why is it important to rehabilitate patients after a fall?

Stop the negative cycle of increased fear of falling – inactivity – muscle weakness – increased risk of falling – falls – increased fear of falling

13

What general management can be given following a fall?

Home assessment and alterations
Exercises – Tai-chi
Group classes involving exercise, break fear of falling cycle
Diagnose and manage underlying conditions
Medications review – beta blockers, diabetic meds, antihypertensives, benzodiazepines, antidepressants, antibiotics (implying infection) and herbal medication

14

What are the risk factors for a fracture following a fall?

Female
Post-menopausal
CKD
Steroids
Smoking
Age
Cancers
Poor diet or malabsorption e.g. coeliac disease
Aromatase inhibitors and anti-epileptic drugs

15

What is a fragility fracture?

Fragility fracture are fracture that occur upon low impact, where a healthy bone should not have broken. Fracture risks are encompassed by the risk of falling, the force of the falls and the bone density.

16

What is FRAX?

Estimate 10-year risk of fragility fracture – look at age, gender weight etc. and can be used for patient aged 40-90yrs. BMD test is optional but greatly increases accuracy.

Low risk - reassure and lifestyle advice
Intermediate risk - DEXA scan
High risk - Bone protection treatment

>10% = high risk, around this is intermediate. Scan based on guidelines and clinical judgement

If done alongside a DEXA scan then results will automatically be characterised as reassure, consider treatment and strongly recommend treatment.

17

What is Qfracture?

Risk assessment tool that also estimates 10-year risk of fragility fracture, based on UK patients and can be used for afults aged 30-99.
Take into account wider variety of risk factors than FRAX

18

What is a DEXA scan and how are the results interpreted?

DEXA scan (BMD test)
Look at hip and lumbar spine for mineral density

T score - in relation to young fit adults of same gender who have peak bone mineral density. Normal >-1
Z score - in relation to others of same age, gender and weight

Osteopenia = T score of -1 to -2.5
Osteoporosis = T score of < -2.5

19

How is osteoporosis managed?

General advice
Reduce alcohol
Calcium/vit D supplementation if deficiencies
Assess dietary intake of calcium and adjust diet appropriately
Stop smoking
Exercise (must be load bearing)

Bone Protection Treatment
Alendronic acid (alendronate) – take in morning, 30 mins before food, sitting upright with 240ml of water. Alternatives include risedronate or etidronate.
SE Upper GI issues: oesophagitis, swallowing problems and gastric ulcers
Zoledronic acid (zoledronate) – annual injection (alternative to allendronic acid)

Denosumab – prevents development of osteoclasts by inhibiting RANKL
SE – Dyspnoea and diarrhoea, hypocalcaemia and URTI

20

What are the 4 types/causes of syncope

• Neurally mediated – inappropriate autonomic response to a trigger e.g. vasovagal, situational e.g. post micturition and carotid sinus hypersensitivity e.g. when moving head
• Postural – syncope dependant on standing up – occurs due to insufficient baroreceptor response e.g. secondary to drugs, hypovolaemic, primary autonomic failure e.g. PD and secondary autonomic failure e.g. diabetes, uraemia an spinal cord lesions
• Structural – mechanical obstruction to the LV inflow or outflow meaning stroke volume cannot compensate during exercise e.g. aortic stenosis, PE and aortic dissection
• Arrhythmias – brady and occasionally tachycardias

21

What is frailty?

A state of increased vulnerability to stressors due to age-related declines in physiologic reserve across neuromuscular, metabolic, and immune systems. Frailty is not age, disability or having multiple long-term conditions. Frailty is a clinical syndrome whereby the person gradually loses the ability to maintain their homeostasis.

22

How can we assess for frailty?

• PRISMA 7 Questionnaire. A seven-item questionnaire to identify disability that has been used in earlier frailty studies and is also suitable for postal completion. A score of > 3 is considered to identify frailty.
• Electronic frailty index
• Timed up and go test (TUGT). The TUGT measures, in seconds, the time taken to stand up from a standard chair, walk a distance of 3 metres, turn, walk back to the chair and sit down.
• The Groningen Frailty Indicator questionnaire. A 15-item frailty questionnaire that is suitable for postal completion. A score of > 4 indicates the possible presence of moderate-severe frailty.

23

Describe the rockwood clinical frailty score?

Rockwood Clinical Frailty Score
1. Very fit
2. Well – no active disease symptoms but less active than previous category
3. Managing well – well controlled medical problems but not active
4. Vulnerable – not dependant but symptoms limit activities
5. Mildly frail – evident slowing and need help with higher order ADLs
6. Moderately frail – need help with all outside activities and most ADL’s
7. Severely frail – completely dependant for personal care but not at high risk of dying
8. Very severely frail – completely dependant and approaching end of life
9. Terminally ill – life expectancy < 6 months

24

What is the barthel index?

The ten variables addressed in the Barthel scale are
1. Presence or absence of faecal incontinence
2. Presence or absence of urinary incontinence
3. Help needed with grooming
4. Help needed with toilet use
5. Help needed with feeding
6. Help needed with transfers (e.g. from chair to bed)
7. Help needed with walking
8. Help needed with dressing
9. Help needed with climbing stairs
10. Help needed with bathing

Gives a score from 0-100 with a higher number being better

25

What is the Nottingham extended ADL score

Nottingham extended ADL score
22-part questionnaire filled in by the patient rating each question based on how that ADL is has been managed or if it has been done at all i.e. ADL not done, done with help, done on your own with difficulty or done on your own.

26

Why does osteoporosis occur and will Alk Phos and calcium levels be normal?

Excessive bone resorption resulting in demineralised bone. Alkaline phosphatase will be normal as will calcium levels.

27

Who should be assessed for osteoporosis?

All women > 65 and all men > 75 should be assess for osteoporosis
Younger patients should only be assessed in the presence of risk factors
• Current or frequent use of oral steroids
• History of hip fracture
• Other causes of osteoporosis
• Low BMI
• Smoking
• Alcohol intake > 14 units per week

Fragility Fractures
• All patients > 75 years of age who have had a fragility fracture are presumed to have underlying osteoporosis. They should be started on first line therapy without the need for a DEXA scan.
• All patients < 75 years of age who have had a fragility fracture should have a DEXA scan and assessed via FRAX

28

What are the indications for a DEXA scan?

Indications for DEXA scan
• As a result of FRAX score or to improve accuracy of FRAX score
• Before starting treatments that may rapidly effect bone density e.g. sex hormone deprivation in breast or prostate cancer
• Those < 40yrs with major risk factors for osteoporosis

29

When should patients be reassessed for osteoporosis following initial assessment?

Patients should be reassessed for their fracture risk if the original calculation was intermediate or only in the consider section and only after a minimum of 2 years of when there has been a change in person’s risk factors.

30

How should the risk of osteoporosis and fragility fractures be managed in patients on at risk of corticosteroid induced osteoporosis?

If patient likely to be on glucocorticoids for >3 months, then start bone protection now

If on glucocorticoids and > 65yrs then start bone protection

If on glucocorticoids and < 65 then organise a DEXA scan but cut off parameters are lower: 0 to -1.5 = repeat in 1-3 years,