Delivering the NSF for Older People: the challenge to the hospital - eLearning Site of APLCGG

13. Problem list

14. She was entirely independent in everyday personal self-care and domestic activities until 18 months earlier. Just after her 81st birthday she fell on her way home from her weekly bingo session. She had felt well that day, it was a hot day and she even had a birthday drink of sweet wine with a friend, before waiting 15 minutes at the bus-stop. As she got up on the bus, she felt dizzy and fell, injuring her right hip. An inter-trochanteric hip fracture was found on X-Ray at the local A/E department. No evidence of other acute illness was found, although her BP was low for her at 118/75.

15. Problem list

16. Mrs May Tumble is an 82 year old widow, caucasian, retired seamstress, who lives alone in a rented 1st floor council flat. Her GP has been called to visit her after a fall. She has a history of hypertension, treated with bendroflumethazide 2.5 mg daily and amlodipine 5 mg daily. Her raised blood pressure was noted 15 years earlier when she had presented with a chest infection. At the time she successfully stopped smoking, as advised by her GP, and started taking a broncho-dilator inhaler, which was helpful, although recently she had not needed it. For several years she had noted difficulty with vision, which changes of reading glasses had not helped.

17. List the problems so far

18. She was entirely independent in everyday personal self-care and domestic activities until 18 months earlier. Just after her 81st birthday she fell on her way home from her weekly bingo session. She had felt well that day, it was a hot day and she even had a birthday drink of sweet wine with a friend, before waiting 15 minutes at the bus-stop. As she got up on the bus, she felt dizzy and fell, injuring her right hip. An inter-trochanteric hip fracture was found on X-Ray at the local A/E department. No evidence of other acute illness was found, although her BP was low for her at 118/75.

19. What caused the first fall 18 months ago ?

20. She was entirely independent in everyday personal self-care and domestic activities until 18 months earlier. Just after her 81st birthday she fell on her way home from her weekly bingo session. She had felt well that day, it was a hot day and she even had a birthday drink of sweet wine with a friend, before waiting 15 minutes at the bus-stop. As she got up on the bus, she felt dizzy and fell, injuring her right hip. An inter-trochanteric hip fracture was found on X-Ray at the local A/E department. No evidence of other acute illness was found, although her BP was low for her at 118/75.

21. What caused the first fall 18 months ago ?

22. She was entirely independent in everyday personal self-care and domestic activities until 18 months earlier. Just after her 81st birthday she fell on her way home from her weekly bingo session. She had felt well that day, it was a hot day and she even had a birthday drink of sweet wine with a friend, before waiting 15 minutes at the bus-stop. As she got up on the bus, she felt dizzy and fell, injuring her right hip. An inter-trochanteric hip fracture was found on X-Ray at the local A/E department. No evidence of other acute illness was found, although her BP was low for her at 118/75.

23. What caused the first fall 18 months ago ?

24. What type of fall ?-Try to diagnose the patient’s fall on this spectrum

25. Deciding what type of fall can be difficult because of

26. Slide 9

27. Pre-syncope

28. Orthostatic hypotension

29. Orthostatic hypotension

30. “Dizziness”

31. Types of dizziness

32. “Dizziness”

33. “Dizziness”

34. Orthostatic hypotension

35. Types of dizziness

36. Vertigo

37. Dysequilibrium

38. Other types of dizziness

39. Falls – myth-slaying

40. So what causes “dizziness” on neck rotation if it’s not VB insufficiency”

41. Falls – myth-slaying

42. So what causes “dizziness” on neck rotation if it’s not VB insufficiency”

43. So what causes “dizziness” on neck rotation if it’s not VB insufficiency”

44. What type of fall was the first one and what were the risk factors ?

45. Orthostatic hypotension

46. Orthostatic hypotension

47. Risk factors for the fracture

48. Slide 25

49. Risk factors for the fracture

50. Orthostatic hypotension

51. Risk factors for the fracture

52. After a dynamic hip screw was put in, she recovered well from the operation and was back on her feet within a few days, initially with a walking frame, later on a stick. After 12 days she went home. Unfortunately she had ongoing right hip discomfort and that made her reluctant to go out much, although she remained able to everything day to day indoors. The discomfort made her feel unsteady so she never stopped using the walking stick.

53. Slide 25

54. Risk factors for the fracture

55. Slide 25

56. After a dynamic hip screw was put in, she recovered well from the operation and was back on her feet within a few days, initially with a walking frame, later on a stick. After 12 days she went home. Unfortunately she had ongoing right hip discomfort and that made her reluctant to go out much, although she remained able to everything day to day indoors. The discomfort made her feel unsteady so she never stopped using the walking stick.

57. Orthostatic hypotension

58. Orthostatic hypotension

59. Orthostatic hypotension

60. Slide 25

61. Medication Review by her GP

62. Medication Review by her GP

63. Medication Review by her GP

64. Medication Review by her GP

65. Medication Review by her GP

66. Do hip protectors work?

67. On this occasion she had been well until a few days before her fall. She had suffered nocturia and frequency and urgency of micturition for 6 months, but for a few days she had dysuria as well. Hurrying to the toilet, she tripped and fell. Luckily there seemed to be no serious injury. Her GP diagnosed a urinary tract infection and treated this with antibiotics for 3 days, and also prescribed tolteridine (anti-cholinergic) to reduce urinary frequency. She stayed at home but was referred to the Falls clinic at the local day hospital and was seen there a few weeks later.

68. What was the cause of the second fall ?

69. What was the cause of the second fall ?

70. On this occasion she had been well until a few days before her fall. She had suffered nocturia and frequency and urgency of micturition for 6 months, but for a few days she had dysuria as well. Hurrying to the toilet, she tripped and fell. Luckily there seemed to be no serious injury. Her GP diagnosed a urinary tract infection and treated this with antibiotics for 3 days, and also prescribed tolteridine (anti-cholinergic) to reduce urinary frequency. She stayed at home but was referred to the Falls clinic at the local day hospital and was seen there a few weeks later.

71. Do hip protectors work?

72. Slide 32

73. On this occasion she had been well until a few days before her fall. She had suffered nocturia and frequency and urgency of micturition for 6 months, but for a few days she had dysuria as well. Hurrying to the toilet, she tripped and fell. Luckily there seemed to be no serious injury. Her GP diagnosed a urinary tract infection and treated this with antibiotics for 3 days, and also prescribed tolteridine (anti-cholinergic) to reduce urinary frequency. She stayed at home but was referred to the Falls clinic at the local day hospital and was seen there a few weeks later.

74. Slide 32

75. After a dynamic hip screw was put in, she recovered well from the operation and was back on her feet within a few days, initially with a walking frame, later on a stick. After 12 days she went home. Unfortunately she had ongoing right hip discomfort and that made her reluctant to go out much, although she remained able to everything day to day indoors. The discomfort made her feel unsteady so she never stopped using the walking stick.

76. Medication Review by her GP

77. Do hip protectors work?

78. On this occasion she had been well until a few days before her fall. She had suffered nocturia and frequency and urgency of micturition for 6 months, but for a few days she had dysuria as well. Hurrying to the toilet, she tripped and fell. Luckily there seemed to be no serious injury. Her GP diagnosed a urinary tract infection and treated this with antibiotics for 3 days, and also prescribed tolteridine (anti-cholinergic) to reduce urinary frequency. She stayed at home but was referred to the Falls clinic at the local day hospital and was seen there a few weeks later.

79. Medication Review by her GP

80. On this occasion she had been well until a few days before her fall. She had suffered nocturia and frequency and urgency of micturition for 6 months, but for a few days she had dysuria as well. Hurrying to the toilet, she tripped and fell. Luckily there seemed to be no serious injury. Her GP diagnosed a urinary tract infection and treated this with antibiotics for 3 days, and also prescribed tolteridine (anti-cholinergic) to reduce urinary frequency. She stayed at home but was referred to the Falls clinic at the local day hospital and was seen there a few weeks later.

81. What was the cause of the second fall ?

82. On this occasion she had been well until a few days before her fall. She had suffered nocturia and frequency and urgency of micturition for 6 months, but for a few days she had dysuria as well. Hurrying to the toilet, she tripped and fell. Luckily there seemed to be no serious injury. Her GP diagnosed a urinary tract infection and treated this with antibiotics for 3 days, and also prescribed tolteridine (anti-cholinergic) to reduce urinary frequency. She stayed at home but was referred to the Falls clinic at the local day hospital and was seen there a few weeks later.

83. What was the cause of the second fall ?

84. What was the cause of the second fall ?

85. What was the cause of the second fall ?

86. What was the cause of the second fall ?

87. What was the cause of the second fall ?

88. What was the cause of the second fall ?

89. What was the cause of the second fall ?

90. A longitudinal perspective

91. Pause for questions

92. Prediction of falls

93. A model to assess Falls Risk- falls in context

94. Clinical Evaluation

95. Aspects of evaluation 1- the risks for falling itself

96. Aspects of evaluation 1- the risks for falling itself

97. Aspects of evaluation 1- the risks for falling itself

98. Aspects of evaluation 1- the risks for falling itself

99. Aspects of evaluation 1- the risks for falling itself

100. Aspects of evaluation 1- the risks for falling itself

101. Aspects of evaluation 1- the risks for falling itself

102. Aspects of evaluation 1- the risks for falling itself

103. Aspects of evaluation 2- the consequences

104. Aspects of evaluation 1- the risks for falling itself

105. Aspects of evaluation 2- the consequences

106. Fear of falling:effects on falls and recovery

107. Relevant to gait and stability higher level gait disorder - slow walking, with small steps and some hesitancy , brisk reflexes, few other signs muscle bulk reduced unequal leg length

108. Relevant to gait and stability higher level gait disorder - slow walking, with small steps and some hesitancy , brisk reflexes, few other signs muscle bulk reduced unequal leg length Relevant to whether a fall does result from this instability Recurrent UTIs (associated with atrophic vaginitis) mild cognitive impairment, MMSE 21/30 medication

109. Relevant to gait and stability higher level gait disorder - slow walking, with small steps and some hesitancy , brisk reflexes, few other signs muscle bulk reduced unequal leg length Relevant to whether a fall does result from this instability Recurrent UTIs (associated with atrophic vaginitis) mild cognitive impairment, aMTS 7/10 medicationPossible contributing factorsorthostatic hypotension

110. Relevant to risk of injuryLoss of height and low BMI (osteoporosis)Low BMI –soft tissue injury

111. Relevant to risk of injuryLoss of height and low BMI (osteoporosis)Low BMI –soft tissue injuryRelevant to risk of functional decline and dependency fear of falling frailty incontinence reduced social network poor vision due to macular degeneration

112. Relevant to risk of injuryLoss of height and low BMI (osteoporosis)Low BMI –soft tissue injuryRelevant to risk of functional decline and dependency fear of falling frailty incontinence reduced social network poor vision due to macular degenerationMedication:bendroflumethazide, amlodipine, calcium +vitamin D

113. Pause for questions

114. Prevention and Treatment

115. Gait and stabilitymanagement of cerebrovascular disease ?exercise training for balance and strengthinsoles etc for leg lengthadequate regular simple analgesia

116. Gait and stabilitymanagement of cerebrovascular disease ?exercise training for balance and strengthinsoles etc for leg lengthadequate regular simple analgesiaPrecipitating factorsrecurrent UTIs

117. Gait and stabilitymanagement of cerebrovascular disease ?exercise training for balance and strengthinsoles etc for leg lengthadequate regular simple analgesia

118. Gait and stabilitymanagement of cerebrovascular disease ?exercise training for balance and strengthinsoles etc for leg lengthadequate regular simple analgesia

119. Gait and stabilitymanagement of cerebrovascular disease ?exercise training for balance and strengthinsoles etc for leg lengthadequate regular simple analgesiaPrecipitating factorsrecurrent UTIs

120. Recurrent Urinary Tract Infections

121. Gait and stabilitymanagement of cerebrovascular disease ?exercise training for balance and strengthinsoles etc for leg lengthadequate regular simple analgesiaPrecipitating factorsrecurrent UTIs

122. Recurrent Urinary Tract Infections

123. Recurrent Urinary Tract Infections

124. Recurrent Urinary Tract Infections

125. Recurrent Urinary Tract Infections

126. Recurrent Urinary Tract Infections

127. Recurrent Urinary Tract Infections

128. Clinical management for May Tumble

129. Clinical management for May Tumble

130. Clinical management for May Tumble

131. Clinical management for May Tumble

132. Thank you for your attention