Falls Assessment in the ED - Kinnear
Summary
This on-demand teaching session is perfect for medical professionals who have to care for patients who have fallen. Attendees will get the chance to learn about the major trauma aspects of falls in the elderly, what to look out for when taking a patient's history, and how to diagnose and manage fallen patients. Also, practical guidance and considerations to improve symptomatic management, such as checking in on with elderly relatives, will be covered. Attendees will be guided step-by-step through the process of identifying, assessing and managing fallen elder patients.
Learning objectives
Learning Objectives:
- Explain the definition of a fall in a medical audience.
- Describe the most common causes of falls in geriatric patients.
- Construct an effective patient history to identify risk factors associated with falls.
- Identify early warning signs of falls and the role of medical intervention.
- Analyze the risks and complications of a lengthy fall and their relation to age and cognitive impairment.
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Computer generated transcript
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
Okay, guys. So and I'm gonna run three brief talk on falls, and then we just get this back. Correct, right? Sorry. From quite well with, like, a little please all day. And I am struggling, so just bear with me two seconds. Okay, so it was a bit falls? No. So I think and downs coming. Really well, just terms of the major trauma spect of things. Um, how is that someone with me to trauma on? Just how in that main say, Oh, actually, some of these patients, um, are elderly by the phone will have major trauma by a fairly will be normal because they're minor. Maximize, um, of injury and fast. Majority of what we see will be awful from standing. Okay, so and and about third off, people over the age of 65 on over half of the ovary disease, and we'll have a fall on Denny. One year was really essentially what we're able, Teo, manage these patients and you'll know that we see you patient to fall all the time. Then there's a nice guidance on involves basically finds a full of unintentional are unexpected loss of bones resulting in coming to rest in the floor, the ground or not take blue knee level. And so I say, what they would include in that is a full from A from a chair, for example, because he end up balloony level on the patient's here. Most risk of falls tend to be those without advancing Age of filthy with ability of thing. Coronary disease are just women are today on. But now they even have a minor fall. I could have, like significant trauma on patient. Okay, So the first thing and really to say, is that quite often calling these mechanical falls. Um, I think it's really important that we have our home. That's probably not really anything besides thing Is that as a mechanical fall. Okay, um, that tends to be some pathology underlying a fall. And even if it's not overly apparent, um, at first look. And on the three kind of mean in areas that we see that cause falls are the so loss of consciousness. Um, I changed the belly, the violence or changing safety at home. Okay. And these are all face right main areas that we can kind of focus our attentions on. We need to satisfy ourselves before we send someone home that these three areas have been done with. Okay on. So anything about consciousness you think about it was a syncope on D syncope. Could be able days worth of talks in his room. Right? And we have a brief, so I don't know later on in the Stoke, and it could be a problem with it in terms of the ability to violence. One really think of vertigo and type and conditions. But probably it extends into your t a n or central causes of dizziness or change the balance and in terms of safety Oh, you know, we need to really think Is this a Is this a patient who is out there baseline? Where is there something recently that's changed on in terms of their functional ability that has made them become on safe home? And really, what I mean, is there becoming more for you? And that's probably more reflective of most of the patients that we see. They are all on the trajectory. That tends to be doing words. Okay, Really want to do is train toe? Um, intervene? The not reject? Very. I'm trying to either slow during the decline or try to make it plateau wolf. So in the street, Guidance says, Ah, long life is anything longer than our which I actually isn't that long. I think we think about a long life has been something over 12 hours. Um, clearly, we worry about oats. Um, Alli. That's 12 hours more than we were ever on alli. That's just on our but and technically speaking, if you've lane for longer than are on the floor, then that creates is a long I. And, um, when you think about it, most patients a problem. The floor for an R if they live in their own and where is the left? With an elderly relative, she isn't able to lift them up. Then, by the time they call for help or call for an ambulance from the time that help her eyes on it works like hard. They're gonna get them off the floor. You know, most of our current pregnancy reaching that and got one arm. So in terms of the ocean alone lies a pretty small, increased risk off, and various things on dehydrations prevail. There a top, um, just because by default they can't reach fluids or food so they become dehydrated and pressure short. Obviously, if they're not able to chef in the lining of hard flow, where that rescues and also manually ask you because of peeing that then I hyperventilating part of lung or on dying in their side, for example, you can move or they're drafty possession. Or there's something else in the background. What's driving on the high before person increased rescue anymore, Man the thirties of the one again. We'll see patients that have been able to, you know, fall on the floor in the bathroom but then able to call you. They're going off the bad to cover them. And then I'm laying all night. And that's what we're probably still 1.5 of the neck about stage on By even worse, the patients who have full like to buy garden in the dead of winter. She are very obviously very hypothermia on there. I've on dialysis is one. I just think it's really worth driving home because I think we all know about that. We don't know to check the CK and these patients who have had a long like I and but just remember that. And that's older, free or population they have. Ah, they will have. Ah, a smaller muscle marks on. But they won't know the c M C K a rise in the blood tests. That's what someone with a big muscle mass mate. But they will still get the CM and and sold their kidneys. So really important that we take the history of the fold were no reassured by normal sck. If the stories have definitely been on the floor for 36 hours, those patients that we should be a matter for fluids and and probably a comprehensive graphic assessment, as we discussed earlier. And that doesn't even take integrate and the injuries that might have happened, you consequence off the fall on What about the head injuries? Lemon Drees or fractures? Okay, so in terms of your full has straight as everything, I guess this is when we come back to time again with medicine. Is not that and so important that we really get going into the night Great details off the fall on in this particular drip of individuals. So the other day for your population may or may not have some cognitive impairment you're collateral. History is off almost importance so important that we, um, get get clots in history and get it early. Okay? And I always think it's really important, for example, and the patients who come from a nursing home or ah did intial and the cares that were with the patient when they fall are working chefs. So if the patient lives on T also six PM, the character wetness out for will be going home at seven. Probably so don't we have until nine pm to think? Well, actually, I could get a class A list right here for one earlier and get make sure you speak to somebody who, actually what must have fall. So in terms of rash itself, we want Teo again be really productive or you get it into the next great detail on dot thank you about as before drinking after So in terms of before what happened before the fall and when did that happen? What were the warning signs if there were any that the patient feeling well, how is the patient being the last couple of days? Has there been a breathing chest? Infection has there being cellulitis as they're being the input from GPU were other healthcare professionals. Um um, West That really we're gonna be thinking about is the stomach and inquiry aren't waist with medical through all of our systems. Uh, ask about those percent signs and symptoms from a system that might be important for us. And, um, again, before we're gonna be thinking about wetness is. So where was I? Did that happen? Was upstairs Downstairs was the day room in the nursing home? Was that in their bedroom? And where well, was there a wetness there? He actually saw what happened. Because the patient my no remember feeling dizzy or lightheaded. But the wetness might be able to tell you that They actually said, being where does their lightheaded before the files really important to get a doctor actually history and then during you're going to think about it. And what exactly were they doing when it happen? So I just stood up for with a walking or with the turning what was going on? And where was the failed and the default Gonna fight stairs and if so, was a concrete or with them stairs are in steps. And what kind of flaring was It was that carpet floor, uh, rug was a wooden floor, were And where there. Any obstacles? So today, on the way down, I end of the cracker had off sideboard or and it was written for something else different over something and that the actual use consciousness didn't remember the fall. And was there any evidence of seizure that time did the news consciousness and was our affect that they have incontinence or and bite their tongue and importance? Well, even even those patients we are, and you might have some mild called, um apparent ask what did they think happened? That's quite common that you'll see these older folks on. They'll tell you Oh, I must have tripped on the rug. Not sort of really careful thing just to pick up in your history. If you're really listening to the patient that patients, I said just and coming take, including other what happened? They don't really remember what happened, but they're saying I must have fallen a rug because why else would have fallen? And so that's something just to try and pick up when you're listening to the history from the patient and it's very easy for us to say over on the trip on the rug thought is that actually what happened to us? Just what they're so amazing Happen. And and again, you just think we went. This is during during the event. And then afterwards you want to know again, touch What was it before? How y'all went on the floor for, um, didn't have any injuries or this or never asked the patient. I have to go on injuries on Have they gotten you on? But you know, once it a weakness, for example, are they confused on on day? Finally probably didn't need to help get to get up after the fall. Or were they able to get in cells off the floor on def didn't help to get up? And is there a change in their functional abilities? So before the fall, they might have been even the toilet and sells books. Can you do that now? You, for example, so important just what we're looking these patients that we see that they are a pot work off and different patient factors, okay, and really important that we try and step step by, can see the whole picture of the patient on give a holistic approach and in terms of risk factors for folds there, there are many. So over say increasing age is an independent risk factor for falls. And as as increasing frailty okay and you have talked to anybody would have really scores will come back to that in a second and other s factors for falls our cognitive or basal impairments. Just mobility and pull the pharmacy on specific medications such on psychoactive drugs like benzodiazepine ones on got on the hypertensive, super pressure medications or diabetic medications. And I have never been changed. And you're worried about drugs and but and blood sugars and under the objects are also independent, arrested for falls because they obviously and we hope that they indicate that there's actually recent infection. And I'm not quite other things there on that list, our environmental hazards. So living in a host that's safe on but has not been made, say, for something more freedom off the process I'll call exacerbate. That's important for us to pick. Okay, because well off our elderly population will drink alcohol on. They won't see that they have a problem. Well, actually, um, yeah. Um, probably won't ask them how much you're drinking. They probably are drinking to excess on this may again be the opportunity for us to t get and I'll speak to you about drinking. Ask them if they want to reduce it drinking. Ah, while they're in the evening, make sure that we get, um a Gmail score gets proper next and depression and the unreasonable the to you kind of restaurant for further falls. Okay, so what I mean was to burn so and the clinical frailty score or the Rockwood score we've covered already. And Justin's talk this morning on that. Now we talk, and I think it's just important hovering over because actually really helpful way for us. Teo. Think it by high free or someone adds, okay. And these are really the little either online or from there and and the doctor's office. We have copies of that okay. And well, really helpful way for us to actually document what we think differently. Score is I'm not gonna help us. That that makes it gently a role in there and their patient journey. And so this is Ah, slight. I phoned on my just about some of the top tips for how to use the free T score on the thing is perfectly helping for us and 80. And so the first things that I shouldn't scored about their baseline. So you might be seeing someone who's basically that brand of the moment because they've got, like, a femur fracture. But what we want to Tedo in as what is there? Be a slain Rockwood. So when they were well, too, because ago, what were what were they able to do? You not want to score them and what they can do right now, I when they're in the department and number three, there is technical. Perhaps stress will bring home a lot whom I keep getting. You know, this is all about your comprehensive history details history on. But ah, along with that number three years has trust, but verifying. So don't just take what that patient tells you and that feels value. But actually get that collateral astri on. Make sure that you get the right information so the patient may say, Oh, yes, Doctor, I can do X y and z ahead, and I cook for myself. But when you speak to the family, they say, Well, he probably could cook for himself, but he actually doesn't because the daughter Mexico's meetings or on the Sun on Drops and Ready means so that collateral history is really key. And it's only if you're over 65. So again, without a few instances where we've had a patient referred to the frailty team. But they're not over 65 on. The Rockets don't want to be used in number 60 fives, and the A score nine really is for terminally ill. Um, okay, so that's one of the what is the only really and contrary that will trump what their baseline ST is because they are terminally ill. So therefore, they are nine. Okay, that means they're actively dying. And number six is where guesses about, like your status score us a grading score. Assume just because you have medical issues. That doesn't mean you're 53. This is all about functional, validates all of a high active independent you are. How much of your HDL's you can actually do yourself and number seven on their basically says in Don't forget those ball normal people. So that's that's the country, for she kind of in the middle on. They might not be the ones that are shaped, never high e things get bad on, but they're not very obviously for your bones, But they're the ones is Emily seven her talk that we can actually season opportunity, Teo, get get in there and try and improve their abilities stable. Okay, so those is in the middle arise the ones that we can target any d Can we make some interventions and not not just a day, but with the help of friendly thing to keep the outpatient home and improve their quality of life at home as well. Because again, this is a body. Keep people home safely and keep keep people home so they can enjoy the last years of their eyes and dementia. You know, dementia patients can be can be scored in the rock, which is one of the big advantages. And, um, hum So again, don't don't don't be afraid to kind of get, like, the natural history and work out what the road we would be. And, um, as we keep saying as you get really drilled into those changes function, they can be quite so always Well, so you know If we say, can you make your dinner? And could you make it under two weeks ago? They might say yes. But what they're actually making today could be very different. We're making two weeks ago. So what I mean is too big thing with the, um make enough till Sunday was dinner for their whole family. But today they're making this other running, not as changing functions. Who and it's really important that we don't just take off his value in the first thing that patients asked us. Okay, so and the creams talk has covered and delirium on before 80 is really important for us to be screening and the, uh, for delirium, which is going to cover that again for a refill. A. So it's four a. Z, which school before 80. So they're alerting us their abbreviate a mental test, which is a test of their cognitive function. Um, attention on deck, it change or fortune course on, but we should be screening all patients with age of 65 formulary in when they come in to the 80. Okay, so we'll move on really? To you these patients, how how do we How do we actually assess things we've covered can be better. The bike riding, working out what happened with the full taking on history. Get the collateral Astri thinking about there being line function on the rope. Good score on screening for delirium on. I would be willing then. Teo, what happens next? Within Expect really? Is the examination okay? So they need a Hatfill head to toe examination, which I think in the cool mentioned earlier, which is really important. And these patients might not tell you what injuries have got, so they knew it made almost that a t l a second resurvey where we're drilling, dying into their head and examination. I'm looking for tiny injuries. Okay, We're looking for two things we're looking for. First of all, kind of science is just causing the full. So have you got, uh, raging still like murmur that might tell us they go up your aortic stenosis number here. Your excuse is is on telling us that that's for this patient has affected Cartago. Put. They didn't have the ability to increase their car to go put the drop in place. Um, and you know, if they're on well or they have bleeding and it changes. How different? Neurologist for a spoon For that. So and there are things in the examination that will guide you, Teo, make you understand what's happened. Patient better. And then Secondly, you're looking for those injuries that the sustained during the fall. Well, as I can discussed west down, you know, we're thinking about neck injuries and have injuries. And one of the first things I'll do when I went to see a patient had a fall is Just have a look right there, hand and see if there's any over. It's external signs of having surgery on top of you for another neck and see if if, after tender there and I'm going to clear the night clinically by moving it Uh huh. Even as I can take my street from the Tokuno. Okay, so and next. Then we're gonna think about investigations. What investigations do need to do? Um um, see these patients through? Well, there's lots of nerve, but these are probably for really beats like things that are absolutely essential. And any one of these with a 65 you come in the fall, you need to be a spinal needle back trigger. It is necessary on the needs, some measurement of their cognitive function. And so those are the four absolute essentials. The others were kind of mentioned that probably would be done fairly routinely. Need these with things like Bloods tank with a C, K and chest X shape pelvis. I tree ct, Brean or neck or other areas Another X rays as appropriate. And again, one of those pearls of them, probably from the DEA, is another patient comes with a with a sore knee. Um, you know, if the knee looks okay and really Coleman for older patients to get referred pain from a like a femur fracture, so and do not missing like a femur fracture because you think you go on the injury on the actual That's okay. And I was gonna talk Teo screen a little older football have a fall with the pelvic actually needy. So if they have a full becoming non truly and you're sending to French test, actually another, actually, just after their problems, when they're going because you will find patients. You have you been in this fracturing, for example on they're not telling you to help me, and because having mobilized in yet I don't know they're sore. So and on instant syncope earlier is kind of one of the things that we need to think about in terms of a loss of consciousness and was the same before or syncope. It was a massive topic, and and this slide really is there to show me that there's kind listen, and dynasties that could be underlying someone who comes with Clubs episode. And that's really important that we cannot keep that in mind aside, the patient may not come with the Classic is a vagal type. History doesn't mean it's not syncope and need to keep in mind on Don't mess with these things. So in terms of mine's but then and I think that there's a few times a day is algesia talked there. Okay, so as we all know, some of these patients are super stoic there in your sort of north on from a stoic tapes that will just happily set from not a pain relief. And but it's so important for us technologies, um, correctly and not least because after we get our X rays and we can't see anything, the next thing you did think about doing this. It's mobilizing them. Um, do you want to have some pain relief on board before you mobilize them after a fall to get an early on decreasing to take it? Obviously, you can first, um, but if they're declining it, you know, actually, no, they're not burning burning us. But I'm not causing arsenal that, you know, we can get in some people. It really easily make me know that we're comfortable. And Nicole touch them again. And her talk earlier. I just, you know, 80% of older foot being and suffering from chronic pee and the only 20% taking regular allergies es really important that we think about it easier. I guess we mentioned you know, the long liars. You want to get some fluid into them. Um, And then obviously think about the Botox. If you think there's infection, that's driving. Driving your rhythm on the agenda. Very ready mentioned. So I was with an A for presentation. The, uh we need to plan on hand. So from the movement now, patient arrives. And 80 we should be thinking, Where is this patient had it? What is the disposition gonna be? What does it look like to get them home or to get them on to the next and special thing? And really, what? Why? That's the case, because we need to make the system or affection for them. We need to get in through the system. It's quickly as we can. So we get into the rate Prius. A script was We come and those drooping a minute. You know, it's really important when you're getting that classroom history. Does he speak to the carriage about what their perception is again? We have quite a few complaints, really. Since school is a lot of left from Ralix of sanity, you know there's just no communication or per communication from the staff and that they weren't really updated in terms of and what was happening or what's gonna happen. And so why you get not possible? History actually ask, cares what their take on on the patient is. Care. Fatigue on stress is really, really high on distance and somebody's carriage Are you basically doing twice for carrying? They will get that crisis point. When that happens, we have to recognize that, so if that cares, that crisis is no really acceptable to send the patient back until that scene of Are they changing anything? And so ask the cares, uh, early doors soon as around and see the patient, if one the next coming for a lot of history. And that's to get that and see, you know, our Medicare is managing with the current setup, the term care package and because of this age in the war, I'm completely upright. Comporting can't have my number than that kind of make sure decision making process more straightforward because we know we need to do something else. We can send the moment. And so I always I had mentioned, you know, thinking about E I e t I d a. You wouldn't have the 80 of the moment. But we are open to fail a good fight and try and get back. And but we still do. You have. You know, he's in facilities and switch workers that we could contact in our little Friday who may have capacity to come down troubles over some patients, and I'm really what we're trying to think of there is, first of all, can we go home with a camera package? Well, it's an extra support at home didn't need to go to that step going bad on which this was working well, right through the complex, distorted coordinators. Or are they good enough to stay at home with the current setup on Come Back to D. A. You for a comprehensive geriatric assessment? Or actually to adjusting to come in the whole spool until they get bad and a good example of that. The patient comes from, ah, residential home patient calling in the hole. And I was not coping with fan because they need nursing one place and you're probably gonna get out from the the So they probably need to be, um, evident. Oh, patients who come from nursing homes and generally won't get physical assessment because the nurse 100 private and the funding in comes through the private through the through the nursing homes. And, um, the one thing I haven't mentioned is the medication review. So again, jeans and his team market for us, and if they look pass, it'll come down and do your medication review for some of these patients on both for the prescribing, pharmacist will be happy to recommend stopping or changing some medications for us just again to make the starters more safe. Okay, so I really just want to finish Just talked with about falls, prevents and stuff because and a Z for all of us. Um, after a full, um, about two thirds of patients will fall again within the year. Okay, that's important. Again. The high that one of our questions that we should be asking is how many falls have you had in the last six ones? We lost year, cause that gives your really period in the care of high well or bottle or no. Well, this patient is my lodging. Um, hum. With each full 60% off, patients will be injured, a quarter of which need another invention. So that's patients who break their hip. For example, I'm really what we're trying to pull. Falls prevention is trying to prevent that fall, which causes neck a femur, which causes them to get the million, which causes it today. Okay, Sorry. Be a problem. Uh, slide. Yeah. Right. So if I come across this online, which is from a chest over Hampton on trust, they basically with this new stumbles and one, I think it's great. Helpful. That's a way for us to help and assess pills. Rescue essentially. So I'll just write through the headline ones, which are What's BS thing was normal for the individual. It's covered. Did they have osteoporosis? So again? Not for us to be nice and osteoporosis, but perhaps suggesting the GP that we think you do that extra anything recessional Councilman in the bones on my X ray. But I should just connecting those dots up and saying to the GP on the ladder, please consider on so most of product and medications if you think it's appropriate. And she just left wrist to make sure patients have on do have a face that we need to have closed on suppers and with boxing that's really important on the only real discharged cried here. That we need to fill felt from the D is that they control it themselves is totally on example the center patient, whom from the and if we know they can't hold it themselves because that's sense of bathroom hose know they can't get the flu. So and we should be trying to make me should be satisfying ourselves that they are have a good enough mobility to get themselves on toward that arm to get themselves off the toilet and anyone who's up more than three times overnight to be fair to the constant service on Because again, that's another pen risk factor for falls if you're up through the night and what to the toilet And we had talked when you're inside, not cover that and medications you have polypharmacy corner. These are your mobility, are older, the hands and that's thousands of pressure. Eso again, you know, think about it that bad that they're in is that certain before them is a two guys Intuniv on when they're in hospital and they have a cold, they'll can you reach it. Didn't want to use it in the US it looks like the pressure kind of falls into. The medication was using my hands, but just think about medications that might be causing their their BP to drop like thing again as well. Do you have a patient I older patients who you are afraid of the lights on because the light rebels going to die on what not so we'll see what the heating so and things that I try as improves your your risk of falls. I say I exercise an environment. So make sure that had night and I test on recently that color correct clean glasses on and that they're getting regular exercise on their environment, a civil suit and know lots of the floor rugs and on the last least supported revisions. Well, levels are vision is required for them and didn't have extra support. Okay, so just take a points from that. And quick was three pills. Eso first of all, how is everything? Make sure we cover before, during and after the full and get your card or less tree, which will be film of useful information and get my head to toe examination. Done. Make sure I don't miss any injuries. Do that relate on. Then finally, and just reiterate that that disposition planning starts a student based arrives into the so let's ask the right questions at the right time on make the journey through the E as efficient as we can. So how do you say any questions there if there are any? Hopefully you've been able to hear me, and I know it's been talking to myself. Yeah, so that has been depressions. Um We will. Thanks, Nicole. That's good for me to know that just don't miss out. Right, So we'll start recording.