FALLS, FRACTURES AND OSTEOPOROSIS (Nabeela Ahmad)

Patient history The patient is a 95 year old non English speaking male living at home with his son (who is his full-time carer). He has recurrent falls and complains of dizziness (especially when changing positions quickly) and weakness in his knees before his falls. He does not slip or trip, but he does lose his balance and also collapses. He did not report palpitations or shortness of breath before the falls. He came in as he had three falls in the previous week and increasing confusion. No loss of consciousness or head injury reported. No fever or focal infective symptoms reported. His co-morbidities include: chronic renal failure; hypertension; hyperlipidaemia; chronic obstructive pulmonary disease; psoriasis and prostate cancer (early stage). His regular medications include: amlodipine, atorvastatin, seretide, diprosone ointment Risk factors Urinary incontinence (and occasional fecal continence) Mobilizes unsteadily. Uses a walking stick and refuses to use 4 wheel frame Declining cognition over the last 6 months Dizziness when stands from lying position

Assessment On examination, he was found to postural hypotension with a systolic drop from 155-100 mmHg, vitals are otherwise stable, with no atrial fibrillation. Neurological exam had no significant findings. There were no signs of infection. He was found to have 6th, 7th and 8th rib fractures (confirmed with x-ray) without any pneumothorax. No signs of other fractures. He was also found to have low Vitamin D levels. He did not have anemia. Pattern of fall This patient had a mechanical fall, most likely due to postural hypotension and an unsteady gait due to increasing weakness. This is exacerbated as the patient refuses to mobilize with a four wheel frame and also because of increasing confusion over the last 6 months and incontinence. Management Medical team Initial assessment of patient: ruling out underlying causes such as atrial fibrillation, strokes and evaluating neurological function Investigation of chest pain: rib fractures and pain management Investigating for possible infection as a delirium screen

Pharmacological: started cholecalciferol and ceased amlodipine ( as a possible cause of postural hypotension) Referral made for allied health review

Nursing team Carrying out procedures for investigations daily Observing vitals regularly Assisting the patient with mobility and transferring Looking after his continence management

Occupational therapist Falls risk assessment: history of falls; incontinence; confused but vision is okay; requires close supervision on transfers Decreased mobility Assisted domestic and community activity of daily living, but independent personal activities of daily living Single storey house with adequate rails and ramps put in place Cause of falls: a combination of loss of balance and collapse

Physiotherapist Happy with discharge but requires increased supervision and needs to use a four wheel frame Assess mobility and whether there are other factors contributing to decreased mobility (i.e. shortness of breath)

Social worker Examining whether the patient is safe to be discharged home or whether a nursing home is more appropriate Concludes safe to discharge home but family will require more information and education on continence management, falls education and they may require assisted services for personal care Patient should stay with family until a place is available at high level care facility (where they are already on the waiting list).

Strengths of a team approach As evidenced by this case, each member of a team managing a falls patient has a different and important role to play in ensuring that the patient is adequately cared for. Having a team approach allows management to be: Integrated: Instead of having the patient go to different professionals to be fully managed in terms of what the patients family can do at home and what adjustments need to be made to prevent

further falls, having a team approach to managing falls allows the different aspects of the case to be managed concurrently. Increased communication: Since the management is concurrent between the disciplines, it is easier for the different team members to communicate with one another and come up with a comprehensive plan. This will also prevent contradictory advice (for example someone suggesting a nursing home and someone assuring that everything can stay the same) and prevent doing one thing twice. Holistic: A team approach makes it easier to look at the patient holistically in terms of the community (a high level care facility able to handle the patients case), personally (encouraging safe mobilization) and medically (reducing risk of fractures and falls by changing medication and advising patient on getting up slowly to prevent a postural drop). Sharing of responsibilities: Having multiple people looking after one patient allows the workload to be shared and tasks can be delegated so each persons time is used effectively.