1. Falls in the Elderly & # Neck of Femur James Fox Rebecca Fairfield

2. Falls in the Elderly

3. Define a ‘fall’ (1) Non-intentionally coming to rest at a lower level -Most common A&E presentation in >65s -30% of over 65s fall each year -50% of over 80s fall each year

4. Causes of falls DAMEDAME -Drugs -Age related -Medical -Environmental

5. Drugs Psychotropics - Tricyclic anti-depressants - Anti-psychotics - Benzodiazapines Dopaminergic drugs Anti-Hypertensives - ACE inhibitors - β blockers - Diuretics Opiates Drugs Age related Medical Environmental

6. Age Related Changes Drugs Age related Medical Environmental - Visual impairment - presbyopia - Age related frailty - Gait and balance - Degenerative diseases - Parkinson's - Cognitive impairment - Delirium - Dementia All increase risks of falls

7. Medical causes Drugs Age related Medical Environmental Syncope Sudden transient loss of consciousness due to reduced cerebral perfusion. Loss of postural control, unresponsiveness with spontaneous recovery causes of syncope -Situational hypotension -Vasovagal -Carotid sinus syndrome -Cardiac arrhythmia/ischemia -Outflow obstruction -PE Loss of consciousness “Drop Attack”

8. Orthostatic hypotension >20 mmHg fall in systolic BP and/or >10 mmHg fall in diastolic BP within 3 minutes With symptoms (causes: drugs, chronic HTN, volume depletion, adrenal insufficiency, autonomic failure) Post-prandial hypotension > 20 mmHg fall in systolic BP after eating a meal Dizziness/vertigo Seizures Strokes Peripheral neuropathy Alcohol Medical causes (cont.) Drugs Age related Medical Environmental

9. Drugs Age related Medical Environmental Trip hazards Poor lighting Clutter Unfamiliar environments Wet/slippery surfaces Bath/toilet problems Any extrinsic factors

10. Impact on patient? Bio: -Fractures -humerus, femur, wrist, pelvis -Soft tissue injury -Head injury -Subdural heam. -Long lies on floor ->1 hour pressure sores, rhabdomyolysis, hypothermia, hypostatic pneumonia Psycho: -Fear of falls → loss of confidence -Anxiety -Panic, agrophobia -Depression Social: -Immobility -Loss of independence -Accommodation change?

11. History taking S - Symptoms P – Previous falls L - Location A - Activity T - Time T – Trauma + drug history

12. Examination? -Balance and gait -Pulse rate and rhythm. Murmurs? -Postural BP -Neuro exam -Vision/hearing -Parkinson’s signs? -Head/neck movements? Investigation? -Bloods -ECG, 24-hour ECG -CT head -EEG Management -Medication review -Vision assessment -Treat underlying causes -Physio: strength and balance training -Home hazard and safety interventions

13. Neck of Femur Fracture

14. Anatomy review

15. Normal x-ray Shenton’s line Formed by -medial edge of femoral neck and - inferior edge of superior pubic ramis.

16. Classic presentation What is the classical presentation of a fracture hip? “Shortened and externally rotated”

17. Classification Hip fractures occur between edge of femoral head and 5cm below less trochanter.

18. Treatment Dependent on type of fracture Intracapsular: hemiarthroplasty (if displaced) and dynamic hip screw if undisplaced. Extracapsular; dynamic hip screw

19. Complications Most significant complication of a NOF fracture? Avascular necrosis In which fracture type is this more common? Intracapsular Why? Majority of the bloody supply to the head of the femur is from the circumflex artery which runs around the neck of the femur and through retinacular fibres of the joint capsule. This blood flow can be compromised during fracture, particular if this fracture is displaced causing compression or kinks.