FRAILTY,FALLS AND PATHOLOGICAL

FRACTURES IN ELDERLY

Presenter:
Dr.Hamisi Mkindi-Resident,PGY3
Supervisor:
Dr.Igembe Nkandala,MD,Mmed,Msc
 OUTILINE

PART 1:FRAILTY PART 2:FALLS AND FRACTURES

• Falls in elderly overview
• Introduction • Fractures in elderly overview
• Frailty phenotype/Index
• Rapid screening tool
• Pathophysiology
• Clinical Application
• Evaluation
• Intervention
 Introduction

• Identification of older individuals who are frail or at risk of becoming

frail constitutes a cornerstone of geriatric medicine.
 Introduction

• Aging-related clinical syndrome of physiological decline,

characterized by marked vulnerability to stressors leading to adverse
health outcomes.(1)
• Two major definitions with proposed assessment tools: the frailty
phenotype (FP) and the frailty index (FI)(2,3)

1. Xujiao Chen et al 3.Fried LP et al

2. Jones DM, Song X
 Frailty Phenotype(FP) and Frailty Index(FI)

• In FP-Frailty is operationalized as a syndrome meeting three or more

of five phenotypic criteria:
• Weakness as measured by low grip strength,
• Slowness by slowed walking speed,
• Low level of physical activity,
• Low energy or self-reported exhaustion,
• Unintentional weight loss.

Prefrail stage-one or two criteria;a subset at high risk of progressing

to frailty.
Non frail-none of the above five criteria
Frailty Phenotype(FP) and Frailty Index(FI)
• FI-CGA by counting the No. of deficits accumulated:diseases, physical
and cognitive impairments, psychosocial risk factors, and common
geriatric syndromes other than frailty.
• The total number of deficits that can be used in the FI is considered to
be 80, with 30–70 items being typically counted.
 RAPID SCREENING TOOLS

• Fatigue ("Have you felt fatigued? Most or all of the time over the past month?") Yes = 1, No= 0

• Resistance ("Do you have difficulty climbing a flight of stairs?") Yes = 1, No = 0

• Ambulation ("Do you have difficulty walking one block?") Yes = 1, No = 0

• Illnesses (“Do you have any of these illnesses: hypertension, diabetes, cancer (other than a minor skin
cancer), chronic lung disease, heart attack, congestive heart failure, angina,asthma, arthritis, stroke, and kidney
disease?”) Five or greater = 1, fewer than 5 = 0

• Loss of weight(“Have you lost more than 5 percent of your weight in the past year?”)Yes=1,No = 0
FRAIL scale scores range from 0 to 5 (0 = best, 5 = worst) and represent frail (3 to 5), pre-frail (1 to
2), and robust (0) health status.
Pathophysiology
 Clinical Application

• Frailty is conceptualized as a vulnerable state associated with high risk

for increased morbidity and mortality.

• Frailty syndrome is considered a useful clinical tool for risk

stratification in the highly heterogeneous elderly population.

• Risk assessment tool for preoperative evaluation in elderly patients

who undergo surgery, those with CV conditions undergoing cardiac
surgery.
 Evaluation

• History and physical exam

-For patients in whom frailty is a potential concern,the following
should be ascertained:
i.Energy levels and excessive fatigue, ability to perform or
maintain physical activities.
ii. Assessment of the patient's ability to rise from a firm
chair five times without use of arms, and the ability to walk across the
room.
 Evaluation cont….

• Lab testing
Complete blood count:
Basic metabolic panel
Liver biochemical tests-including albumin
Vitamin B12
Vitamin D
Thyroid-stimulating hormone (TSH)
 Interventions
Aim to:
1) Prevent, delay, reverse, or reduce the severity of frailty.
2) Prevent or reduce adverse health outcomes in those whose frailty is
not reversible.

-Exercise is the interventional modality that has most consistently

shown benefit in treating frailty and its key components(muscle
strength and functional mobility).
-Occupational therapy
 Interventions

• Nutritional supplementation — For patients with weight loss as a

component of frailty, attention should be focused on medication side
effects, depression,difficulties with chewing etc.
-Oral nutritional supplements between meals (low-volume, high caloric
drinks or puddings) may be helpful in adding protein and calories.
-Vitamin D supplementation.

• Medication review — Periodic evaluation of a patient's drug regimen is an

essential component of medical care for an older person, and it is especially
important for patients who are pre-frail or frail.
 FALLS

• A fall is an event that results in a person unintentionally coming to

rest at a lower level (usually the floor).
• Falls are common and important, affecting one-third of people living
in their own home each year.
 FALLS-Epidemiology

• 30% of people older than the age of 65 years and 50% of people older
than age 80 years fall each year.

• Almost 60% of those with a history of falls in the previous year will
suffer from a subsequent fall.

• Up to 50% of falls result in some type of injury, the most serious of

which include hip, head trauma, and cervical spine fractures.
FALLS-Risks
Intrinsic risk factors:
Age Related changes (Poor Vision,
Musculoskeletal function-
decreased limb strength)
Diseases. Female sex .
Extrinsic risk factors:
Drugs-Multiple Medx.
Environmental
Improper assistive
devices
 CAUSES OF FALLING IN ELDERLY

I: Inflammation of joints (or joint deformity)

H: Hypotension (orthostatic blood pressure changes)
A: Auditory and visual abnormalities
T: Tremor (Parkinson's disease or other causes of tremor)
E: Equilibrium (balance) problem
F: Foot problems
A: Arrhythmia, heart block or valvular disease
L: Leg-length discrepancy
L: Lack of conditioning (generalized weakness)
I: Illness
N: Nutrition (poor; weight loss)
G: Gait disturbance
 Consequence of falls

Physical: Psychological:
Soft tissue injury Fear of falling
Increased dependency
Subdural hematoma
Depression
Hip fracture
Anxiety
Immobilization /
disability Loss of confidence
Hospitalization Social withdrawal
Pressure sore
 Assesment-History/Physical Exam

Gather information about the following factors:

• Fall circumstances (e.g., timing, physical environment)
• Symptoms before and after the fall
• Use of drugs, including alcohol
• Previous falls, fractures, and syncope, even as a young adult
• Previous near-misses
• Comorbidity (cardiac, neurological [stroke, Parkinson’s disease,
seizures], cognitive impairment, diabetes)
• Functional performance (diffi culties bathing, dressing, or toileting)
 Examination

This can sometimes be focused if the history is highly suggestive of a particular

pathology.

But perform at least a brief screening examination of each system:

• Functional: The “get up and go” test provides information about balance and
gait and is performed by asking the patient to stand from a chair, walk 10 feet,
turn around, walk back, and sit back down.
This test can also be used for comparison at different time points and for
screening (completion time >16 seconds correlates with increased fall risk).
Assess gait, use of walking aids, and hazard appreciation.
 Examination

• Musculoskeletal: Examine the major joints for deformity,

instability, or stiffness.

• Neurological: Assess to identify stroke, peripheral neuropathy,

Parkinson’s disease, vestibular disease, myelopathy, cerebellar
degeneration, visual impairment, and cognitive impairment.

• Cardiovascular: Always check lying and standing BP. Check pulse rate
and rhythm. Listen for murmurs (especially of aortic stenosis).
 Tests

• Many tests are of limited value, but the following are considered
routine:
• CBC • Electrolytes
• Vitamin B 12 • BUN and creatinine
• Urinalysis (UA) and urine culture • Thyroid function tests
• Glucose • Vitamin D
Treatment
 FRACTURES

• Fragility fractures are frequent in the elderly. The lifetime risk of

osteoporotic fractures lies within the range of 40–50% in women and
13–22% for men with mortality higher in men.(1)
• Osteoporosis is a skeletal disorder characterized by compromised bone
strength, resulting in bone fragility and susceptibility to fractures.
• More common in women than in men, although the incidence among
men is increasing.

• The prevalence of osteoporosis and osteoporotic fractures increases

with age.
1.Olszynski et al
 Pathophysiology

• Total bone mass increases throughout childhood and adolescence,

peaks in the third decade, and then declines at about 0.5% per year.

• Loss of bone mass accelerates after menopause in women (up to

5% per year), but declines gradually in men.

•At the cellular level osteoblasts and osteoclasts work synergistically

at a bone resorption pit to maintain bone homeostasis.
Risk Factors
 Clinical Features

• Occur at the wrist, hip (femoral neck or trochanter), or vertebral body

that are sustained at low-energy levels.

• Fractures can be sustained from a fall, but can also contribute to falls.

• Vertebral body fractures can cause a wedge deformity of one or more

Vertebrae.
 Diagnosis

• Dual energy X-ray absorptiometry (DEXA) to define osteoporosis (T score less

than –2.5 below mean peak bone mass) and osteopenia (T score between –1
and –2.5).

• DEXA scanning of the hip and spine provide a quantitative measure of bone
mineral density that can be used to assess risk of fracture in that region.

• Fracture risk is assessed using bone density together with age,body mass
index (BMI), known diagnosis of secondary osteoporosis, personal and
family history of a fragility fracture, diagnosis of inflammatory diseases, and
glucocorticoid, tobacco, or alcohol use.
 Diagnosis

• Think of secondary causes if the Z score is lower than –2.5 (compares it to age- sex-, and
weight-matched adults).

• X-rays may show fractures and give an idea of bone quality.

• Although blood tests are usually normal (except after a fracture), the following laboratory
testing are considered routine:
• Chemistry profile including alkaline phosphatase, calcium, and phosphorous
• Hormonal assays: TSH, PTH, 25-hydroxy-vitamin D
• Testosterone levels in men
• If calcium or alkaline phosphate is elevated, consider alternative diagnosis, e.g.,
metastases or Paget’s disease
 Treatment

1.Ortho-Geriatric Comanagement
2. Timely Surgery
-Especially when the lower extremity is involved.(1)
-when considering upper limb fragility fractures, mainly proximal
humerus or distal radius, nonoperative treatment remains the gold
standard.
3. Fall Prevention
-Pharmacological interventions targeting osteoporosis include
calcium and vitamin D supplementation, bisphosphonates, PTH agonists,
and the RANKL inhibitor
1.Nyholm et al