Falls in The Elderly: A Case Study

Introduction

In this paper, I would like to discuss regarding the case of eighty years old Mrs. Grace. She was received in the Emergency Department (ED) at 5:30 p.m. with intense pain from fall. I will discuss about her presenting condition, pathophysiology, notable deviations, her regular medications with their indication, contraindication, side effects and the effect of medication which was given to her in ED. Also, track where more findings are necessary. Mrs. Grace was brought by her son after he found her on the floor. The main complaint was unendurable suffering from unnoticed fall. He said that she was unable to stand on her feet. While assessing Mrs. Grace, her right leg seemed to be shortened and rotated internally. Her right upper limb and face showed several lesions and discoloration with slashing four centimeters down her right lower arm. The ambulance crew administered Fentanyl 100mcg intranasally. It was noted that her vital signs like blood pressure, temperature, respiration rate, oxygen saturation were all normal except for the heart rate which showed tachycardia. All observations were 147/77mmHg, 37.2º C, 24breath/min, 99% and 112beat/min respectively.

Fall in geriatric people is associated with several predisposing factors. The primary mechanism includes slipping, tripping, and stumbling. Moreover, it depends on the surrounding where elder citizens live and with whom they live with. Abraham and Fiallos (2017) suggests that the more people get old, the more is risk for falling and subsequent injury occur. Living conditions like inadequate lighting, absence of handlebars in bathroom, loose rugs, wet floor, loose slipper aid in fall. Delves, Seamus, Burton and Roitt (2012) points out that when any injury takes place, inflammation occurs moving white cells, complements and other plasma proteins into the infection site which shows four main signs swelling, pain, heat and redness. This lead to raised pulse and lowered blood pressure which are the body response to pain. According to Peate (2017) pain can be best described as a subjective experience. Health care professionals must rely on the patient’s own description of the pain. Moreover, many patients are not able to convey about their pain experiences. So that non verbal cues play an important role in determining the extent of treatment.

Saftari and kwon (2018) states that fall has become a major concern for public health as elderly population increases in size. There is a need to recognize the pressing need of fall. They documented that visual function like visual acquity, contrast sensitivity and stereo acquity are inter related with the risk of fall. Ladwig and Auckley(2011) recommend that Mrs. Grace had disturbed sensory perception (visual) related to ageing process. They further suggest increased susceptibility to falling which may cause physical harm. Effective measures should be carried out in order to minimize recurrent falling. Risk factor includes extrinsic environmental conditions like cluttered surrounding, insufficient lit room, no handle in shower and bath, restraints, slippery floor. Intrinsic conditions such as patient diminished mental status, use of anti-anxiety agents, antihypertensive medications, hypnotics, opiates and physiological conditions like difficult gait, impaired balance, visual problems, hearing difficulties, impaired physical mobility, etc aid in fall of patient.

Boot camp, (2014) a program “On your feet” help elderly people gain their strength and body equilibrium back who have suffered trauma related to fall. The program consists of three health care team members a nurse, physiotherapist and occupational therapist. A physiotherapist begins by educating the patient dealing with components of exercise and seeking patient with satisfaction survey. Occupational therapist focuses on surrounding of a patient to reduce fall incidence as well as making the environment safe. At present, the team is working for the promotion of the program to general physician in order to find people prior to the suffering. Fisher, Bates and Banerjee (2017) demonstrate comprehensive geriatric assessment (CGA) is the most productive way to upgrade outcomes for elder people with frailty. Geriatricians aim to collaborate with the multidisciplinary team to incorporate quality care to the frail elderly.

Huang, Duong, Leong and Quanch (2017) focuses on displaying an aged Asian American (AA) in community health centers and other clinic in order to distinguish those who are at potential risk for fall is suggested. Moreover, their study demonstrates that by discovering these patients who are at increased risk for fall, geriatrician can take prophylactic measures. For instances, medicine modifications, vitamin D recommendation, secure home analysis can be done in advance to avoid catastrophic fall.

Vemuri et al.(2018) points out the fact that  good shaped gastrointestinal tract is relatively functional throughout the maturity but ingestion of external bodies like use of medication causes agitation as ageing begins. Complication related with ageing occurs simultaneously with the physiological changes that arise in the body. Their studies conclude that alteration in microbial composition in gastrointestinal tract, immune response and metabolism leads to several inflammatory disorders. Ageing has direct effect on the way the food move to the intestine and alters digestion process. Moreover, metabolism and regulation of the immune system decreases with increase in age. Besides, Bottiger et al. (2018) noted that the most common adverse effect in ageing are constipation, sedation while using multiple drug results in increased risk of bleeding. Their study suggest  Pharmacological Risk Assessment Online (PHARAO) may be used as a tool for diagnosis which helps in distinguishing whether the current sign and symptom are related to medication or disease instead of making irrelevant interventions.

Pharmacological application

Bupivacaine causes blockade of impulse propagation along the nerve fiber pathway by preventing the inward movement of sodium ions through the nerve membrane. It is a long acting local anesthesia. Following epidural injection, it shows long duration of action.  Absorption takes place in two phases in the epidural space; the first phase occurs in seven minutes and the second in six hours. The slow absorption rate limits the rate of elimination of bupivacaine. It is then excreted in urine. This medication should be used with caution in patient taking antiarrhythmic drug, since cardiac potential may rise.

Fentanyl is an opoid agonist analgesic with the rapid onset of action and acting duration. It is therefore given in combination with other drug. Its pharmacokinetic is described in three compartment models, with a distribution time of 1.7 minutes, redistribution of 13 minutes and a final elimination half life of 219 minutes. Absorption occurs in skeletal muscle and fat. pH alteration between plasma and central nervous system (CNS) affect its distribution. Metabolism occurs in liver and excreted in urine. CNS manifestations are more common when bupivacaine is used with fentanyl. These symptoms may be excitatory or depressant chatracterized by like light-headedness, drowsiness, dizziness, blurred vision, disorientation, unconsciousness and respiratory depression (“Marcain with fentanyl”,2019).

Panadol has analgesic and antipyretic properties which act by inhibiting prostaglandin synthesis in the CNS. Its half is one to two hours. It is rapidly absorbed in the gastrointestinal tract following oral administration. Rate of absorption depends on rate of gastric emptying. It is then distributed rapidly and evenly throughout most of the tissue fluids. Metabolism takes place in liver and excreted in urine. It is used in the treatment of mild to moderate pain like headache, muscle ache, toothache, cold, fever. When administered through intravenous, adverse reaction like nausea, vomiting, diarrhea, dyspepsia, increase in liver enzymes and pain at site of injection may be seen. Overdose may cause liver failure. It should be used with caution in patients with impaired liver function and renal failure (“panadol”, 2019).

Bryant and Knights (2015) state neurofen is a non steroidal anti inflammatory drug (NSAIDs). It counteracts with prostaglandin synthesis and provides relief for the pain by producing anti-inflammatory effects. It is indicated to control pain. This drug is best absorbed orally. Most of these drugs metabolism takes place in liver and the metabolites are excreted by the kidney. Retention of fluid, electrolyte disturbance, rise in blood pressure are some adverse effects of neurofen. They further reports that all adverse reaction in the world are brought by the recurrent use of NSAIDs.

Morphine is derived from opium poppy which acts with the opium receptor in the brain providing relieving effect altering the pain perceptions and emotional responses. Apart from transdermal route, morphine is well absorbed through all other route of administration. It is widely distributed and crosses the blood brain barrier after absorption. Metabolism takes place in liver and excreted through kidney. It is indicated when non-opiod analgesics does not produce satisfactory response.  It is contraindicated in patient with respiratory depression, increased intracranial pressure, cardiac arrhythmias, severe liver or renal diseases. Most elderly suffer from hypoxia or hypercapnia therefore, respiratory depression occurs commonly in elder people even a mild therapeutic dose may prominently reduce pulmonary ventilation. When morphine is used in combination with paracetamol, gastric emptying is delayed which will directly delay the paracetamol absorption.(Tiziani, 2017)

Amiodarone is indicated for prevention and treatment of atrial and ventrical dysrhythmias. Also, helps in managing acute arrrhythmia. It has the quality of dissolving in lipids so it its absorption is poor. As it has high affinity to bind with protein, it is distributed throughout the body in adipose tissues, liver and lung. Its onset varies from several days to week so iis elimination takes place in two phases. Its adverse effect includes loss of deep tendon reflexes resulting from neuromuscular blockade. When used with anticoagulant like warfarin, it increases anticoagulant effect by retarding the effect of warfarin. Adverse reactions include dizziness, tremors, allergic reaction and blurred vision.

Rivaroxaban is an oral anticoagulant that binds directly to the intrinsic and extrinsic pathways of Xa factor and work by preventing fibrinogen conversion to fibrin. Its absorption takes place rapidly with the bioavailability ranging from 60-80%. It is metabolized by demethylation and hydroxylation. Because of which approximately 30% of urine is excreted unchanged. Bleeding is the common adverse effect of this drug.

Byrne, Sierra, Tolhurst (2017) classified number of errors made by nurses during discharge are failing to supply prescribed medication on the discharge prescription, the supply of medication which was not prescribed on the prescription. Unlabelled medication supplied from the ward without any instruction. Further, they re-audited and concluded that two nurses must independently assemble and check the discharge prescription as per local policy.

To sum up, several factors should be considered before performing any surgery in an elderly patient .Health professionals should evaluate patients baseline functional status, any signs of frailty, interactions of prescribed medication with the regular medications, home environment, presence of unsafe materials, social support in order to find out whether the surrounding patient is living is suitable .Confirm if the patient can be sent back to her home and make sure that the patient does not come back with the similar problem after few days of discharge. Patient education regarding medication during discharge is essential. Unrecognized cognitive status may affect outpatient compliance and worsen patient outcome.

REFERENCES

• Abraham, K. M., Fiallos, C. (2017). Falls in Elderly: causes, injuries and management, PMID: PMC4241333.
• “Boot camp”gets patients back on their feet. (2014). Nursing New Zealand (Wellington, N.Z.: 1995), 20(10), 8. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=25632533& site=ehost-live
• Bottiger, Y., Laine, K., Korhonen, T., Lahdesmaki, J., Shwmwikka, T., Julander, M.,… Andersson,  M.L. (2018). Development and pilot testing of PHARAO-a decision support system for pharmacological risk assessment in the elderly, European Journal of Clinical Pharmacology, 74(3), 365-371 https://doi.org/10.1007/s00228-017-2391-3
• Byrne, C., Sierra, H., &  Tolhurst, R. (2017) Does a checklist reduce the number of errors   made in nurse-assembled discharge prescriptions? British Journal of Nursing (Mark Allen Publishing),  26(8),  464-467  https://doi.org/10.12968
• Bryant, B. J., & Knights, K. M. (2015).Pharmacology for Health Professionals Ebook (Vol. 4th Edition), Chatswood, New South Wales: Mosby Australia. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=970115&site=ehost-live
• Delves, P.J., Seamus, J.M., Burton, D.R. and Roitt, I.M. (2012). Roitt’s Essential Immunology, 12th edn. England; Wiley-Blackwell.
• Fisher, J. M.,& Bates, C., & Banerjee, J. (2017). The growing challenge of major trauma in older people: a role for comprehensive geriatric assessment? Age and Ageing, 46(5), 709-712 https://doi.org/10.1093/ageing/afx035
• Huang, S., Duong, T., Leong, L., & Quach, T., (2017). Understanding Falls Risk and Impacts in Chinese American Older Patients at a Community Health Center, Journal of Community Health, 42(4), 763-769 https://doi.org/10.1007/s1090
• Ladwig, G. B., & Ackley, B.J., (2011). Mosby’s Guide to Nursing Diagnosis(Vol. 3rd ed). Maryland Heights, Mo: Mosby. Retrieved from https://search.ebscohost.com/login.aspx?direct=true=&db=nlebk&AN=445371&site=ehost-live
• Marcain with Fentanyl.(2019). in eMIMSCloud Retrieved from https://www.emims.com.au/Australia/drug/info/Marcan%20with%20Fentanyl
• Peate, I. (2017). Fundamentals of Applied Pathophysiology: An Essential Guide for Nursing and Healthcare Students (Vol. Third edition). Hoboken, NJ: Wiley-Blackwell. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=1556079&site=ehost-live
• Saftari, L. N.,& Kwon, O. S. (2018). Ageing, vision and falls: a review. Journal of Physiological Anthropology, 37(1), 11. https://doi.org/10.1186/s40101-018-0170-1
• Tiziani, A. (2017). Havard’s Nursing Guide to Drugs –Mobile Optimised Site (Vol. Tenth edition), Chatswood, N.S.W: Elsevier. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=1613604&site=ehost-live
• Vemuri, R., Gundamaraju, R., Shastri, M. D., Kalpurath, K., Ball, M., … Eri, R. (2018). Gut Microbial Changes, Interactions, and Their Implications on Human Life cycle: An Ageing Perspective. Biomed Research International, 2018, 4178607, https://doi.org/10.1155/2018/4178607