From Risk to Resilience, Tailoring Strategies for Managing Recurrent Falls in the Elderly
Prepared by: Dr Nor Hazwani Zenol Ariffin
Supervisor: Dr Elizabeth Chong Gar Mit
We received a referral of Mrs K, a 93-year-old lady with recent right hip fracture for rehabilitation.
Background:
Hypertension, under GP follow up - takes T Nifedipine 30mg PRN if home BP monitoring SBP > 150
Vision impairment- left eye congenital blindness and right eye cataract (done IOL implant)
Bilateral knee osteoarthritis, done bilateral TKR more than 10 years ago
Left neck of femur fracture March 2023, done bipolar hemiarthroplasty
Medications:
T. Nifedipine 30mg PRN
T. Paracetamol 1g PRN
Self purchase Calcium/Vitamin D and Vitamin B supplement 1 tab OD
She had recent fall in April 2024 when she misjudged the steps while walking down the stairs. Following the complaint of pain and unable to ambulate, she was diagnosed with right hip fracture in private centre and proceeded with bipolar hemiarthroplasty. Post fall she walks using walking frame.
On further history, she had a previous fall a year back in March 2023 while walking in the market and lost her balance while crossing a drain. She sustained left neck of femur fracture and was operated on in a private centre. Initially post fall she was walking with a walking stick and became home bound.
She stays with her husband who has parkinsonism and vision impairment due to glaucoma in a 2-storey house. Her children who were all staying outside, hired a live-in maid after the first fall to help with house chores and cooking. Subsequently she was able to walk independently albeit slower and sometimes furniture-walk.
Question 1: Could anything be done to prevent a second fall?
Below is the summary of her mobility and function of activity of daily living for the last few years:
Prefall March 2023 | Post fall March 2023 | Post fall April 2024 | |
Mobility | Unaided | Walking stick initially, subsequently unaided but slower with some furniture-walk | Walking frame |
BADL | Independent | Independent | Independent but markedly slower |
IADL | Able to cook, go to the market and buy groceries Able to handle cash transaction Able to take care of husband Able to do hobbies: gardening and sawing clothes/blanket Takes medication on her own Billing done by son Doesn’t know how to use phone / take out money from ATM | Still able to cook but sometimes forgot certain recipes, subsequently taken over by maid Able to do light house choressweeping the floor, fold clothes and hang laundry Mainly homebound Still able to do gardening but less due to physical limitation Marketing and groceries done by children due to her physical limitation | Taken care by maid and children, no longer cooking as well- unable to stand for long and became slower Medication supervised by childrenneeded reminder due to forgetfulness |
Cognition | Occasionally misplaced objects, but no other noticeable decline in short term memory No repetition | Frequently misplaced objects Occasionally forget about recent event | Frequently misplaced objects Occasionally forget about recent event |
Continence | Dual continent, no constipation | Dual continent, no constipation | Dual continent, no constipation |
Mood and behaviour:
Currently described being in low mood due to physical limitation
Frequently mentioned to her children that she wishes to die and doesn’t wish to trouble her family members.
Occasionally difficult to sleep at night
She described normal appetite, but son noticed she’s been eating less amount since the second fall. Occasionally she complained of burning sensation at the epigastric area and feeling bloated, however no blackish stool. She has never been investigated for peptic ulcer disease.
Examination:
Medium build lady, edentulous with no loss of temporal muscle wasting.
She is coherent but noted bilateral hearing impairment. Her affect was appropriate. She’s able to follow 3 step command with good bed mobility- able to sit unaided with good sitting balance and able to roll side to side and bridge independently
BPL 149/66, PR 69
BPS 1 min 146/60, PR 78
BPS 3 min 165/81, PR 76
BPS 5 min 166/76, PR 74
T 37
DXT ranging 5.4 to 7
Lungs clear air entry bilateral lung field
CVS S1S2, no murmur
Per abdomen soft, non tender, no hepatosplenomegaly with active bowel sound
Lower limb examination:
Loss of muscle bulk at bilateral thigh and leg
Well healed scar at right hip
Bilateral knee crepitus, right more than left. Both knees were not swollen.
Neurological examination:
Tone normal bilateral upper limb and lower limb
Power over bilateral upper limbs were 5
Power over bilateral lower limb as follows:
Right hip flexion and extension 4
Left hip and bilateral knee flexion and extension and ankle dorsiflexion and plantarflexion 5
Sensory over bilateral upper and lower limb intact
Reflexes 2+ bilateral upper and lower limb
Proprioception intact
No cerebellar signs
Cranial nerve otherwise grossly intact
MMSE: 22/29 (Orientation 8, Registration 3, Attention & calculation 4, Recall 2, Language 5, Copying 0)
GDS: 14/15
Question 2: What is your provisional diagnosis? How would you manage her?
Investigations:
FBC: Hb 14.3 / WCC 8.02 / PLT 236
RP and electrolyte: urea 3.8 / Na 141 / K 3.9 / Cr 50 / Corrected Ca 2.36 / Mg 0.78 / PO4 1.12
LFT: Alb 43 / TB 12 / ALP 64 / ALT 3
ECG: SR, HR 75, no ST-T changes
BMD 2023:
Question 3: Above was the BMD that was done after the first fracture. However, she was not treated for osteoporosis after the first fall. Would you have managed her differently?
Related articles:
Cui, Y., Liu, B., Qin, MZ. et al. Effects of early mental state changes on physical functions in elderly patients with a history of falls. BMC Geriatr 23, 564 (2023). https://doi.org/10.1186/s12877-023-04274-6
Bradley D. Lloyd, Dominique A. Williamson, Nalin A. Singh, Ross D. Hansen, Terrence H. Diamond, Terence P. Finnegan, Barry J. Allen, Jodie N. Grady, Theodora M. Stavrinos, Emma U.R. Smith, Ashish D. Diwan, Maria A. Fiatarone Singh, Recurrent and Injurious Falls in the Year Following Hip Fracture: A Prospective Study of Incidence and Risk Factors From the Sarcopenia and Hip Fracture Study, The Journals of Gerontology: Series A, Volume 64A, Issue 5, May 2009, Pages 599– 609, https://doi.org/10.1093/gerona/glp003
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