Hip Fractures and Falls in Older Patients

What's going on this week... a news article in the BMJ follows on from an earlier post I had on here about hospital at weekend. Apparently the new 'evidence' of worse outcomes for patients at the weekend is re-igniting calls for more out-of-hours cover to allow hospitals to offer a full service at weekends. Sounds great in principle and would no doubt lead to better outcomes for patients but how's it going to be funded, and where are the added staff going to come from? Interestingly the Royal College of Physicians have issued a call for any hospital that admits acutely ill patients to have a consultant physician on site for at least 12 hours a day, seven days a week, who should have no other duties during this time.

An article was published this week about the use of anti-hypertensives in patients with gout or symptomatic uricaemia. This caught my eye because last week one of the doctors I work with was telling me about a patient on her ward who developed gout but had acute kidney injury. The acute management of gout mainly comprises non-steroidal anti-inflammatories eg. ibuprofen, however these are contra-indicated in renal impairment. It's long been known that hyperuricaemia and untreated hypertension commonly co-exist. High uric acid levels in the blood can predict development of hypertension, diabetes and chronic kidney disease. A recent study however shows that amongst UK GPs, the use of calcium channel blockers and losartan in patients with hypertension was associated with a significantly reduced risk of incident gout. Diuretics, beta-blockers and ACE inhibitors were associated with increased risk of gout. As well as preventing gout, losartan in particular is believed to protective renal effect.

Teaching this week was on the topic of falls, one of the 'geriatric giants' that's talked about at medical school. Every night shift - it's the same story. Request comes in to the FY1, please review patient - fall. The frequency that this happens at night in a hospital where there are nursing staff keeping a close eye on patients makes it alarming to think how many 'falls' happen in the community on a day to day basis. In particular, older patients suffering from hip fractures have poor outcomes (see dramatic photo). The main points I took from this teaching was that the diagnosis is all in the history. 'Dizzy' is not a good descriptive turn because it means something different for so many people, ask the patient 'what does dizziness mean to you?'. The examination should include balance tests eg. the sit to stand test, assessment of gait and the push test. All too often patients admitted with falls are assessed by having an ECG with a 24 hour cardiac monitor and lying / standing blood pressures. However cardiology is only one group of causes. Look for neurological signs in older people, such as nystagmus. Think about otological causes eg. inner ear diseases. Don't miss hip fractures and of course mechanical is a major cause of falls so it's worth remembering that simple prevention can be much better than a cure. Having an occupational therapist go out to see a patient's home and suggest ways to make it safer could prevent a hip fracture and save a life.