PTY711 - Faculty of Health, Social Care and Education Assignment

Assignment Task

Case Study

Frailty/Geriatric Medicine

Mrs Other is an 80-year-old female, admitted after a fall downstairs in which she lost consciousness for approximately three minutes. A detailed problem list has been collated based on her admission (Appendix 1), with the following three problems identified using the ICF framework (Figure 1 – Lexell and Brogårdh, 2015): Falls risk of unknown origin, acute subdural haematoma with cognitive decline, and poly-fractures restricting independence. The problems will be prioritised and discussed interchangeably throughout.

 1- Acute subdural haematoma with cognitive decline:

Mrs Other’s haematoma is situated and compressed against the frontoparietal region of her brain, impacting planning, initiation, insight, reasoning, and attention (Gawron et al., 2013). This is evidenced from her cognitive assessment with good attention and recall noted in-task, although her ability to retain information thereafter is impeded. Whilst it should be assumed she has capacity in accordance with Principle 1 of the Mental Capacity Act (MCA) 2005 (Legislation.gov, 2005), her worsening cognitive deficits call into question her ability to weigh-up and remember her decisions.

On admission, it appears no formal diagnosis of dementia had been identified; although, prior to developing post-traumatic amnesia (PTA), her Addenbrooke’s Cognitive Examination (ACE-III) score was 74/100, indicative of mild onset of dementia (Giebel and Challis, 2016). Research suggests that extended durations of PTA is associated with longer-term disability (Hart et al., 2016) and therefore, the 10 days she experienced PTA may contribute to further decline in her cognitive function which will need to be monitored. This is compounded by her background of hypertension (HTN), which is closely linked to vascular dementia (Li et al., 2017).  

Mrs Other’s cognitive decline has led to anxiety surrounding function. This has not only arisen because of her fear of falling again but the deficits sustained from her traumatic brain injury (TBI) will impair her planning and execution of activities, accentuated by her reduced insight and safety awareness. Moreover, behaviour changes are a cardinal sign of a frontoparietal TBI (Levine et al., 2011) thus, any irrational changes to her emotional state will likely inhibit her confidence when mobilising or attempting stairs.

Being off her functional baseline due to her poly-fractures will undoubtedly lead to fear-avoidance, which may result in her sleeping downstairs in a chair and practicing poor hygiene routines, as both bathroom and bedroom at home are on the 1 ^st floor. Based on this, her BD POC does not adequately support her care needs and she is therefore vulnerable to worsening frailty, neglect, and subsequent mortality.

2 - Poly-fractures restricting independence

The fractures sustained to her 2 ^nd -5 ^th ribs will make deep breathing difficult due to pain, resulting in reduced tidal volume and increased hypoventilation. She will therefore struggle to expectorate secretions, increasing her predisposition to atelectasis and subsequent risk of pneumonia. Prolonged inefficiency in her work of breathing may then lead to Type 2 Respiratory Failure due to low oxygenation and hypercapnia. The severity of which is evident, as the Imperial College Hospital Rib Trauma Guidelines (2019) report respiratory complications typically develop within 48-72 hours post-rib fracture, with mortality rates shown to increase by 10-13% in elderly populations.

As she is no longer independently mobile as per her baseline function, her inactivity from PTA and bed rest between therapy sessions will not only increase her susceptibility to chest infections but will also have adverse effects on function. As such, the non-weight baring (NWB) status of her clavicle fracture has heavily restricted the use of her upper limb during transfers and personal care, both now requiring assistance of one. Due to her reduced insight on cognitive assessment, there is a risk that she may attempt to weight-bear through the affected arm to transfer out of bed, risking re-injury and further falls.

The significance of her hypothyroidism has also shown to correlate to poor bone healing in elderly populations, as under-regulation of thyroxin impacts bone density, increasing the risk of osteoporosis (Segna et al., 2018). This therefore needs to be an on-going consideration regarding fracture healing rate but also the fracture risk associated with increased frequency of falls following her initial trauma.

3 - Falls risk of unknown origin

It is estimated that 30% of the elderly population will experience falls related trauma, with an increased likelihood of recurrent falls thereafter due to worsening frailty (Tejiram et al., 2021).

As per Mrs Other’s past medical history of HTN, no significant conclusions have been drawn in literature between haemodynamic instability and falls (Teh and Fisher, 2012). However, close associations have been identified between the use of moderate to high HTN medication, with a 30-40% increased risk of injurious falls reported (Berry and Kiel, 2014). This is an important factor to note considering the absence of her drug history on admission and the reliance on her carer to manage her medications, meaning adverse effects may present if the dosage and timings are inconsistent. Similarly, her hypothyroidism is also shown to increase the incidence of syncope in the elderly, as the effect of thyroxine replacement therapy significantly reduces blood pressure (Gutch and Kumar, 2018).

It is therefore unknown whether her fall is cardiac or mechanical in origin, nor whether she has experienced multiple falls in the last month, as there is also no evidence of falls history on admission. Not only would this help inform the management of the patient but consequently, an increased frequency of falls would endanger the recovery of her TBI.

4. Short-term management

Considerations prior to commencing physiotherapeutic intervention have been outlined (Appendix 2). Once established, Mrs Other will require her observations to be routinely screened, specifically blood pressure on laying to standing, as her TBI on a background of HTN may predispose her to risk of haemorrhagic stroke (Turner et al., 2021). A full neurological examination would be performed in conjunction with Occupational Therapy to screen for upper and lower limb deficits, and to reduce the disturbance of multiple therapy reviews, which is shown to increase distress levels in patients with suspected dementia (Galvin, Valois and Zweig, 2014). Importantly, this would allow her cognition to be reviewed by repeating the ACE-III post-PTA, which may reveal worsening cognitive function compared to pre-assessment.

Mrs Others secondary risk of respiratory complications will be mitigated using active cycle of breathing techniques to expectorate secretions. Low-mid volume huffs are shown to reduce intra-thoracic pressure compared to coughing in pain limiting conditions, such as rib fractures (Button and Button, 2013). Slumped sitting positions which compromise diaphragmatic breathing can be avoided by alternating to right side laying when resting. This will alleviate her left sided fractures to reduce pain as well as improve any potential V/Q mismatch.

A sling will help to offload her clavicle fracture and combined with passive range of the affected arm, will reduce the risk of frozen shoulder to improve her ability to complete functional tasks. She will require ongoing transfer and mobility reviews, including a stairs assessment when considering her home environment across three-stories. As such, Berg Balance and Timed-Up & Go are useful outcome measures to objectively reassess clinical frailty from acute settings to community (Ries et al., 2015). Assessment of her orientation when mobilising will also provide further insight into her safety awareness.

Details of her cognition will need to be shared with the wider multi-disciplinary team, specifically the nursing staff to ensure she remains NWB through her left clavicle and does not attempt to mobilise independently. This would need to be reflected on the board above her bed to reiterate her restrictions.

5. Long-term management

Mrs Other’s decision regarding her long-term management will be determined by the outcome of her capacity assessment (Appendix 3). The Comprehensive Geriatric Assessment tool will be implemented to ensure Mrs Other’s needs are holistically considered as she begins to transition back into the community (Appendix 4 - British Geriatric Society, 2019). 

Based on implementing the least restrictive option as part of the MCA 2005, increasing her POC from BD to QDS will support her personal care needs and allow Mrs Other to remain in her own home. As such, familiarity is shown to be an important environmental consideration in patients with suspected dementia (Margot-Cattin et al., 2021). However, due to the size of her property and living alone with ongoing safety concerns, she will require a micro-environment for single level living. This would be combined with PT/OT as part of a 6-week reablement programme, with intermediate care shown to reduce readmission by 48.9% (Bauer et al., 2019). During this period, she will be supported through falls prevention, and continuously reassessed from both an ADL and PADL perspective to ensure her needs are being met. She will also be monitored for any evidence of seizure activity which can occur during the first three weeks post-TBI (Sun et al., 2017).

As Mrs Others comminuted clavicle fracture is displaced and may require surgical intervention, a follow-up appointment with fracture clinic will be arranged as an outpatient. However, if reablement is proven unsuccessful after 6-weeks and her outcome measures remain significantly off her functional and cognitive baseline, she would be transferred to a care home for closer support to promote the longevity of her wellbeing in a safe environment.

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