Board Question of the Week:  September 7, 2012:

In a community hospital in a large urban area, the rate of delirium for patients on the orthopedic service is higher than the rate for similar patients at other hospitals in the city.  The hospital decides to implement a delirium reduction program based on the Hospital Elder Life Program (HELP) and published trials.

Based on previously published data, a delirium reduction program is most likely to be be successful if it targets which of the following risk factors?

A) polypharmacy, cognitive impairment, hearing or vision impairment, diabetes, and previous history of postoperative delirium

B) Inattention, polypharmacy, constipation, immobility, and hearing or vision impairment

C) Cognitive impairment, sleep deprivation, immobility, vision or hearing impairment, and dehydration

D) Cognitive impairment, polypharmacy, constipation, pressure ulcers, urinary incontinence, and orthostatic hypotension

Board Question of the Week:  August 23, 2012:

An 82 year old woman comes to the office for a routine visit.  She recently moved in with her daughter, who manages her medications.  Last week, she tripped on the step at the entry to the kitchen, fell, and fractured her wrist.  She has mild dementia, hypertension, dyslipidemia, OA, and a history of a duodenal ulcer.  She has early cataracts in both eyes and wears glasses with multifocal lenses.  Medications include donepezil, metoprolol, HCTZ, simvastatin, omeprazole, a MVI, and acetaminophen.

On examination, BP is 140/70 lying, 130/74 standing.  The remainder of the exam is unchanged from previous visits.  She completes the Timed Up and Go test in 12 seconds.

Which of the following would decrease her risk of another fall?

A) Treatment of postural hypotension

B) Wearing single distance glasses while walking

C) Use of a cane or walker for better balance

D) Review of medications

Answer:  B

This patient has recently moved and is likely not yet familiar with her daughter's house and the step up to the kitchen.  The multifocal lenses in her eyeglasses put her at risk of tripping -- they impair contrast sensitivity and depth perception because the wearer looks down through the near vision, lower segment of the lens.  Studies have shown that people wearing multifocal lenses are more likely to trip on a step because of inaccurate judgment of the step height. Changing to single distance eyeglasses improves judgment of foot placement.

Board Question of the Week:  August 17, 2012

Which of the following is most likely to reduce the incidence of in-hospital falls?

A) Use of bed alarms to alert staff

B) Use of specially colored, nonslip slipper socks

C) Use of four siderails

D) Team discussion of patient's risk factors

E) Individualized exercise programs to improve balance

Answer:  D

In hospital falls can result in several complications, including fear of falls, injury, and increased LOS.  There is little evidence to support any particular intervention to reduce falls in the acute care setting.  The best evidence available supports care planning by nursing staff to reduce risk factors for individual patients.

Bed alarms can be effective alerts, but hospital staff have to remember to activate them or respond in time to prevent a fall.  Colored, nonslip slipper socks, along with wrist bands and room markers, are used to identify patients at risk of falling, but there has been no study demonstrating that this single intervention is effective.  The use of restraints, including 4 side rails, has not been shown to reduce the incidence of falls and may increase the risk of fall injuries. In hospital exercise programs have not been shown to prevent falls.

Board Question of the Week:  August 09, 2012:

A 90 year old woman comes to the office because, over the past year, she has had increasing difficulty walking.  Her gait is slower, and she feels as if she might fall backward at times.  She has HTN, hypothyroidism, and OA, and she has had CABG surgery 10 years ago, with no recurrence of angina.

On examination, she has moderate dorsal kyphosis and arthritic changes in her fingers and knees.  Strength and reflexes are symmetric.  She has some increased muscle tone.  She uses her arms to push up from the chair; once standing, she has difficulty starting to walk.  Her gait is symmetric, with a normal base, but her foot clearance and stride length are both decreased.  She turns slowly and carefully, with an increased number of steps.

Which of the following is the most likely cause of her gait abnormality?

A) Osteoarthritis

B) Proprioceptive deficits

C) Cerebrovascular disease

D) Parkinson's disease

E) Cautious gait

Answer:  C

This older patient has known vascular disease.  The difficulty starting to walk, the slow gait, with decreased foot clearance, and the tendency to fall backward suggest subclinical cerebrovascular disease.  Her advanced age and history of HTN place her at risk of microvascular disease affecting cerebral white matter and lacunar infarcts.

the patient has OA, but does not have evidence of pain with walking.  Her gait is symmetric.  Proprioceptive deficits, with loss of position sense, lead to a wide based steppage gait which she does not have.  The typical gait of PD involves initial hesitation, then small, shuffling steps with no arm swing and difficulty with balance.