Comprehensive Assessment and Management of an Elderly Patient with Multiple Health Concerns
What are Mrs. Smith’s major risk factors for falls?
Mild hearing loss is one of the risk factors that can increase Mrs. Smith’s risk of falling by three times. The risk increases as the hearing loss extends. This is because of a reduced awareness of a person’s immediate environment, such as not hearing another person when such a person approaches. Similarly, difficulty in hearing causes the brain to strain more. The increase in the brain’s cognitive load can cause fewer cognitive resources to be needed for maintaining gait and balance. These factors place people with hearing loss at an increased risk of falling (Jiam & Agarwal, 2016).
Diabetes is another factor that increases a person’s risk of falling. A person 65 years old or older has a 17 times likelihood of falling compared to a younger person with no diabetes. However, adopting healthy habits and prevention strategies can help prevent falling. Elevated blood glucose levels significantly impact the body’s longest nerves, which convey sensory information from the toes to the spinal cord. The resulting loss of muscle tone and sensation is felt most on the ankles and feet, thus making it harder to walk, stand up, and more so on uneven surfaces. The neuropathy threat is a major reason people with diabetes have a high fall prevalence (Hewston & Deshpande, 2016).
Osteoarthritis in her knee is the third factor. Osteoarthritis goes beyond just making the joints stiff and sore. It damages the hips and knees and can interfere with mobility and balance, increasing the risk of falls and making a person more vulnerable to bone fracture. Joint pain has been shown to increase a person’s fall risk. The more the number of joints affected by arthritis, the higher the possibility of a person falling (Manlapaz et al., 2019). De Zwart et al. (2015) add that one reason for falls is that pain is a symptom of severe osteoarthritis and enhanced joint damage. Despite X-rays showing any signs of joint pain that are severe, persons with pain have a higher likelihood of falling. Pain makes people avoid using the aching limb, leading to greater unsteadiness, poor function, and muscle weakness.
Lisinopril 10 mg daily and diphenhydramine are known to cause dizziness as a side effect (Healthline, 2018a; Healthline (2018b). Dizziness can lead to patient falls, as is the case of Mrs. Smith.
What interventions would you recommend to minimize her risk?
According to Wang et al. (2016), the leading cause of disability and death due to injury in persons aged 65 and above is falling. People in this age group fear falling even when they have not experienced any falls. This fear may cause older adults to avoid engaging in activities such as shopping, walking, or participating in social activities (Wang et al., 2016).
Mrs. Smith should have her hearing and eyes tested. According to Montero & Speechley (2018), the slightest changes in hearing and sight can cause her to fall. If she gets new contact lenses or eyeglasses, she will need to take time to get used to them. She will need to wear her glasses or contacts whenever she needs them. She will also need to get a hearing aid if she already does not have one and ensure that it fits well and that she wears it well. Abrams (2017) adds that when hearing aids are worn properly, a person becomes more attuned to the environment and is less likely to fall. Additionally, improved hearing can prevent the cognition overload caused by hearing loss. The hearing aid will also help her distinguish between subtle sounds and their direction. For example, with a hearing aid, Mrs. Smith will be in a better position to hear a pet or another person approaching her, reducing her chances of falling because of surprise collision falls or tripping over these. With enhanced hearing, she will be able to use sound information as reference points for audio sounds so as to maintain balance in the same way that people use visual cues (Abrams, 2017).
Mrs. Smith will be advised to stay physically active. She will need to have an exercise program that is ideal for her. Exercising regularly will help strengthen her muscles and make the ligaments, tendons, and joints more flexible. She can engage in activities that involve mild weight-bearing, such as climbing stairs and walking, which can slow down bone loss (Chan et al., 2015).
Getting enough sleep is also important. To improve her sleep quality, Mrs. Smith will need to understand the reasons for her insomnia. These underlying reasons include stress, depression, and feeling emotionally hopeless and flat; struggling with chronic worry and anxiety; having gone through a recent traumatic experience; and the type of medication she is taking that could be causing her to lack sleep (Takada et al., 2018). Farther, Mrs. Smith will need to look for someone she can confide in and talk to face-to-face. Additionally, bright sunlight will help regulate melatonin and her sleep-waking cycles. The patient will need to get at least 2 hours of sunlight or use a light therapy box. Additionally, regular daily exercises will help in promoting good sleep (Takada et al., 2018).
Mrs. Smith will need to limit the alcohol she drinks, if any because even a minimal amount can affect her reflexes and balance. Besides, the rate of hip fractures among the elderly increases with an increase in alcoholic drink intake (Callis, 2016). Also, she will need to stand up slowly because getting up too fast causes a drop in her blood pressure. This can make her feel wobbly; hence, her blood pressure needs to be checked when she stands as well as when she lies down (Callis, 2016).
Phelan et al. (2015) recommend using an assistive device if she needs help feeling steady as she walks. The appropriate use of a walker or a cane can prevent falls. She should ensure that the walker or cane is the right size and that the wheels roll smoothly. This will be important when she is walking in unfamiliar areas or where there are uneven walkways. An occupational or physical therapist can help decide which devices can be helpful and teach her how to use the devices safely. Farther, Mrs. Smith will need to be careful when she is walking on icy or wet surfaces. Her back or front door areas will need to be spread with salt or sand. Also, she will need to wear low-heeled, rubber-soles, non-skid shoes or no-skid, lace-up shoes that offer her feet full support. She will also need to avoid walking on the floor or stairs with socks or slippers and shoes with smooth soles. Further, during the end-of-year cleaning, she will have to look for ways to reduce the trip hazards, such as repairing carpet patches and rugs (Phelan et al., 2015). It is also advisable to repair and clean pathways as well as mark the steps’ edges to make them more visible, in addition to installing grabbers and handrails where needed.
Lastly, Mrs. Smith will need to be active and healthy by eating healthy foods and engaging in regular exercise. This will help maintain her bone and muscle strength, which prevents stiff joints. Making sure that she is eating foods rich in Vitamin D and calcium or even supplements of these can help maintain bone strength. Also, she will need to keep her fluid levels up (Pohl et al., 2015).
References
Abrams, H. (2017). Hearing loss and associated comorbidities: What do we know? Hearing Review, 24(12), 32-35.
Callis, N. (2016). Falls prevention: Identification of predictive fall risk factors. Applied nursing research, 29, 53-58.
Chan, W. C., Yeung, J. W. F., Wong, C. S. M., Lam, L. C. W., Chung, K. F., Luk, J. K. H., … & Law, A. C. K. (2015). Efficacy of physical exercise in preventing falls in older adults with cognitive impairment: a systematic review and meta-analysis. Journal of the American Medical Directors Association, 16(2), 149-154.
de Zwart, A. H., van der Esch, M., Pijnappels, M. A., Hoozemans, M. J., van der Leeden, M., Roorda, L. D., … & van Dieën, J. H. (2015). Falls associated with muscle strength in patients with knee osteoarthritis and self-reported knee instability. The Journal of Rheumatology, 42(7), 1218-1223.
Healthline (2018 a). Lisinopril, Oral Tablet. Retrieved from https://www.healthline.com/health/lisinopril-oral-tablet
Healthline (2018 b). Popular Over-the-Counter Oral Antihistamine Brands. Retrieved from https://www.healthline.com/health/allergies/antihistamine-brands
Hewston, P., & Deshpande, N. (2016). Falls and balance impairments in older adults with type 2 diabetes: thinking beyond diabetic peripheral neuropathy. Canadian journal of diabetes, 40(1), 6-9.
Jiam, N. T. L., Li, C., & Agrawal, Y. (2016). Hearing loss and falls: A systematic review and meta‐analysis. The Laryngoscope, 126(11), 2587-2596.
Manlapaz, D. G., Sole, G., Jayakaran, P., & Chapple, C. M. (2019). Risk factors for falls in adults with knee osteoarthritis: a systematic review. Pm&r, 11(7), 745-757.
Montero‐Odasso, M., & Speechley, M. (2018). Falls in cognitively impaired older adults: implications for risk assessment and prevention. Journal of the American Geriatrics Society, 66(2), 367-375.
Phelan, E. A., Mahoney, J. E., Voit, J. C., & Stevens, J. A. (2015). Assessment and management of fall risk in primary care settings. Medical Clinics, 99(2), 281-293.
Pohl, P., Sandlund, M., Ahlgren, C., Bergvall-Kåreborn, B., Lundin-Olsson, L., & Wikman, A. M. (2015). Fall risk awareness and safety precautions taken by older community-dwelling women and men—A qualitative study using focus group discussions. PLoS one, 10(3), e0119630.
Takada, S., Yamamoto, Y., Shimizu, S., Kimachi, M., Ikenoue, T., Fukuma, S., … & Sekiguchi, M. (2018). Association between subjective sleep quality and future risk of falls in older people: results from LOHAS. The Journals of Gerontology: Series A, 73(9), 1205-1211.
Wang, D., Zhang, J., Sun, Y., Zhu, W., Tian, S., & Liu, Y. (2016). Evaluating the fall risk among elderly population by choice step reaction test. Clinical interventions in aging, 11, 1075.
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Question 
Unit 3 Case Study
Instructions
Please review the attached document for details on this case study assignment. Please construct your responses and upload the document to this assignment area.
Complete the case study questions by documenting your response as the ‘Plan’ you would construct for this encounter with the patient – include the categories of diagnostics, therapeutics, education, and collaboration/consultation.
As we learned earlier this semester there is no longer access to the Hartford case studies without paying a fee.
Here is the information for your first case study. Please construct your responses and upload them into the Case Study 1 drop box.
Complete the case study questions including the appropriate interventions that should be done to address her symptoms.
Unit 3 Case Study
Opal Smith (Part 1) – retrieved from page 235 of the Ham and Sloane course text.
Opal Smith, an 80-year-old woman, comes to your office as a new patient. She has hypertension, type 2 diabetes (diet-controlled), osteoarthritis, and mild hearing loss. Mrs. Smith’s main reported symptoms are bilateral mild knee pain and some sense of unsteadiness on walking. She denies dizziness, postural symptoms, or falls in the past year. She takes lisinopril 10 mg daily, a multivitamin, calcium with vitamin D, acetaminophen as needed for pain, and diphenhydramine as needed for occasional insomnia. She has lived alone since her husband died 3 years ago. She still drives and has several friends with whom she visits. One of her friends suffered a fall several months ago and fractured a hip, from which she is still recovering. Mrs. Smith is somewhat worried about her own unsteadiness and risk of falls.
On exam, her blood pressure is 136/78 mmHg, pulse 72, weight 150 lbs (68 kg), and height 5 ft 5 in. She is mildly hard of hearing but communicates well. She has some mild crepitus on the motion of her knees; her gait is slowed with short steps and is somewhat wide-based. The rest of her examination is unremarkable, as are all routine laboratory tests. At the end of her examination, Mrs. Smith asks you for fall prevention recommendations.
- What are Mrs. Smith’s major risk factors for falls?
- What interventions would you recommend to minimize her risk?
Instructions: Please prepare and submit a paper 3-4 pages in length (not including APA format) answering the questions or responding to the prompts presented.