FALLS G.P.V.T.S. DAY

Dr Alastair Kerr

Consultant Geriatrician

5th April 2006

Clinical scenario 1

• 80 yrs Female• Two trips in garden recently• Fall getting out of bed.• Didn’t turn light on• Poor vision• Hx vertebral # and positive F.H.• Nocturia x2Continent• Fear of falling• Nitrazepam 5mg nocte

On examination

• Tall, thin. Normal cognition.• P84 reg. HS- normal.• Bp 150/84 No postural drop• Normal lower limbs and feet• Normal balance. Romberg : Negative• Gait: cautious, sl wide base & short step• Rise from chair - normal• Vision 6/12• High heeled shoes

Discussion

• What are the differential diagnoses ?

• What are her risk factors for falling?

• What are her risk factors for osteoporosis?

• What referrals would you make and why?

• What advice would you give the patient?

• Would you prescribe any medication?

• What are the differential diagnoses ?– Simple trip; postural hypotension ; nitrazepam

• What are her risk factors for falling?– >80; >2 falls/yr; hypnotic; poor vision; unsafe gait;

shoes• What are her risk factors for osteoporosis?

– >80; previous #; family history; low BMI; high falls risk• What referrals would you make and why?

– Optician; OT(Home&footwear); physio (Balance/strength exs)

• What advice would you give the patient?– Lifestyle re osteoporosis; withdraw nitrazepam; turn

on light; sensible shoes• Would you prescribe any medication?

– Calcichew D3 forte; bisphosphonate

Clinical scenario 2

• 73 yrs Female

• 15yrs NIDDM & hypertension

• Voiding difficulties & recurrent UTI’s – long term Nitrofurantoin

• Occasional diarrhoea

• Collapse – standing at sink – felt unsteady – no L.O.C.

• Dizzy on first standing

• Always tripping

• Feet feel like cotton wool

• House bound as falling +++

• Atenolol, Bendrofluazide, Tolbutamide ,Nitrofurantoin

On examination

• Normal affect and cognition• High BMI• P72reg No murmurs• Bp 133/86 lying 110/80 standing• No peripheral pulses• Reduced light touch,JPS and no ankle

jerks• Romberg +

• Impaired gait

• Slow rise from chair

• Vision 6/9

• Footwear sensible

• HbA1C 8%

• Ur 13 Cr 161

• Urine: NAD

Discussion

• What are the differential diagnoses?• What are her falls risk factors?• What are her osteoporosis risk factors?• Would you stop any medication?• TEDS ?• What referrals would you make?• What medication would you start?• Any other suggestions?

• What are the differential diagnoses?– Postural hypotension with autonomic neuropathy due to

diabetes; peripheral neuropathy due to Nitrofurantoin• What are her falls risk factors?

– >2 falls/yr; postural hypotension; poor balance/gait; >3 drugs; • What are her osteoporosis risk factors?

– Chronic renal failure; falls risk• Would you stop any medication?

– Atenolol; Nitrofurantoin• TEDS ?

– No as P.V.D.• What referrals would you make?

– Physio; OT; S/worker; chiropody; diabetic nurse• What medication would you start?

– Calcichew D3 forte (?fludrocortisone if still postural bp drop)• Any other suggestions?

– Pendant alarm

Clinical scenario 3

• 78yr female

• Widow. Lives alone.

• Known HT,IHD,OA hips & knees

• Recurrent falls “Legs won’t do what I want them to do” “feet feel nailed to the floor” “my body turns but legs feel stuck & I fall over”

• 6/12 deterioration in walking

• Worsening memory – reliant on daughter

• New urinary incontinence – frequency, urgency,nocturia – too slow to WC

• Bendrofluazide, Perindopril, Aspirin, Simvastatin, Glucosamine

On examination

• MMSE 22/30

• SR Bp 140/86 – no drop

• Abdo – NAD

• Upper limbs normal

• Lower limbs – hypertonic, hyperreflexic

• Right upgoing plantar

• Eye movements / fundi - normal

• Quads wasting

• Urinalysis – NAD

• Vision 6/9

Discussion

• What are the differential diagnoses?• What one investigation would you do?• What are her falls risk factors?• What are her osteoporosis risk factors?• What referrals would you make?• Which drugs need reviewing?• What drugs would you start?• What would you tell daughter?

• What are the differential diagnoses?– Arteriosclerotic parkinsonism; normal pressure hydrocephalus;

cervial myelopathy• What one investigation would you do?

– CT brain• What are her falls risk factors?

– >2 falls/yr; incontinence; >3 drugs; cognitive impairment; gait/balance abnormalities

• What are her osteoporosis risk factors?– Frail; housebound; falls risk

• What referrals would you make?– Physio; OT; continence service; S/worker; ?CPN

• Which drugs need reviewing?– Stop bendrofluazide (worsen incontinence); ?madopar trial

• What drugs would you start?– Calchichew D3 forte

• What would you tell daughter?– Improve her diet; encourage regular exercise

Clinical scenario 4

• 72 yr male• Good health• No medications• Colles # 2yrs ago• Smokes 10/day• Alcohol 4u/wk• Car crash – sudden swerve onto pavement and

then into wall.• Next thing ambulance arriving.

• Pt has no memory of events & no warning

• Denies L.O.C.

• A&E : Examination normal. ECG & cardiac enzymes normal - discharged

• Previous similar episode – Colles #

• Occas dizzy if looks up or turns quickly-lose sense of balance

Discussion

• What are the differential diagnoses?

• Why is this not epilepsy?

• What investigations would you want to carry out?

• What is the treatment of choice for this condition?

• What are the differential diagnoses?– Syncope:vaso-vagal,carotid sinus hypersensitivity,

arrhythmia

• Why is this not epilepsy?– See next slide

• What investigations would you want to carry out?– Postural bp; bloods; ECG; Tilt table; carotid sinus

massage

• What is the treatment of choice for this condition?– Pacemaker

Seizure v syncope

Seizure SyncopeAura N/V/sweaty/pallor

Prolonged confusion Quick recoveryProlonged tonic-clonic Short tonic-clonic(coincides with LOC) (After LOC)Tongue biting No tongue bitingBlue face(Incontinence)

Syncope made easy

• Make diagnosis by history• Examination incl postural bp• ECG• Possible diagnoses:

– Vasovagal syncope– Carotid sinus hypersensitivity– Postural hypotension– Cardiac arrhythmias– Structural cardiac/cardiopulmonary disease

Is heart disease present or absent?

• Based on Hx(supine,palps,exertion), examination or abnormal ECG

• If NO heart disease, excludes cardiac cause of syncope (low mortality)

• If heart disease present then strong predictor of cardiac cause(low specificity) – higher mortality

Cardiac investigation

• 24 hr tape

• 1 week tape

• ECHO

• Implantable loop recorder(Reveal)

If no heart disease

• Tilt table test

• Carotid sinus massage

Clinical scenario 5

• 69yr female• 4 fits in 2 yrs and 3 unexplained falls• On sodium valproate – not controlling fits• Presents with #humerus post fit• Witness “Pallor” “Limbs jerking”• Dizzy pre-fits. Urinary incontinence.• Not confused on waking – “tired & washed out”• Examination - normal

What could be the diagnosis?

Give 5 possible diagnoses

What tests would you like to do?

What are her osteoporosis risk factors?

• Give 5 possible diagnoses– Uncontrolled epilepsy; hypoglycaemia; vaso-

vagal syncope; arrhythmia; C.S.H.

• What tests would you like to do?– Tilt table; carotid sinus massage; internal loop

recorder

• What are her osteoporosis risk factors?– Valproate; previous #

Clinical scenario 6

• 59yr female• Intermittent “dizziness” with associated loss of

balance.• Brought on by head movements(eg bending

forward or head extension) or turning over in bed• Recent viral illness• No medications• No alcohol/smoking• Examination - normal

Discussion

• What one question would you like to ask the patient?

• What possible diagnoses?

• What could you do to confirm the diagnosis?

• What is the treatment?

• What one question would you like to ask the patient?– Symptoms of vertigo?

• What possible diagnoses?– BPPV; postural hypotension; C.S.H.

• What could you do to confirm the diagnosis?– Dix-Hallpike manoeuvre

• What is the treatment?– Epley manoeuvre

Benign paroxysmal positional vertigo (BPPV)

• Commonest causes of vertigo

• Due to otoconial debris in semicircular canals

• Increases with age ; female>male

• Brief episodes (<1 min) vertigo (+/- imbalance) with specific head positions

• Episodic lasting few days – months

• Asymptomatic intervals months - yrs

Causes of BPPV

• Idiopathic

• Advanced age

• Post head trauma

• Vestibular neuritis

• Examination - normal

Dix-Hallpike manoeuvre

• Produces symptoms and torsional nystagmus

• Latent period

• Lasts 10-20 secs

Epley manoeuvre

• Repositioning treatment

• Complete recovery 70 % after one session

• 90% after second treatment