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

FALLS G.P.V.T.S. DAY. Dr Alastair Kerr Consultant Geriatrician 5 th 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 x2 Continent Fear of falling

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

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  1. FALLS G.P.V.T.S. DAY Dr Alastair Kerr Consultant Geriatrician 5th April 2006

  2. 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 x2 Continent • Fear of falling • Nitrazepam 5mg nocte

  3. 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

  4. 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?

  5. 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

  6. 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

  7. Always tripping • Feet feel like cotton wool • House bound as falling +++ • Atenolol, Bendrofluazide, Tolbutamide ,Nitrofurantoin

  8. 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 +

  9. Impaired gait • Slow rise from chair • Vision 6/9 • Footwear sensible • HbA1C 8% • Ur 13 Cr 161 • Urine: NAD

  10. 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?

  11. 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

  12. 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

  13. Worsening memory – reliant on daughter • New urinary incontinence – frequency, urgency,nocturia – too slow to WC • Bendrofluazide, Perindopril, Aspirin, Simvastatin, Glucosamine

  14. 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

  15. Quads wasting • Urinalysis – NAD • Vision 6/9

  16. 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?

  17. 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

  18. 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.

  19. 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

  20. 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?

  21. 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

  22. Seizure v syncope SeizureSyncope Aura N/V/sweaty/pallor Prolonged confusion Quick recovery Prolonged tonic-clonic Short tonic-clonic (coincides with LOC) (After LOC) Tongue biting No tongue biting Blue face (Incontinence)

  23. 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

  24. 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

  25. Cardiac investigation • 24 hr tape • 1 week tape • ECHO • Implantable loop recorder(Reveal)

  26. If no heart disease • Tilt table test • Carotid sinus massage

  27. 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

  28. What could be the diagnosis? Give 5 possible diagnoses What tests would you like to do? What are her osteoporosis risk factors?

  29. 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 #

  30. 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

  31. 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?

  32. 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

  33. 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

  34. Causes of BPPV • Idiopathic • Advanced age • Post head trauma • Vestibular neuritis • Examination - normal

  35. Dix-Hallpike manoeuvre • Produces symptoms and torsional nystagmus • Latent period • Lasts 10-20 secs

  36. Epley manoeuvre • Repositioning treatment • Complete recovery 70 % after one session • 90% after second treatment

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