Transcript FALLS G.P. DAY

FALLS G.P.V.T.S. DAY
Dr Alastair Kerr
Consultant Geriatrician
5th April 2006
Clinical scenario 1
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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
On examination
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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
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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
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Always tripping
Feet feel like cotton wool
House bound as falling +++
Atenolol, Bendrofluazide, Tolbutamide
,Nitrofurantoin
On examination
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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 +
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Impaired gait
Slow rise from chair
Vision 6/9
Footwear sensible
HbA1C 8%
Ur 13 Cr 161
Urine: NAD
Discussion
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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
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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
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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
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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
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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 quicklylose 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
Aura
Prolonged confusion
Prolonged tonic-clonic
(coincides with LOC)
Tongue biting
Blue face
(Incontinence)
Syncope
N/V/sweaty/pallor
Quick recovery
Short tonic-clonic
(After LOC)
No tongue biting
Syncope made easy
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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
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24 hr tape
1 week tape
ECHO
Implantable loop recorder(Reveal)
If no heart disease
• Tilt table test
• Carotid sinus massage
Clinical scenario 5
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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; vasovagal 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
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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