Immobility, Falls, Dizziness and Blackouts - in 1 hour! Dr C Mitchell SpR Geriatrics / GIM

Objectives Examine common clinical presentations affecting mobility, with a focus on the elderly List the important investigations in these patients, and how to interpret them Be aware of other implications of falling / syncope, including driving and fracture risk Perform and interpret the Dix-Hallpike manoeuvre Recognise the wider implications of mobility problems and the role of the MDT Formulate problem lists and comprehensive management plans for the falling / syncopal / immobile patient

Examine common clinical presentations affecting mobility, with a focus on the elderly

List the important investigations in these patients, and how to interpret them

Be aware of other implications of falling / syncope, including driving and fracture risk

Perform and interpret the Dix-Hallpike manoeuvre

Recognise the wider implications of mobility problems and the role of the MDT

Formulate problem lists and comprehensive management plans for the falling / syncopal / immobile patient

Blackouts / Syncope Some causes? Break them down into groups eg: Cardiac (Arrhythmic / Structural) Identify important parts of history and examination for these groups. What investigations should all LOC patients receive? What special investigations are needed for specific subgroups?

Some causes?

Break them down into groups eg: Cardiac (Arrhythmic / Structural)

Identify important parts of history and examination for these groups.

What investigations should all LOC patients receive?

What special investigations are needed for specific subgroups?

Tilt Testing Consider in unexplained blackouts Involves progressively tilting patient from flat to upright, monitoring HR & BP Can be provoked with GTN Often also includes CSM Can identify neurocardiogenic syncope Can divide response into cardioinhibitory, vasodepressor or mixed

Consider in unexplained blackouts

Involves progressively tilting patient from flat to upright, monitoring HR & BP

Can be provoked with GTN

Often also includes CSM

Can identify neurocardiogenic syncope

Can divide response into cardioinhibitory, vasodepressor or mixed

Driving – DVLA Restrictions Simple faint – No restrictions LOC with low risk for recurrence – 4 weeks LOC with risk factors – 4 weeks if underlying cause treated, license revoked for 6 months if no cause found Abnormal ECG Clinical evidence of structural heart disease More than one episode in 6 months Occurrence while sitting/lying/driving resulting in injury Any suspicion of epilepsy – revoked for 1 year

Simple faint – No restrictions

LOC with low risk for recurrence – 4 weeks

LOC with risk factors – 4 weeks if underlying cause treated, license revoked for 6 months if no cause found

Abnormal ECG

Clinical evidence of structural heart disease

More than one episode in 6 months

Occurrence while sitting/lying/driving resulting in injury

Any suspicion of epilepsy – revoked for 1 year

Orthostatic Hypotension Lying / Standing BP x 3 Check BP after lying for >5 mins Recheck after standing for 1min and 3min Common causes are: Hypovolaemia (Remember Addison’s) Medications inc alpha blockers, diuretics, ACE-I, nitrates, calcium channel blockers, antidepressants Acute illness Dysautonomia (inc PD, DM) Alcohol Treat with advice, medication review, TEDs, fludrocortisone, or midodrine

Lying / Standing BP x 3

Check BP after lying for >5 mins

Recheck after standing for 1min and 3min

Common causes are:

Hypovolaemia (Remember Addison’s)

Medications inc alpha blockers, diuretics, ACE-I, nitrates, calcium channel blockers, antidepressants

Acute illness

Dysautonomia (inc PD, DM)

Alcohol

Treat with advice, medication review, TEDs, fludrocortisone, or midodrine

VERTIGO

Vertigo One type of dizziness Subjective / Objective Usually caused by failure of the vestibular system Inner ear Vestibular nerve (CN8) Brainstem Cerebellum

One type of dizziness

Subjective / Objective

Usually caused by failure of the vestibular system

Inner ear

Vestibular nerve (CN8)

Brainstem

Cerebellum

Vertigo One type of dizziness Subjective / Objective Usually caused by failure of the vestibular system Inner ear Vestibular nerve (CN8) Brainstem Cerebellum Peripheral Central

One type of dizziness

Subjective / Objective

Usually caused by failure of the vestibular system

Inner ear

Vestibular nerve (CN8)

Brainstem

Cerebellum

Large crossover in symptoms Peripheral vs Central Peripheral Central Abrupt onset Intense Nausea / Vomiting Auditory complaints Associated with head position More gradual onset Less intense

Large crossover in symptoms

Large crossover in signs too: Peripheral vs Central Peripheral Central Nystagmus – delayed, fatiguable Auditory disturbance Immediate, non-fatiguable (Vertical nystagmus specific) Other CN signs Other PNS signs esp ataxia

Large crossover in signs too:

Causes Peripheral BPPV Meniere’s disease (vertigo, tinnitus, progressive hearing loss) Ototoxicity (gentamicin, heavy metals, chemotherapy + many more) Vestibular neuritis Alcohol Central Migraine Stroke / TIA Head trauma MS SOL (Acoustic neuroma, frequently CN7 involvement) Hypotension (classically ‘lightheaded’ rather than vertiginous)

Peripheral

BPPV

Meniere’s disease (vertigo, tinnitus, progressive hearing loss)

Ototoxicity (gentamicin, heavy metals, chemotherapy + many more)

Vestibular neuritis

Alcohol

Central

Migraine

Stroke / TIA

Head trauma

MS

SOL (Acoustic neuroma, frequently CN7 involvement)

Hypotension (classically ‘lightheaded’ rather than vertiginous)

BPPV Commonest cause of peripheral vertigo Dix-Hallpike test used to diagnose: Nystagmus is delayed (5-10s), torsional , and fatiguable Fast phase towards affected side At least 30s between repetitions Usually benign and self limiting (<2 weeks) Around 20% will be persistent / recurrent Most of these are treatable

Commonest cause of peripheral vertigo

Dix-Hallpike test used to diagnose:

Nystagmus is delayed (5-10s), torsional , and fatiguable

Fast phase towards affected side

At least 30s between repetitions

Usually benign and self limiting (<2 weeks)

Around 20% will be persistent / recurrent

Most of these are treatable

How to do the Dix-Hallpike Patient sat upright Lean back quickly, head below body level Turn head 45 ° to one side Watch for nystagmus for up to 1min Wait 30s Repeat on opposite side Have a sick bowl ready

Patient sat upright

Lean back quickly, head below body level

Turn head 45 ° to one side

Watch for nystagmus for up to 1min

Wait 30s

Repeat on opposite side

Have a sick bowl ready

Falls Scale of the problem Reversible / Irreversible causes Modifiable risk factors Role of the MDT Interventions Rehab / Exercise / Falls prevention Medicines review

Scale of the problem

Reversible / Irreversible causes

Modifiable risk factors

Role of the MDT

Interventions

Rehab / Exercise / Falls prevention

Medicines review

Fracture Prevention XRs are not useful for evaluating BMD However an incidental finding of severe osteopaenia should prompt consideration of DXA In primary prevention, DXA indications are vague. Consider in those with >1 RF for osteoporosis: Family history Previous corticosteroid use Early menopause Smoking Low BMI Sedentary Lifestyle

XRs are not useful for evaluating BMD

However an incidental finding of severe osteopaenia should prompt consideration of DXA

In primary prevention, DXA indications are vague. Consider in those with >1 RF for osteoporosis:

Secondary Prevention - WOMEN Give Calcium / Vit D unless confident pt is replete Treat all over women over 75 with a fragility # Women age 65-74 – DXA, treat if osteoporotic Treat if T-score –2.5 Women under 65 – DXA, treat if severe Treat if T-score –2.5 and 1+ risk factor or if T-score –3 (severe osteoporosis)

Give Calcium / Vit D unless confident pt is replete

Treat all over women over 75 with a fragility #

Women age 65-74 – DXA, treat if osteoporotic

Treat if T-score –2.5

Women under 65 – DXA, treat if severe

Treat if T-score –2.5 and 1+ risk factor

or if T-score –3 (severe osteoporosis)

Secondary Prevention - MEN Give Calcium / Vit D unless confident pt is replete Treat all men with hip # Men with vertebral # - DXA, treat if osteoporotic Treat if T-score –2.5

Give Calcium / Vit D unless confident pt is replete

Treat all men with hip #

Men with vertebral # - DXA, treat if osteoporotic

Treat if T-score –2.5

Osteoporosis Rx Currently Risedronate / Alendronate are first line Strontium is also first line for over 80s If bisphosphonate not tolerated, other options are strontium, or raloxifene for women For revere osteoporosis, experts may use teriparatide (synthetic PTH)

Currently Risedronate / Alendronate are first line

Strontium is also first line for over 80s

If bisphosphonate not tolerated, other options are strontium, or raloxifene for women

For revere osteoporosis, experts may use teriparatide (synthetic PTH)

A Falls Service 2 Tasks: Design a falls OPD service, taking into account: How and where the clinic will be run What staff are required What other resources will be needed How patients will be identified / referred Design a Rapid response service for admitted fallers: Can admission be prevented? Where the service should operate What staff are required How the service will link up with OPD services

2 Tasks:

Design a falls OPD service, taking into account:

How and where the clinic will be run

What staff are required

What other resources will be needed

How patients will be identified / referred

Design a Rapid response service for admitted fallers:

Can admission be prevented?

Where the service should operate

What staff are required

How the service will link up with OPD services

Immobility In many ways, issues are similar to falls Acute or chronic? Identify reversible / treatable causes Assess for rehab potential Develop multi-disciplinary problem list Implement management plan with MDT

In many ways, issues are similar to falls

Acute or chronic?

Identify reversible / treatable causes

Assess for rehab potential

Develop multi-disciplinary problem list

Implement management plan with MDT

Cases In groups, discuss the clinical case presented to you. For each case: Formulate a problem list Form a differential diagnosis for any medical problems Develop a multidisciplinary management plan

In groups, discuss the clinical case presented to you. For each case:

Formulate a problem list

Form a differential diagnosis for any medical problems

Develop a multidisciplinary management plan

Summary Mobility presentations cover a huge variety of pathologies Watch out for the serious and reversible ones Investigations can be useful, but must be carefully selected The Hallpike test is quick, easy, and can pick up a truly reversible cause. The Epley manoeuvre can then be used to treat BPPV Modifying risk factors with a multidisciplinary approach is always important, even if a medical cause is apparent Always consider the consequences of mobility problems, including fracture risk, driving, and psychosocial impact

Mobility presentations cover a huge variety of pathologies

Watch out for the serious and reversible ones

Investigations can be useful, but must be carefully selected

The Hallpike test is quick, easy, and can pick up a truly reversible cause. The Epley manoeuvre can then be used to treat BPPV

Modifying risk factors with a multidisciplinary approach is always important, even if a medical cause is apparent

Always consider the consequences of mobility problems, including fracture risk, driving, and psychosocial impact