The lecture has been given on May 7th, 2011 by Dr. Asso Fariadoon Ali Amin.

1. Investigation & Management of Falls & Syncope Dr Asso Fariadoon Ali Amin MRCP(UK) GIM/ Care of Elderly physician

3. Mechanical or accidental falls refer to a fall secondary to slipping or tripping over something. Mechanical falls among Elderly above the age of 65 admitted to hospital are uncommon and recurrent falls should never be considered accidental. Older people often fall as a result of medical condition , many of which can be treated.

4. Definition:- of fall is unintentionally coming to rest on the ground or some lower level and other than a consequences of sustaining a violent blow, loss of consciousness, or sudden onset of paralysis as in stroke or epilepsy.

6. Hospital admission:- admission due to falls are six times higher in older people above the age of 65.

7. Psychological:-

8. 1/3 of those age over 60 years develop a fear of falling

9. loss of confidence

10. Post fall anxiety

11. self imposed functional limitation

12. Social isolation

13. Depression.

14. Disability

15. Long Lie:- defined as remaining on the floor for more than 1 hour. Which can result in:-

16. Pressure sore

17. Hypothermia

18. Orthostatic pneumonia

19. Rhabdomyolysis

20. Dehydration

21. Increase mortality , 50% of those remain on the floor for 1 or more hour are dead within 6 months- 1 year.

23. Vascular:- Myocardial infarction or Cererbrovascular accident

24. Metabolic:- hypoglycaemia, hyponatremia Single fall which may be accidental Recurrent falls

26. Advanced age

27. Living alone

28. Previous falls

29. Limited activity of daily living

30. Age related changes

31. reduced ability to discriminate edges. ( e.g. Stairs) ,

32. reduced peripheral sensation,

33. slower reaction time

34. muscle weakness

35. Poor gait and balance

36. Medical problem:- e.g. Parkinson's disease, cognitive impairment, CVA, Poor vision ( cataract and glaucoma) , foot problems, arthritis, peripheral neuropathy, incontinence

37. Medication:- antihypertensive, antipsychotic, sedative, opiates, diuretic, hypoglycaemic specially long acting oral drugs and insulin

39. Taking four or more medications – especially sedating drugs, anti-hypertensives, anti-depressants, diuretics, anti-anginals, Digoxin

40. Visual impairment

41. Impaired cognition or depression

42. Postural hypotension, Carotid Sinus Hypersensitivity, Vasovagal tendency

44. Steep Stairs

45. Loose carpets & rugs

46. Slippery floors

47. Badly fitting footwear or clothing

48. Lack of grab rails or raised seating

51. Vital signs including respiratory rate

52. Conjunctivae for severe anaemia

53. Chest, abdomen, CVS, neurological examination

54. Blood pressure lying and standing

55. Cognitive function

57. NSF – who should be referred to a specialist falls service? Those who have had a previous or new fragility fracture Those who attend A&E having fallen Those who have called out an ambulance having fallen Those who have two or more intrinsic risk factors in the context of a fall Those who have frequent unexplained falls Those who fall in a care home Those who live in unsafe housing Those who are very afraid of falling

59. Symptoms:- dizziness, vertigo, chest pain, palpitation, speech problem

60. Previous fall:- is this the first fall secondary to acute illness or recurrent secondary to mobility problem or cognitive function.

61. Location:- outdoor or indoor ( outdoor has a better prognosis than the ones at home)

62. Activity:- walking, hanging out washing, standing on a chair, standing from sitting

63. Time:- after meal, early in the morning.

64. Trauma:- sustained?

65. Medication review

66. Cognitive function assessment ( AMT)

67. Functional assessment ( get up and go test)

68. Vision assessment ( cataract-acuity, visual field)

69. Hearing

70. CVS examination

71. Blood Pressure Lying and standing *

72. Investigation:- FBC, Urea and electrolyte, LFT, TFT, CRP, Urine , ECG,

74. Tricyclic antideprresant

75. Skeletal muscle relaxant like baclofen

76. Opiate

77. Diuretic

78. Antihypertensives specilly ACE I and alpha blockers

80. Causes:- Vasovagal :- vagal stimulation for example in fears and bad news Postural hypotension:- main causes dehydration, septicaemia, medication, autonomic in Diabetes and addison’s disease. Carotid sinus hypersensitivity Cardiovascular :- arrythmia and outlet obstruction e.g. Aortic stenosis. Neurology:- TIA and stroke.

81. ORTHOSTATIC HYPOTENSION Common condition Most marked after meal, high temperature, exercise, and at night. Reduction in systolic BP of 20mmHg on standing Reduction in systolic BP to less than 90mmHg on standing Reduction in diastolic BP of 10mmHg with symptoms

83. Dehydration

84. Septicemia

85. Prolonged hypertension

86. Autonomic failure (pure, diabetic, parkinsons)

89. Increased brainstem input & reduced sympathetic outflow & increased vagal tone

91. CAROTID SINUS HYPERSENSITIVITY Carotid sinus massage for 5 seconds: Cardio inhibitory: 3 second or more period of asystole Vasodepressor: a 50mmHg fall in systolic blood pressure Mixed response

92. CSH - THERAPY Cardio-inhibitory: permanent pacing Vasodepressor: very difficult to treat, consider those therapies used for orthostatic hypotension

94. Menieres disease

95. BPV

96. Causes of syncope and pre-syncope

97. Post Circulation infarction

98. Vertebrobasilar insufficiency

99. Anxiety and depression

101. EXAMINATION Heart rate / rhythm Postural BP Carotid bruits Carotid sinus massage Presence of murmurs Neurology: evidence of stroke, cerebellar signs, Parkinson’s Disease

102. INVESTIGATIONS Baseline bloods : anaemia, renal dysfunction, diabetes 12 lead ECG Holter monitoring Tilt testing : 80’ head up tilt for 45 minutes +/- GTN provocation. CSM supine & 80’ head up tilt

103. Tilt Table Testing Advise patient to avoid caffeine, large meals & alcohol prior to test Omit cardiac drugs prior to test Consent for the procedure Lie flat on tilt table for 15 minutes CSM Supine Tilt for 30 minutes If no events – carry out CSM when tilted If no events – administer 2 puffs GTN sublingually & monitor for a further 15-20 minutes depending on response

104. Life Example 66 lady from India, diabetic on metformin, presented with history of recurrent falls in the last 6 months. She also complained of generally feeling weak, tired, lost 7kg in the last 3 months with nausea and vomiting in the morning . O/E Bp Lying 130/80 Standing 100/60 76 years old , history of recurrent fall, with history Of hypertension on amlodipine, and osteoarthritis of Both knees. Last fall happened while searching for a book in his library . O/E BP L/S normal , bilateral Knee swelling, X-ray neck severe OA (previous film)

105. Life Examples 74 man , hypertensive on amlodipine ,and amiloride, and lisinopril also has history of bilateral knee OA with left sided TKR. Recently visited a surgeon for symptoms of BPH , started on Doxazocin 4mg . Presented with feeling light headed , dizzy, and followed by blackout and then fall. 77 old man , history of parkinson disease , presented with recurrent falls associated with feeling dizzy on standing up ,BP (L) 140/90 (S) 110/70

106. The End