Falling has many causes and nervous system disorders can present at first by falling. Falling can be serious in old age patients.

1. Neurological
Causes
of Frequent
Falling
Ahmed Mohamed Ibrahim Abdalla

2. What Are Falls
A fall occurs when a person who is
standing slips from an upright position
and comes into contact with the
ground.

3. • Falls in older people have been
substantially covered in medical literature,
but falls in young and middle aged have
been scantily considered. The prevalence
of falls increases with age, from about 18%
in the young (20-45 years), to 21% in the
middle aged (45-65 years), and 35% in
older adults (>65 years). The falls risk rises
to 45% in adults over the age of 80.
• Walking has been found to be the most
common fall-related activity .

4. Consequences
Falls are much a concern because of
their consequences, both physically
and psychosocially especially in
elderly.
- Physically: Injuries & Fractures.
- Psychologically: fear of falling that
may lead to more frequent falls.

5. Causes of Falls
Intrinsic Causes
A . Cardio-vascular
B. Central Nervous
System
C. Musclo-skeletal
D. Visual
E. Drugs
F. Psychogenic
Extrinsic Causes
1. Insufficient lighting
2. Unaccustomed
environment
3. Hazards placed in
inconvenient places
4. Uneven carpet or
floor
5. Inappropriate shoes

6. A: Cardiovascular factors
1. Arrhythmia
2. Postural hypotension
3. Decreased cardiac output
4. Decreased venous return
5. Carotid sinus hypersensitivity
6. Others: Stenosis of the carotid
arteries

7. B. Musculoskeletal factors
related to walking
1. Pain and disease of joints
2. Myopathy
3. Fractures and dislocation

8. C. Visual
1. Cataract
2. Refractive errors
3. Inappropriate glasses
4. Glaucoma

9. D. Drugs
1. Sedatives
2. Hypnotics
3. Others: Hypoglycemics, drugs
causing
motor dysfunction

10. E. Psychogenic factors
1. Fear of unpredictable space
2. Fear of falling again
3. Others

11. Neurological Causes of falls
in the young
• Multiple sclerosis
• Juvenile dermato-myositis
• Muscular dystrophies.
• Hereditary ataxias.
• Guillain—Barre Syndrome

12. Neurological Causes of falls
in the Middle aged
• Multiple sclerosis.
• Spinocerebellar ataxia.
• Cerebellar degeneration including
chronic ethanol abuse.
• Sensory ataxia (e.g. vitamin B12
deficiency).
• Stroke.

13. Neurological Causes of falls
in older people
• Dementia
• Stroke
• Parkinson's Disease
• Normal pressure hyrdocephalus
• Amyotrophic lateral scelrosis
• Peripheral Neuropathy

14. Stroke:
The high fall risk for individuals with
stroke is not only present in the acute
phase, but it remains a considerable
health concern throughout the post-
stroke life span.

15. Stroke
Other impairments
(eg. Cognitive &sensory)
Decline physical abilities
(Gait & Balance)
Falls
Fear of falling
Reduced Physical Activities
Fractures
Loss of bone mineral
density

16. Seizures
• Falling may occur during an epileptic
seizure and is typical of some epileptic
syndromes—namely, epilepsies with grand
mal seizures, myoclonic seizures, and
atonic and tonic seizures in generalized
cryptogenic or symptomatic epilepsies.
• Falling is also possible in partial seizures,
when secondary generalization follows the
partial onset or when the motor ictal
pattern causes a loss of postural control
leading to a fall. A sudden drop has been
described in patients with partial epilepsy .

17. Atonic Seizures
• In an atonic seizure, muscles suddenly lose
strength. The eyelids may droop, the head
may nod, and the person may drop things
and often falls to the ground. These
seizures are also called "drop attacks" or
"drop seizures."
• The person usually remains conscious.
These seizures typically last less than 15
seconds. They often start in childhood yet
last into adulthood. Many people with
atonic seizures are injured when they fall.

18. Multiple Sclerosis
• Symptoms
❑ Numbness and paresthesia
❑ Motor weakness or,
❑ Autonomic symptoms
❑ Gait problems

19. Gait Disorders
in Multiple Sclerosis
Multiple sclerosis patients frequently
experience walking limitations, which
affect their daily activities, social life,
emotional health, and socioeconomic
status.

20. Gait disturbance in multiple sclerosis
is often due to a combination of some
factors
Neurologic
impairments
Impairments affecting the
lower extremities, upper
extremities, and trunk:
• Paresis (weakness)
• Spasticity
• Cerebellar ataxia
• Sensory loss (dorsal
columns)
• Visual impairment (visual loss,
diplopia)
• Fatigue
• Neuropathic pain
Side effects of multiple sclerosis disease-modifying and symptomatic
therapies may affect walking performance. For example, medications for
spasticity may cause sedation, dizziness, and increased muscle weakness.
Iatrogenic
factors

21. Diagnosis of MS
2010 McDonald MRI Criteria
• clinical evidence
• (MRI) findings: DIS & DIT
Dissemination in Time
1. A new T2 and/or
gadolinium-enhancing
lesion(s) on follow-up MRI,
with
reference to a baseline scan,
irrespective of the timing of
the baseline MRI
2. Simultaneous presence of
asymptomatic gadolinium-
enhancing and nonenhancing
lesions at any time.
Dissemination in space
≥ T2 lesion in at least 2 of 4 areas
of the CNS:
• Periventricular
• Juxtacortical
• Infratentorial
• Spinal cord

22. Parkinsonian symdromes
Those are classified into :
• Idiopathic(primary), (PD)
• Acquired(secondary)
• Parkinson plus syndromes(multiple systems
degeneration)

23. Parkinson's Disease
• Parkinson disease (PD) is the second most
common neurodegenerative disorder after
Alzheimer disease.
• Patients with Parkinson’s disease often fall
due to defective postural reflexes, sudden
freezing, and uncoordinated turning; their
stooped flexed posture predisposes them
to fall
• PD is a disease of clinical diagnosis,
typical pattern of disease and
symptoms are very suggestive of PD
diagnosis

24. Secondary parkinsonism
• Multiple cerebral infarction
• Post encephalitic e.g. encephalitis
lethargica
• Toxicity; CO and Mn poisoning
• Drug induced PD; mainly
antipsychotic(fluphenazine,
buterophenons), mitronidazole
• Traumatic(multiple head trauma; boxing)
• Basal ganglia tumor
• Normotensive Hydrocephalus
• Vasculopathy; i.e. atherosclerosis

25. Normal Pressure Hydrocephalus
• A gradually progressive disorder with
classic triad consists of abnormal gait,
urinary incontinence, and dementia.
The gait disturbance is typically the
earliest feature noted.
• Triad due to compression on
periventricular white matter and brain
stem

26. Symptoms and signs of
Parkinson’s disease
Motor symptoms
• Cardinal: rigidity, tremors and
Brady-kinesia
• Non cardinal: postural instability,
abnormal posture ,gait disturbance,
swallowing difficulty, monotonous
speech, mask face , decrease
blinking ,etc

27. Non motor symptoms
• autonomic dysfunction: orthostatic
hypotetion, seborrhea, excessive
sweating,constipation, gastric dysmmotility
(gastroparesis) ,dysphagia, urinary
incontinence and sexual dysfunction
• Neuropsychiatric Problems: speech,
cognition Dementia, mood, behavioural
and thought
• sensory and sleep disturbance: insomnia,
disturbed vision, anosmia, parathesia and
pain

28. Dementia
In vascular dementia there is early
disturbance in gait, with unsteadiness
and frequent, unprovoked falls. Early in
the condition this is typically more
marked than in Azheimer's disease.
There may be focal neurological
abnormalities such as visual disturbances
(eg, field defects), sensory or motor
symptoms (eg, dysphasia, hemiparesis,
visual field defects) or extrapyramidal
signs (eg, dystonias and Parkinsonian
features).

29. • Cautious gait is seen in early Alzheimer's disease.
Changes to gait may be subtle at first, presenting
initially with a reduction in the speed and stride
of walking.
• Balance disturbance, short-stepping gait and
apraxia increase with the severity of disease.
Frontal gait disorder is also more common in
Alzheimer's disease patients.
• The degree of impairment is associated with
factors related to the severity of the disease (low
Mini Mental State Examination (MMSE) , but also
to factors such as age, sex, depression, obesity,
and the presence of comorbidities.

30. Cerebellar Disorders
• Ataxia is the most prominent
manifestation of cerebellar disease.
Ataxic gait consists of arrhythmic
(irregular) steps, unsteadiness, wide
base, and highly impaired tandem
gait. There may be associated
cerebellar signs (eg, dysarthria,
intention tremor, nystagmus)

31. - Congenital:
e.g, Dandy-Walker malformation
- Hereditary ataxias
e.g
• Friedreich ataxia (the most prevalent)
• Abetalipoproteinemia
• Ataxia with isolated vitamin E
deficiency
• Spinocerebellar ataxias

32. Acquired conditions
• Neurodegenerative disorders (eg, multiple system
atrophy),
• Systemic disorders: alcoholism (alcoholic
cerebellar degeneration), celiac disease,
heatstroke, hypothyroidism, and vitamin E
deficiency.
• Multiple sclerosis
• Cerebellar strokes
• Repeated traumatic brain injury
• Toxin exposure: Carbon monoxide, heavy
metals, lithium, phenytoin, and certain solvents.
Toxic levels of certain drugs (eg, anticonvulsants)
can cause cerebellar dysfunction and ataxia.

33. Diagnosis
• Diagnosis of cerebellar disorders is
clinical and includes a thorough family
history and search for acquired
systemic disorders.
• Neuroimaging, typically MRI, is done.
Genetic testing is done if family
history is suggestive.

34. Sensory Ataxia
Symptoms
• Gait problems, incoordination , numbness of legs
Signs
• Wide-based gait with impaired position and vibration
sense, high stepping gait. incoordination worsens on
closing eyes (positive Romberg’s sig, patient often
looks at the ground while walking
• Sensory ataxia is distinguished from cerebellar
ataxia by the presence of near-normal coordination
when the movement in question is visually observed
by the patient, but marked worsening of
coordination when the eyes are shut, indicating a
positive Romberg's sign.

35. Peripheral Neuropathy
Causes
• Diabetes mellitus
• Vitamin deficiency, particularly B12 and folate
• Alcohol
• Autoimmune diseases, including lupus, rheumatoid
arthritis or Guillain-Barre syndrome
• AIDS, whether from the disease or its
treatment, syphilis, and kidney failure.

36. Symptoms
• Numbness of limbs , hands ,and feet
Signs
• Loss of sensation (Glove &stock)
• Muscle weakness
• Autonomic signs (Orthostatic
hypotension , near syncope ,
arrhythmias)

37. Guillain-Barre Syndrome
Symptoms
• Weakness of limbs (legs more than arms)
numbness of feet and hands, gait problems
Signs
• Ascending symmetrical weakness ( lower
limbs more than upper limbs)severity may
range from mild weakness to paralysis with
respiratory failure
• Cranial nerve affection
• Usually VII and X cranial nerves leading to
bilateral facial paralysis and bulbar
symptoms

38. • Muscular dystrophies. e.g.,
myotonic muscular dystrophy,
congenital muscular dystrophy.
Emery—Dreifuss muscular
dystrophy and Duchenne muscular
dystrophy

39. Symptoms
• Muscle weakness (proximal/distal), gait
problems
Signs
• Waddling gait
• Hypotonia
• Kyphosis of the spine
• Proximal Joint contractures
• Hip dislocation
• Mild mental retardation
• Seizures
• Respiratory Insufficiency

40. Dermatomyositis
• An inflammatory disease of the
muscle (myositis), skin and blood
vessels.
Symptoms
• Weakness of arms and legs, skin
rash

41. Signs
A violet-colored or dusky red rash
• most commonly on the face, eyelids, and
areas around the nails, elbows, knees, chest
and back. The rash, which can be patchy with
bluish-purple discolorations, is often the first
sign of dermatomyositis. Also a Rash on the
knuckles occasionally can be misdiagnosed as
eczema when on fact it is dermatomyositis.
Gottron's papules.
Discrete erythematous papules overlying
the metacarpal and interphalangeal joints

43. Progressive muscle weakness
• particularly in the muscles closest to
the trunk (such as those in the hips,
thighs, shoulders, upper arms and
neck). This can affect the ability to get
out of a chair, off the floor or into the
car and leads to falls. The weakness
affects both the left and right sides of
the body equally, and tends to
gradually worsen.

44. Alcoholism
• Alcoholism affects gait at every level of the nervous
system.
• Major alcohol-related deficits include cognitive deficits,
weakness due to myopathy, asterixis (sudden loss of
muscle tone), cerebellar ataxia, chorea, and loss of
position sense (sensory ataxia).
• The Wernicke-Korsakoff syndrome of thiamine deficiency
includes confusion and ataxia, both of which impact gait
(the third is extraocular movement problems).
• Alcoholic neuropathy is a distal, predominantly sensory or
sensorimotor polyneuropathy. The dysaesthesia of
alcoholic neuropathy sometimes discourages walking.
• Alcoholic cerebellar degeneration affects mostly the
vermis, leading to a wide-based gait, poor tandem gait,
and perhaps leg ataxia, but usually no arm ataxia.

45. ALS:
Amyotrophic Lateral Sclerosis
symptoms
• Difficulty walking or doing your normal daily activities
• Tripping and falling
• Weakness in your leg, feet or ankles
• Hand weakness or clumsiness
• Slurred speech or trouble swallowing
• Muscle cramps and twitching in your arms, shoulders and
tongue
• Difficulty holding your head up or keeping good posture
•
Signs
• Progressive muscle weakness and wasting due to loss of
lower motor neurons
• Spasticity due to loss of cortico-spinal upper motor
neurons

46. Medication & Falls
• Certain anti-epileptic medications
have an impact on balance and
walking. For instance, high doses
of phenytoin and/or carbamazepine
can impair balance.

47. • Polypharmacy (more than four
medications) is a risk factor for falls,
and psychiatric medications are
major offenders
• Selective serotonin reuptake
inhibitors (SSRIs) are associated
with falls and can cause more
postural instability than tricyclics.

48. • Parkinsonism is usually caused by
antipsychotics, less often by other
dopamine-blocking agents such as
metoclopramide and
prochlorperazine, still less often by
SSRIs, valproate, and calcium-channel
blockers.
• Hypotension can be caused by any
number of agents, including several
antipsychotics, antidepressants and, of
course, antihypertensive drugs.

49. • Clozapine and valproate, by causing
asterixis (negative myoclonus), can
cause falling when the legs lose
tone. Gabapentin may also cause
asterixis-related falls.
• Vestibular functioning can be
suppressed to bad effect by
meclizine and benzodiazepines and
can be ablated by aminoglycosides.