Chapter 3. Falls and Drop Attack Flashcards
Question 3-1:
Which of the following conditions predisposes to episodic
falls?
A. Common origin ofboth anterior cerebral arteries
B. Obstruction ofthird-ventricular outflow
C. Basilar artery thrombotic disease
D. Spinal cord damage
E. All of the above
Answer 3-1: E.
Common origin of the anterior cerebral
arteries results in predisposition of bilateral
parasagittal ischemia. A single embolus may
lodge in this common vessel which then
results in bilateral leg weakness. Obstruction
of third ventricular outflow by colloid cyst,
aqueductal stenosis, or tumors can produce
episodic increased intracranial pressure which
then eM cause loss of consciousness. Basilar
artery thrombosis predisposes to loss of
brainstem perfusion. Spinal cord damage from
any cause affects motor function including
coordination which predisposes to falls. (p24·
25)
Question 3-2:
Patients with Parkinson’s disease are more likely to fall. Which
of the following is not a common contributing factor?
A. Peak.-dose dyskinesias
B. Off periods
C. Impaired postural reflexes
D. Convulsive motor activity
Answer 3-2: D.
Convulsions are uncommon in patients with
Parkinson’s disease. Drug-induced dyskinesias
often predispose to falling since the
movements are often enatic and outside of the
patient’s ability to compensate for the
movement. Off periods also predispose, since
the patient cannot react well to a loss of
balance. The impaired postural reflexes are
typical of parkinsonism. (P25)
Question 3-3: Aging predisposes to falls by which ofthe following mechanisms? 1. Impaired proprioception 2. Arthritis 3. Impaired vision 4. Loss of muscle bulk Select: A =1,2,3. B =I, 3. C =2, 4. D =4 only. E = All
Answer 3-3: E.
All of these are common sequelae to aging
and predispose to falls. Impaired
proprioception is present in patients with
peripheral neuropathy but also develops to a
limited extent in normal aging. Likewise,
impaired vision impedes the visual cues which
make gait more stable. Arthritis and normal
loss of muscle bulk impair the body’s ability
to make the corrective movements needed for
intact gail (P26)
Question 3-4: Cataplexy is an uncommon cause of falls and is associate with narcolepsy. Which of the following is not a cardinal feature of narcolepsy? A. Excessive daytime sleepiness B. Hypnagogic hallucinations C. Poor nocturnal sleep D. Sleep paralysis
Answer 3-4: C.
Poor nocturnal sleep can be a cause of
excessive daytime sleepiness, certainly in the
differential diagnosis of narcolepsy. However.
poor sleep is not a cardinal feature of
narcolepsy. (P26)
Question 3-5:
How can cataplexy be differentiated from epilepsy?
A. Epileptic syncope does not occur without other signs ofconvulsive activity
B. Cataplexy is provoked whereas epilepsy is typically not provoked
C. Consciousness is preserved in cataplexy but disturbed in patiCllts with epilepsy
D. Arrhythmias are typical of cataplexy but not seizures
Answer 3-5: B.
Cataplexy is typically provoked by a stimulus,
whereas epilepsy is usually unprovoked;
rarely, seizures are stimulus-evoked. Patients
with epilepsy do not always have convulsive
activity, so the absence of jerking does not
rule out epilepsy. Also, epilepsy is not always
associated with loss of consciousness.
Arrhythmias are not expected with cataplexy
whereas they can develop in some patients
with epilepsy.
Question 3-6: Associated with rigidity. A. Parkinson's disease B. Progressive supranuclear palsy C. Both D. Neither
Answer 3-6: C.
Both PO and PSP are associated with
propensity to falls plus rigidity. PSP has
several clinical features in common with PO,
and differentiating between these entities can
be difficult.
Question 3-7: Greater tendency to fall backwards A. Parkinson's disease B. Progressive supranuclear palsy C. Both D. Neither
Answer 3-7: B.
PSP is associated with a greater tendency to
fall backward whereas PO is associated with a
greater tendency to fall forward, though
falling backward can occur
Question 3-8: Associated with spasticity. A. Parkinson's disease B. Progressive supranuclear palsy C. Both D. Neither
Answer 3-8: B.
Spasticity can occur in PSP but is absent in
PD.
Question 3-9: May be preceded by REM sleep behavior disorder. A. Parkinson's disease B. Progressive supranuclear palsy C. Both D. Neither
Answer 3-9: B.
Idiopathic REM sleep behavior disorder is a
precursor to PSP. and is also an independent
cause of falls in the elderly.
Question 3-10:
Which of the following statements concerning vestibular causes off falls are true?
1. Patients with Meniere’s disease may suddenly fall without accompanying vertigo
2. Aberrant signals from vesnbular receptors result in inappropriate postural adjustment
3. Patients with vertigo can have gait ataxia and falls without appendicular ataxia
4. Peripheral vestibulopathy is the most likely cause of cryptogenic falls in middle-aged women
Select A =1,2,3. B= 1,3. C= 2, 4. D =4 only. E= All
Answer 3-10: A.
Patients with Meniere’s disease may fall
without preceding or accompanying vertigo.
Patients with all peripheral causes of vertigo
will have gait difficulty with a propensity to
fall without appendicular ataxia. The cause of
these peripheral causes of vertigo is errant
signal from the receptors which then cause
corrective postural maneuvers which throw
the patient off balance. Cryptogenic falls in
middle-aged women are felt to be due to a
central pathogenesis.
Question 3-11:
Anterior cerebral artery ischemia can produce drop attack, falls without disturbance of consciousness.
T. True
F. False
Answer 3-11: T.
Transient anterior cerebral artery ischemia can
produce drop attacks without disturbance of
consciousness. Bilateral leg weakness can
result if both arteries have a common origin,
an anomaly in about 20% of individuals
Questions 3.12 : Orthostatic hypotension is rarely a cause of Falls in elderly. T. True F. False
Answer 3-12: F.
Orthostatic hypotension is a common cause of
falls in the elderly. This is true not only in
patients with autonomic neuropathy and
parkinsonism, but also in otherwise normal
elderly patients. Drug effects also have to be
considered
Question 3-13 :
Drop attacks may be exacerbated by carbamazepine in patients with Rolandic epilepsy.
T. True
F. False
Answer 3-13: T.
Rolandic epilepsy is a benign epilepsy of
childhood. Drop attacks in these patients may
be precipitated by carbamazepine
Question 3-14:
A 70-year-old right-handed man with stroke resulting in left hemiparesis has two episodes of falls which have an incomplete history, and neither of which were observed by health-care workers. The list below includes possible reasons for the fall. Prolonged period of somnolence and confusion following the fall.
A. Recurrent TIA
B. Another CVA
C. Seizure secondary to the first CV A
D. Simple fall associated with poor coordination associated with the fall
E. Cardiac arrhythmia with decreased cerebral perfusion
Answer 3-14: C.
Seizure is the most likely if the patient has
prolonged somnolence and confusion. While
tonic-clonic activity is most suggestive of
seizures, not ail have motor activity. Also, the
motor activity may not always be observed.
Question 3-15:
A 70-year-old right-handed man with stroke resulting in left hemiparesis has two episodes of falls which have an incomplete history, and neither of which were observed by health-care workers. The list below includes possible reasons for the fall. Pre syncopal sensation and diaphoresis preceding the fall, with no sequelae.
A. Recurrent TIA
B. Another CVA
C. Seizure secondary to the first CV A
D. Simple fall associated with poor coordination associated with the fall
E. Cardiac arrhythmia with decreased cerebral perfusion
,uswer 3-15: E.
Cardiac arrhythmia is most likely to produce
presyncopal sensations. The diaphoresis also
suggests a hyperadrenergic state which is most
likely with cardiac causes and systemic
hypotension. The lack of sequelae after the
fall would argue against TIA or recurrent
CVA.
