Falls, Dizziness And Syncope Flashcards
Why do elderly fall
SITUATIONAL
risk taking
INTRINSIC
Failure to maintain
postural control
EXTRINSIC
environmental
How to maintain balance
SENSORY INPUTS
• peripheral nerve
• vision
• vestibular
CENTRAL
PROCESSING
• global cerebral failure
• motor cortex + connections
• basal ganglia/extrapyramidal
• cerebellum
• spinal cord
NEUROMUSCULAR OUTPUT
• peripheral nerve
• muscles
• skeleton and joints
How to manage falls
PREVENTION
1. Deconditioning of postural reflexes + muscle strength
prevented by exercise - Tai-Chee, Rekei, Calinetics
combined with walking (> 30 minutes 3x a week)
2. Professional advice on the use of walking aids
3. Advice on sensible footwear and care of feet
MINIMIZE RISKS OF FRACTURE
1. Prevent and treat osteoporosis
COMPREHENSIVE ASSESSMENT IF HIGH RISK
• 1 x fall with injury
• 2 x fall in 12 months
• 1 x fall with abnormal gait
Assessing a patient with falls
METHOD
1. Identify contributory environmental and situational
factors
2. Clinical evaluation of patient to identify intrinsic
factors
3. Multidisciplinary intervention including medical,
environmental adaptation by occupational therapist
and strength and balance training + walking aids by
physiotherapist
Intrinsic factors that causes a fall
Medications that might cause a fall
• Psychotropics – hypnotics, antipsychotics, antidepressants
• Cardiac/antihypertensive drugs – postural hypotension, arrhythmias
• Anticholinergic side effects (NB tricyclic antidepressants and older
neuroleptic antipsychotics + clozapine)
Gait and balance assessment
- Get-up-and-go
- Sternal nudge
- Romberg
- One-legged-stance
- Tandem walk
Get up and go test
Romberg test
Ask patient to stand with feet together and arms at the sides then
close eyes for at least 10 seconds
• Staggering and having to take a step to prevent falling
= peripheral sensory neuropathy
• Swaying back and forth
= slow postural reflexes with increased falls risk
(may be abnormal in cerebral or vestibular disease but then there should be
symptoms or abnormal cerebellar signs present)
Sternal nodge
Ask patient to stand with feet together and eyes open then nudge
with 2 fingers on sternum with arm behind patient to catch them if
they lose balance (as hard enough as to move 1kg block 5 cm)
• Swaying or staggering = poor postural control
Lab investigations for falls
B12 and TSH
Plan with a patient with falls
- Physiotherapy for strength and balance training,
assessment for assistive devices and to address
fear of falling - Manage contributory medical problems
- Rationalize medication
- Occupational therapy to modify environment to
minimize risks and educate. - Behavior modification – situational factors usually
addressed by physio and OT; remember alcohol
and self medication
Syncope vs dizziness
SYNCOPE
Transient loss of consciousness
accompanied by loss of postural tone
DIZZINESS
Abnormal sensation resulting in a feeling of
impaired balance or postural control
Dizziness with no loss of consciousness types
Light headed
Disequilibrium
Vertigo
Vertigo causes
GENERALIZED ANXIENTY DISORDER
VESTIBULAR+/- DEAFNESS
BRAINSTEM+ CNS SIGNS
VERTEBROBASILAR INSUFFICIENCY
Cardiac presyncope
Vertigo test
Peripheral vertigo causes
• BPPV (Benign Paroxysmal Positional
Vertigo)
• Meniere’s
• Vestibular Neuronitis
• Progressive pathology
Central vertigo causes
Focal neurological signs or symptoms related to brainstem or cerebellar pathology
Episodic vertigo causes
BPPV
Meniere
TIA
BPPV(Benign paroxysmal positional vertigo)
• 1 – 2 minutes of intense vertigo on turning head
Diagnosis
• Dix-Hallpike manoeuvre
Treatment
• Epley’s manoeuvre
Menieres disease
Diagram to classify vertigo
Postural hypotension
> 20 mmHg ↓ systolic BP +/- 10 mmHg ↓ diastolic BP
within 3 minutes of standing + symptoms
Postural hypotension pathophysiology
Causes: - inadequate vasoconstriction +/- ↑ HR
- ↓ intravascular volume
Symptoms
-dizzy on standing, NB if vasodilated
- getting out of warm bed/ bath
- after big meal or alcohol
- standing in hot place
Automatic nervous systems dysfunction that leads to postural hypotension
CENTRAL: Age related slowing of reflexes
- 1• - Multisystem Atrophy
PERIPHERAL: afferent – Guillain-Barré
efferent – Diabetes mellitus
DRUGS: α + β blockers
Vasodilators –ACE inhibitors, Calcium channel blockers, Nitrates
Anticholinergics – Antidepressants, antipsychotics, Opiods
Reasons for intravascular volume depletion postural hypotension
Diuretics. ↓ cortisol. Or acute blood loss/dehydration
Cardiac syncope
Last a few minutes
Oriented and awake afterwards
No warning
Generalized seizure
Last half an hour
Post ictal confusion
With or without tonic clonic movement
With or without aura and incontinence
Blood pressure pathologies
Neurally mediated syncope
• Neurocardiogenic syncope
• Situational syncope
• Carotid sinus hypersensitivity
Neurally mediated syncope pathophysiology
Syncope pathophysiology
Carotid sinus hypersensitivity sinus massage contraindications
• Carotid bruit
• Carotid stenosis
• MI in last 3 months
• Known sick sinus
• On antiarrhythmic drugs
Other causes of syncope
STRUCTURAL HEART DISEASE
• Aortic stenosis
ARRHYTHMIA
• Bradyarrhythmia – sick sinus syndrome
- slow atrial fibrillation
- heart block 3rd degree
some 2nd degree (Wenckebach)
• Tachyarrhythmia – ventricular tachycardia
Clinical assessment of syncope
History, full exam including CVS + BP +lying and standing
ECG + chest xray
