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Internal Medicine > Geriatrics- Falls > Flashcards

Geriatrics- Falls Flashcards

1
Q

Why are falls important?

A

Falls are significant due to their high incidence and serious consequences among older adults.

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2
Q

What is the incidence of falls in the elderly?

A
  • 30% per year in those over 65 years old
  • 50% per year in institutionalized elderly
  • Recurrent falls occur in ½ of institutionalized fallers
  • 75% of those over 85 years old will fall within 2 years
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3
Q

What are the consequences of falls?

A

10% result in serious injury, and 5% lead to fractures

1/3 develop a fear of falling, leading to a decline in function

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4
Q

What is a warning related to falls?

A

10% of falls occur during acute illness, highlighting the need for vigilance in this context.

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5
Q

Why do the elderly fall?

A

Extrinsic
- environmental

Intrinsic
- failure to maintain postural control

Situational
- risk taking

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6
Q

How is balance maintained

A

Sensory inputs
Central processing
Neuromuscular output

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7
Q

Sensory inputs

A
  • peripheral nerve
  • vision
  • vestibular
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8
Q

Central processing

A
  • global cerebral failure
  • motor cortex + connections
  • basal ganglia/ extra pyramidal
  • cerebellum
  • spinal cord
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9
Q

Neuromuscular output

A
  • peripheral nerve
  • muscles
  • skeleton and joint
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10
Q

Effect on aging on postural reflexes

A

Slowed postural reflexes

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11
Q

Factors that influences failings

A

Impaired sensory perception
Decreased muscle strength
Abnormal centre of gravity
Fear of falling
Slow postural reflexes

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12
Q

Impaired sensory perception

A

Eyes
Vestibular
Proprioreception
Peripheral sensation

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13
Q

Abnormal centre of gravity

A

Chin up
Shoulders forward
Buttocks out
Kyphosis 2ry to osteoporosis

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14
Q

Decreased muscle strength

A

Sarcopenia
Deconditioning

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15
Q

Fear of falling

A

Wide based gait
Shuffling feet
Bent forward
Hang on to furniture or use walking aid

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16
Q

What can help prevent deconditioning of postural reflexes and muscle strength in the elderly?

A

Engage in exercises like Tai Chi, Reiki, and Calisthenics combined with walking for more than 30 minutes, three times a week.

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17
Q

What professional advice should be sought regarding mobility aids?

A

Consult professionals for appropriate advice on the use of walking aids to enhance safety and mobility.

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18
Q

What footwear recommendations can help prevent falls?

A

Wear sensible footwear and maintain proper foot care to minimize the risk of falls.

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19
Q

How can the risk of fractures be minimized in elderly individuals

A

Prevent and treat osteoporosis through appropriate medical interventions and lifestyle changes.

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20
Q

What constitutes a high risk for falls in the elderly?

A

A comprehensive assessment is needed if there has been:

  1. One fall with injury,
  2. Two falls in the last 12 months,
  3. One fall with an abnormal gait.
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21
Q

Assessing a patient with falls

A

PURPOSE
To identify and correct or modify factors causing 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

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22
Q

Sensory input that causes falls

A

vision
vestibular
peripheral nerve

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23
Q

CNS factors that cause falls

A

delirium + dementia DRUGS
seizure
motor – strokes
extrapyramidal
cerebellar
spine - spasticity
- sensation

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24
Q

CVS factors that cause falls

A

CVS
postural BP drop
dizziness/ syncope

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25
Q

Musculoskeletal system factors that causes falls

A

MSS
joints
bones
feet

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26
Q

Intrinsic factors causing falls

A
  • sensory inputs
  • CNS
  • CVS
  • MSS
  • myopathy
  • peripheral neuropathy
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27
Q

What details should be gathered about the fall’s circumstances

A

Gather information on the location, time of day, and activity at the time of the fall.

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28
Q

Why is it important to inquire about previous falls?

A

Document the number of previous falls and the circumstances surrounding them to assess risk factors.

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29
Q

What situational factors should be considered in fall history?

A

Consider assistive devices used, whether the individual wears glasses, and alcohol consumption.

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30
Q

What associated symptoms should be assessed following a fall?

A

Evaluate for symptoms such as dizziness, syncope, or disequilibrium.

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31
Q

What should be assessed regarding current function and mobility?

A

Evaluate activities of daily living (ADLs), instrumental activities of daily living (IADLs), mobility level, and use of assistive devices.

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32
Q

Why is it essential to review the patient’s medical diagnoses?

A

Understanding existing medical conditions helps identify potential contributors to fall risk.

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33
Q

Which psychotropic medications should be considered in fall risk assessment?

A

Consider hypnotics, antipsychotics, and antidepressants, as they may affect balance and cognition.

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34
Q

How can cardiac and antihypertensive medications contribute to falls?

A

These medications can cause postural hypotension and arrhythmias, increasing fall risk.

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35
Q

Which medications are notable for anticholinergic side effects that can impact fall risk?

A

Be aware of tricyclic antidepressants, older neuroleptic antipsychotics, and clozapine, as they may cause dizziness and confusion.

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36
Q

What is the purpose of cognitive screening in fall assessments?

A

To evaluate cognitive function and identify any impairments that may increase fall risk.

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37
Q

Why is visual acuity important in fall risk assessment?

A

Poor visual acuity can affect balance and spatial awareness, increasing the likelihood of falls.

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38
Q

What does the Get-Up-and-Go test measure?

A

It assesses mobility and balance by timing how long it takes a person to stand up from a chair, walk a short distance, and return.

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39
Q

What is the Sternal Nudge test used for?

A

To evaluate balance by applying a gentle push to the sternum and observing the individual’s ability to maintain stability.

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40
Q

What does the Romberg test assess?

A

It evaluates proprioception and balance by having the individual stand with feet together, first with eyes open and then closed.

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41
Q

What is the purpose of the One-Legged Stance test?

A

To assess balance by timing how long the individual can maintain balance on one leg.

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42
Q

What does the Tandem Walk test measure?

A

It assesses balance and coordination by having the individual walk in a straight line, placing one foot directly in front of the other.

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43
Q

GAIT AND BALANCE ASSESMENT

A

Get-up-and-go
Sternal nudge
Romberg
One-legged-stance
Tandem walk

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44
Q

What are the steps for conducting the Get-Up-and-Go test and what should be observed?

A

Instructions to Patient:

Sit in a straight-backed chair with knees at 90°.
Get up without using your arms.
Stand still for a moment.
Walk forward 3 meters.
Turn around and walk back to the chair.
Turn and sit down.

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45
Q

What does difficulty getting up from a chair indicate?

A

It indicates proximal muscle weakness.

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46
Q

What does swaying while standing still suggest?

A

It suggests poor postural control.

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47
Q

What should be observed during walking for signs of abnormal gait?

A

Look for a wide-based gait, small stride length, or poor heel strike, which may indicate frailty and increased fall risk.

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48
Q

What does taking more than 3 steps to turn around indicate?

A

It indicates poor balance.

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49
Q

What does staggering on a turn or falling into a chair suggest?

A

It suggests poor postural control or muscle strength.

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50
Q

What does staggering and taking a step to prevent falling indicate during the Romberg test?

A

It indicates peripheral sensory neuropathy

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51
Q

What does swaying back and forth during the Romberg test suggest?

A

It suggests slow postural reflexes, which increases fall risk; it may also indicate cerebral or vestibular disease if accompanied by other symptoms or abnormal cerebellar signs.

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52
Q

Question: How do you conduct the Sternal Nudge test?

A

Ask the patient to stand with feet together and eyes open, then gently nudge the sternum with two fingers, having an arm behind them to catch them if they lose balance (apply enough force to move a 1 kg block 5 cm).

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53
Q

What does swaying or staggering during the Sternal Nudge test indicate?

A

It indicates poor postural control.

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54
Q

EXAMINATION

A

CVS: lying + standing BP, cardiomyopathy
aortic stenosis, ECG
CNS: motor – spasticity, weakness
sensory – all modalities incl. proprioception
cerebellar
MSS: muscle pain + weakness
joints – pain, ROM, deformity

LABORATORY INVESTIGATIONS
TSH, B12

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55
Q

INTERVENTION PLAN

A
  1. Physiotherapy for strength and balance training, assessment for assistive devices and to address fear of falling
  2. Manage contributory medical problems
  3. Rationalize medication
  4. Occupational therapy to modify environment to minimize risks and educate.
  5. Behavior modification – situational factors usually addressed by physio and OT; remember alcohol and self medication
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56
Q

What is syncope?

A

Syncope is a transient loss of consciousness accompanied by loss of postural tone.

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57
Q

How is dizziness defined?

A

Dizziness is an abnormal sensation resulting in a feeling of impaired balance or postural control.

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58
Q

Types of dizziness without loss of consciousness

A
  • vertigo
  • light headness
  • disequilibrium
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59
Q

What is vertigo?

A

Vertigo is a type of dizziness characterized by the sensation of spinning or movement, often related to inner ear issues.

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60
Q

What does lightheadedness feel like?

A

Lightheadedness is a sensation of feeling faint or as if you might pass out, but without a complete loss of consciousness.

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61
Q

What is disequilibrium?

A

Disequilibrium refers to a feeling of unsteadiness or loss of balance, often due to issues with the vestibular system or proprioception.

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62
Q

What characterizes peripheral vertigo?

A

Peripheral vertigo is caused by issues in the inner ear or vestibular system.

63
Q

Peripheral vertigo

A

BPPV (Benign Paroxysmal Positional Vertigo)
Meniere’s
Vestibular Neuronitis
Progressive pathology

64
Q

What is Benign Paroxysmal Positional Vertigo (BPPV)?

A

BPPV is a common cause of vertigo triggered by changes in head position, caused by dislodged calcium crystals in the inner ear.

65
Q

What is Meniere’s disease?

A

Meniere’s disease is a disorder of the inner ear characterized by episodes of vertigo, tinnitus, hearing loss, and a sensation of fullness in the ear.

66
Q

What is vestibular neuronitis?

A

Vestibular neuronitis is an inflammation of the vestibular nerve, often resulting in sudden, severe vertigo without hearing loss.

67
Q

What does progressive pathology refer to in peripheral vertigo?

A

Progressive pathology refers to ongoing or worsening conditions affecting the vestibular system, leading to persistent or recurrent vertigo.

68
Q

What characterizes central vertigo?

A

Central vertigo is caused by lesions or dysfunction in the central nervous system, particularly affecting the brainstem or cerebellum.

69
Q

What indicates central vertigo during assessment?

A

The presence of focal neurological signs or symptoms related to brainstem or cerebellar pathology indicates central vertigo.

70
Q

What are the typical symptoms of BPPV?

A

BPPV causes 1–2 minutes of intense vertigo triggered by turning the head.

71
Q

How is BPPV diagnosed?

A

BPPV is diagnosed using the Dix-Hallpike manoeuvre, which involves positioning the patient to provoke vertigo and observe for nystagmus.

72
Q

What is the treatment for BPPV?

A

BPPV is treated using the Epley’s manoeuvre, a series of head and body movements to reposition the dislodged calcium crystals in the inner ear.

73
Q

What is Meniere’s disease?

A

Meniere’s disease is a disorder of the inner ear characterized by episodes of vertigo, tinnitus, fluctuating hearing loss, and a sensation of fullness in the ear.

74
Q

What are the main symptoms of Meniere’s disease?

A

Episodic vertigo lasting from 20 minutes to several hours
Tinnitus (ringing in the ear)
Fluctuating sensorineural hearing loss
A feeling of fullness or pressure in the affected ear

75
Q

What is the underlying cause of Meniere’s disease?

A

Meniere’s disease is believed to be caused by abnormal fluid buildup (endolymph) in the inner ear.

76
Q

How is Meniere’s disease diagnosed?

A

Meniere’s disease is diagnosed based on clinical presentation, including a history of recurrent vertigo, hearing tests showing sensorineural hearing loss, and exclusion of other causes of vertigo.

77
Q

What treatments are available for Meniere’s disease?

A

Dietary changes: Reducing salt intake to lower fluid retention.

Medications: Diuretics, anti-vertigo medications (e.g., meclizine), and anti-nausea drugs.

Surgery: In severe cases, surgery may be considered to alleviate symptoms.

Lifestyle changes: Avoiding caffeine, alcohol, and stress.

78
Q

What is lightheadedness?

A

Lightheadedness is a sensation of feeling faint or as if you might pass out, without actually losing consciousness.

79
Q

What are common causes of lightheadedness?

A

Dehydration
Low blood pressure (hypotension)
Sudden standing (orthostatic hypotension)
Anemia
Hypoglycemia (low blood sugar)
Anxiety or panic attacks

80
Q

What are the associated symptoms of lightheadedness?

A

A feeling of being about to faint
Dizziness
Nausea
Weakness
Blurred vision
Tingling or cold sensation in extremities

81
Q

How is the cause of lightheadedness diagnosed?

A

Diagnosis involves taking a detailed medical history, physical examination (including blood pressure and heart rate), and possible blood tests to check for anemia or hypoglycemia. Orthostatic hypotension may be diagnosed by measuring blood pressure changes upon standing.

82
Q

How is lightheadedness treated?

A

Treatment depends on the underlying cause but may include:
Drinking fluids for dehydration
Eating a balanced diet for low blood sugar or anemia
Medications to manage blood pressure
Addressing anxiety through relaxation techniques or medication

83
Q

POSTURAL HYPOTENSION

A

> 20 mmHg ↓ systolic BP +/- 10 mmHg ↓ diastolic BP
within 3 minutes of standing + symptoms

84
Q

What is postural hypotension?

A

Postural hypotension, also known as orthostatic hypotension, is a condition where blood pressure drops significantly upon standing, leading to dizziness or lightheadedness.

85
Q

What are the main causes of postural hypotension?

A

Inadequate vasoconstriction or failure to increase heart rate

Decreased intravascular volume (e.g., due to dehydration or blood loss)

86
Q

What are the symptoms of postural hypotension?

A

Symptoms include dizziness upon standing, and it can be exacerbated by:

Getting out of a warm bed or bath
After a large meal or alcohol consumption
Standing in hot environments

87
Q

How is postural hypotension diagnosed?

A

Diagnosis is made by measuring blood pressure while the patient is lying down, then again after standing for 1–3 minutes. A significant drop in systolic blood pressure (≥20 mmHg) or diastolic blood pressure (≥10 mmHg) indicates postural hypotension.

88
Q

What is the treatment for postural hypotension?

A

Treatment may include:
Increasing fluid and salt intake (unless contraindicated)
Using compression stockings
Gradually rising from lying or sitting positions
Medications to improve blood pressure control, such as midodrine or fludrocortisone

89
Q

How can postural hypotension be prevented?

A

Preventive measures include:
Avoiding rapid position changes (e.g., rising slowly from bed)
Staying hydrated and avoiding alcohol or large meals that could trigger symptoms
Wearing compression stockings if necessary

90
Q

What is autonomic nervous system (ANS) dysfunction?

A

ANS dysfunction refers to the impairment of the autonomic nervous system, affecting its ability to regulate involuntary bodily functions, such as heart rate, blood pressure, and digestion.

91
Q

What are the central causes of autonomic nervous system dysfunction?

A

Central causes include:
Age-related slowing of reflexes
Primary conditions such as multisystem atrophy (MSA), a neurodegenerative disorder

92
Q

What are the peripheral causes of autonomic nervous system dysfunction?

A

Peripheral causes include:
Afferent dysfunction (sensory nerves), such as Guillain-Barré syndrome

Efferent dysfunction (motor nerves), such as diabetes mellitus affecting nerve control

93
Q

What medications can cause autonomic nervous system dysfunction?

A

Medications that can cause ANS dysfunction include:
- α and β blockers: Affect blood pressure control
- Vasodilators: Such as ACE inhibitors, calcium channel blockers, and nitrates
-Anticholinergics: Found in antidepressants, antipsychotics, and opioids

94
Q

What is intravascular volume depletion?

A

Intravascular volume depletion refers to a reduction in the volume of blood circulating within the blood vessels, which can lead to low blood pressure and poor perfusion of tissues.

95
Q

What are the main causes of intravascular volume depletion?

A

Causes include:
Diuretics: Excessive fluid loss due to medication
Decreased cortisol: Seen in adrenal insufficiency
Acute blood loss or dehydration: Leading to a reduction in circulating blood volume

96
Q

What symptoms indicate intravascular volume depletion?

A

Symptoms include:
Dizziness, especially on standing (postural hypotension)
Fatigue
Rapid heart rate (tachycardia)
Low blood pressure (hypotension)

97
Q

What is syncope?

A

Syncope is a transient loss of consciousness due to a temporary failure to maintain adequate cerebral perfusion (blood flow to the brain).

98
Q

What is a transient ischemic attack (TIA)?

A

A TIA is a brief, temporary episode of neurological dysfunction caused by a temporary blockage of blood flow to the brain, often described as a “mini-stroke.”

99
Q

What are the key features of cardiac syncope?

A

Cardiac syncope typically lasts a few minutes. Patients are oriented and awake after the event, and there is usually no warning other than feeling faint before the episode.

100
Q

: What distinguishes a generalized seizure from other forms of syncope?

A

A generalized seizure is followed by at least 30 minutes of post-ictal confusion, unlike other forms of syncope where orientation is quickly regained.

101
Q

What physical symptoms may accompany a generalized seizure?

A

Symptoms of a generalized seizure may include:
- Tonic-clonic movements (muscle rigidity and jerking)
- Incontinence (loss of bladder or bowel control)
- Aura (sensory disturbances before the seizure)

101
Q

What is an aura in the context of a generalized seizure?

A

An aura is a warning sign that some people experience before a seizure, which can manifest as visual disturbances, unusual smells, or sensations.

102
Q

What is perfusion?

A

Perfusion refers to the process of delivering blood to the tissues, ensuring adequate oxygen and nutrient supply for cellular function.

103
Q

What is the formula for perfusion pressure?

A

Perfusion pressure is calculated as:

PerfusionPressure
=Flow /Resistance

​

Where “Flow” refers to cardiac output, and “Resistance” refers to peripheral vascular resistance.

104
Q

What factors contribute to cardiac output?

A

Cardiac output is the product of stroke volume and heart rate:

CardiacOutput
= StrokeVolume
×HeartRate

105
Q

What determines peripheral vascular resistance?

A

Peripheral vascular resistance is influenced by:
Intravascular volume (amount of fluid in blood vessels)
Vessel tone (degree of vasoconstriction or vasodilation)

106
Q

What are the main determinants of blood pressure?

A

Blood pressure is influenced by outflow obstruction, peripheral resistance, pump function, heart rate, and venous return.

107
Q

What are the causes of outflow obstruction that affect blood pressure?

A

Outflow obstruction can be caused by:
Aortic stenosis (narrowing of the aortic valve)
HOCM (Hypertrophic Obstructive Cardiomyopathy) (thickening of the heart muscle, obstructing blood flow)

108
Q

What factors influence peripheral resistance in blood pressure regulation?

A

Peripheral resistance is determined by:
Intravascular volume (amount of blood in circulation)
Vessel tone (degree of vasoconstriction or vasodilation)
Sympathetic nervous system activity (regulates vessel tone and resistance)

109
Q

What are the causes of pump failure that affect blood pressure?

A

Pump failure, leading to reduced left ventricular function, can result from:
Cardiomyopathy (disease of the heart muscle)
Ischemia (lack of blood flow to the heart muscle)

110
Q

How does heart rate affect blood pressure?

A

Blood pressure can be affected by:
Bradyarrhythmias (slow heart rate)
Tachyarrhythmias (fast heart rate)
Sympathetic nervous system activity (increases heart rate and contractility)

111
Q

What factors affect venous return and consequently blood pressure?

A

Venous return can be reduced by:
Decreased intravascular volume (due to dehydration, blood loss, etc.)
Pulmonary embolism (blockage of blood flow in the lungs)
Pulmonary hypertension (high blood pressure in the lung arteries)

112
Q

What is neurally mediated syncope?

A

Neurally mediated syncope is a transient loss of consciousness caused by a sudden, inappropriate reflex response that leads to a drop in heart rate or blood pressure, reducing cerebral perfusion.

113
Q

What is neurocardiogenic syncope?

A

Neurocardiogenic syncope (also known as vasovagal syncope) occurs due to a reflex that leads to a sudden drop in blood pressure and/or heart rate, often triggered by emotional stress, pain, or prolonged standing.

114
Q

What is situational syncope?

A

Situational syncope occurs in response to specific triggers that affect the autonomic nervous system, leading to a sudden decrease in heart rate or blood pressure. Common triggers include:
- Coughing
- Swallowing
- Urination (micturition syncope)
- Defecation

115
Q

What is carotid sinus hypersensitivity?

A

Carotid sinus hypersensitivity is an exaggerated response to pressure on the carotid sinus (located in the neck), which can cause a sudden drop in blood pressure and/or heart rate, leading to syncope. It is often triggered by head movements, wearing tight collars, or shaving.

116
Q

NEURALLY MEDIATED SYNCOPE

A

Neurocardiogenic syncope
Situational syncope
Carotid sinus hypersensitivity

117
Q

What is the purpose of carotid sinus massage?

A

Carotid sinus massage is a diagnostic tool used to identify carotid sinus hypersensitivity by stimulating the carotid sinus and monitoring the patient’s heart rate and blood pressure for any abnormal reflex response.

118
Q

Why is carotid bruit a contraindication for carotid sinus massage?

A

A carotid bruit indicates possible carotid artery stenosis, where the artery is narrowed. Massaging the area may dislodge a clot or plaque, leading to a stroke.

119
Q

Why is carotid stenosis a contraindication for carotid sinus massage?

A

Carotid stenosis involves the narrowing of the carotid artery, and massaging this area could increase the risk of embolization and stroke.

120
Q

Why is known sick sinus syndrome a contraindication for carotid sinus massage?

A

Sick sinus syndrome involves abnormal heart rhythms due to improper functioning of the sinus node. Carotid sinus massage can worsen bradyarrhythmias, leading to syncope or other dangerous heart rhythms.

121
Q

Why is the use of antiarrhythmic drugs a contraindication for carotid sinus massage?

A

Patients on antiarrhythmic drugs may have altered heart rate control, and carotid sinus massage could induce bradycardia or hypotension, increasing the risk of adverse cardiac events.

122
Q

Contraindications of carotid sinus massage

A

Carotid bruit
Carotid stenosis
MI in last 3 months
Known sick sinus
On antiarrhythmic drugs

123
Q

CLINICAL ASSESSMENT of SYNCOPE

A

History, full exam including CVS + BP +
ECG + chest xray

50% certain diagnosis
1. vestibular and brainstem disorders
2. seizures, anxiety
3. heart block, sick sinus, slow AF
4. Postural hypotension
5. Situational syncope, vasovagal

124
Q

NO CAUSE FOUND for SYNCOPE

A

> 3 syncopal episodes in < 6 months

Carotid sinus massage echocardiography
Tilt table test
24 hour ECG

cause found- treat
no cause- repeat 24 hr ECG, loop recorder , ? seizure/ psych

125
Q

What is the purpose of the tilt table test?

A

The tilt table test is used to evaluate how the body responds to changes in position, particularly in diagnosing causes of syncope, such as orthostatic hypotension or neurally mediated syncope.

126
Q

How is the tilt table test performed?

A

During the test, the patient lies flat on a table that can be tilted. The table is gradually raised to an upright position (usually 60-80 degrees) while monitoring the patient’s heart rate, blood pressure, and symptoms for a specified period.

127
Q

What are the indications for performing a tilt table test?

A

The tilt table test is indicated for:
Patients with unexplained syncope or near-syncope
Assessment of orthostatic hypotension
Evaluation of autonomic dysfunction

128
Q

What is the most effective advice that you can give older patients that will reduce their risk of falls as they age?

A. Core exercises combined with postural changes
B. Resistance training to improve muscle strength
C. Use a walking stick or other aid when they start feeling unsteady
D. Regular walking to keep fit

A

A. Core exercises combined with postural changes

129
Q

Which drugs increase the risk of postural hypotension in the elderly?

A. Anti-emetics
B. Proton pump inhibitors
C. Diuretics
D. Non-steroidal anti-inflammatory

A

C. Diuretics

130
Q

Which of the following are contraindications to carotid sinus massage?

A. Hypertension
B. Carotid bruit
C. Myocardial infarction in the last two years
D. Epilepsy

A

B. Carotid bruit

131
Q

An 85-year-old woman who has been fit, active and fully independent in all her IADL’s and ADLS is brought to casualty following a single unexplained fall in her house. On clinical assessment she has no injuries, is not confused, is on no medication. Examination of the cardiovascular, nervous and musculoskeletal systems is normal.

What should you exclude before discharging her?

A. An acute medical illness
B. An arrhythmia
C. The onset of frailty
D. Vestibular dysfunction

A

A. An acute medical illness

132
Q

Which test can be used to differentiate central from peripheral vertigo?

A. Sternal nudge
B. Dix – Hall Pike Manoeuvre
C. Head-impulse test
D. Romberg Test

A

C. Head-impulse test

133
Q

An 85-year-old man presents following an episode of loss of consciousness lasting a few minutes. He describes getting out of bed feeling a little lightheaded then having some difficulty in passing urine then feeling warm and his vision “greying out” prior to losing consciousness.

What is the most likely cause of his syncope?

A. Neurocardiogenic syncope
B. Carotid sinus hypersensitivity
C. An arrhythmia
D. Aortic stenosis

A

A. Neurocardiogenic syncope

134
Q

Which of the following classify a patient as high risk of falls?

A. Three falls in the last 12 months
B. One fall in the last 12 months with injury
C. One fall in the last 6 months with injury
D. Three falls in the last 12 months with an abnormal gait

A

B. One fall in the last 12 months with injury

135
Q

An elderly patient presents to the emergency unit with soft tissue injuries following a fall. Apart from the injuries the clinical examination is unremarkable. A witness reports that the patient was unconscious for a few minutes following the event.

What is the most reliable symptom or feature which would help you to differentiate a seizure from syncope?

A. Urinary incontinence
B. Jerking movements
C. Confusion following regaining consciousness which lasted 40 minutes
D. An abnormal feeling or sensation preceding the event

A

C. Confusion following regaining consciousness which lasted 40 minutes

136
Q

An elderly patient presents with recurrent falls. The only abnormality after a thorough history and full examination is a positive Romberg’s test.

What investigation is most likely to identify a potential cause for the falls?

A. Vitamin B12
B. TSH
C. ECG
D. CT brain

A

A. Vitamin B12

137
Q

An elderly patient sees you following a fall and reposts that she sometimes feels as though she is “off balance”. She has a history of hypertension and osteoarthritis. Her clinical assessment, including falls risk assessment and examination does not reveal and abnormalities.

What is the most important information you need to elicit on the history?

A. A thorough systemic inquiry of cardiovascular symptoms
B. Any history of vertigo or deafness
C. A history of the circumstances surrounding the fall
D. A complete drug and substance history

A

D. A complete drug and substance history

138
Q

What is the commonest consequence of a fall in an elderly person?

A. Soft tissue injury requiring medical assessment
B. Fracture
C. Recurrent falls
D. Fear of falling

A

D. Fear of falling

139
Q

What problem, which could cause or contribute to the risk of falling, can be identified when the patient performs the first instruction of the Get-Up-and-Go test?

A. Poor postural control
B. Slowed postural reflexes
C. Loss of proprioception
D. Proximal muscle weakness

A

D. Proximal muscle weakness

140
Q

In which of the following would the tilt-table test be diagnostic?

A. Neurocardiogenic syncope
B. Vertigo
C. Disequilbrium
D. Cardiogenic arrythmias

A

A. Neurocardiogenic syncope

141
Q

An 85-year-old woman is found to have Benign Positional Paroxysmal Vertigo BPPV).

What is the treatment of choice?

A. Surgery to remove Otolith
B. Dix-Hallpike manoeuvre
C. Anti-emetic agent
D. Epley’s manoeuvre

A

D. Epley’s manoeuvre

142
Q

A 68-year-old woman is diagnosed with carotid sinus hypersensitivity. What is the diagnostic investigation of choice?

A. CT angiogram
B. ECG
C. Carotid doppler
D. Carotid sinus massage

A

D. Carotid sinus massage

143
Q

A 76-year-old man sways during the stand still component of the get-up and go test.

What is this indicative of?

A. Weakness of proximal muscles
B. Reduced muscle strength
C. Poor postural control
D. Poor balance

A

C. Poor postural control

144
Q

What is the definition of sarcopaenia?

A. Slowing of postural reflexes
B. The loss of skeletal muscle mass and strength as a result of ageing
C. Deconditioning
D. Abnormal centre of gravity

A

B. The loss of skeletal muscle mass and

145
Q

An 80-year-old man presents following a fall. He describes waking with an urgent need to urinate and rushing to the toilet then feeling lightheaded and then losing his balance. He is on chronic medication for hypertension, ischemic heart disease and benign prostatic hypertrophy.

What is the most likely cause of his fall?

A. Postural hypotension
B. Vestibular pathology
C. An arrhythmia
D. Aortic stenosis

A

A. Postural hypotension

146
Q

What consequence of normal ageing in the nervous system increases the risk of falls in otherwise healthy, non-frail, elderly persons?

A. Decreased visual acuity
B. Reduced peripheral proprioception
C. Slowing of postural reflexes
D. Muscle weakness due to sarcopenia

A

C. Slowing of postural reflexes

147
Q

A 78-year-old woman presents with increasing effort intolerance and dizziness when standing up which has been progressive over the preceding week. She then had an episode of loss of consciousness after getting up from a chair and walking 4 steps. At triage she is noted to be orientated, apyrexial, pulse rate 38, BP 105/60, respiratory rate 16 bpm.

What is the most likely underlying cause of her syncope?

A. Postural hypotension
B. Aortic stenosis
C. Complete heart block
D. Neurocardiogenic syncope

A

C. Complete heart block

148
Q

An 81-year-old man presents complaining of vertigo with associated tinnitus. On examination he is found to have hearing loss.

What is the most likely cause of the vertigo?

A. Benign positional proximal vertigo (BPPV)
B. Vestibular neuronitis
C. Meniere’s Disease
D. Cerebellar atrophy

A

C. Meniere’s Disease

149
Q

A patient reports that they have had a fall and describe that it was associated with an intense sensation of the room turning and a loss of balance which lasted a few minutes. On further inquiry they report a few episodes in the previous six months but no other associated symptoms.

What is the most likely diagnosis?

A. Meniere’s Disease
B. A brainstem lesion
C. Vertebrobasilar insufficiency
D. Benign Paroxysmal Positional Vertigo (BPPV)

A

D. Benign Paroxysmal Positional Vertigo (BPPV)

150
Q

An elderly patient, who is starting to become frail, tells you that although she has not fallen, she is afraid that she could fall and has adapted her activities to prevent falling. Her clinical assessment does not reveal and abnormalities.

What is the most appropriate management of her problem?

A. Advise a walking stick
B. Refer her to a physiotherapist
C. Advise modifying her home to reduce the risk of falls
D. Reassure her and advise regular exercise

A

B. Refer her to a physiotherapist

151
Q

A 65-year-old man presents complains of episodic vertigo associated with turning in bed at night. What is the most likely diagnosis?

A. Vestibular neuronitis
B. Benign proximal positional vertigo (BPPV)
C. Acoustic neuroma
D. Meniere’s Disease

A

B. Benign proximal positional vertigo (BPPV)

152
Q

A 68-year-old woman with a background history of cervical osteoarthritis and hypertension, presents complaining of dizziness when hanging the washing and closing curtains.

What is the most likely diagnosis?

A. Brainstem lesion
B. Acoustic neuroma
C. Benign positional proximal vertigo (BPPV)
D. Vertebro-basilar insufficiency

A

D. Vertebro-basilar insufficiency

Internal Medicine (14 decks)

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