Medicine 5th year, 2nd lecture (Dr. Asso Fariadoon Ali Amin)
1. Investigation & Management of Falls & Syncope Dr Asso Fariadoon Ali Amin MRCP(UK) GIM/ Care of Elderly physician
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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.
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
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
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
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