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EVERYTHING YOU NEED TO KNOW ABOUT FALLS Diya and Bart Here’s what we do: ■ Weekly tutorialsopen to all! ■ Focussed on core presentationsand teachingdiagnostictechnique If you’re new here… ■ By medicalstudents,for medical students Welcome to ■ Reviewed by doctors to ensure accuracy Teaching ■ We’ll keep you updated about our Things! upcomingevents via email and groupchats! FALLS DIFFERENTIALS DiyaFalls ■ 1 in 3 people over 65 have a fall at least once a year (1 in 2 in over 80s) ■ Cost the NHS £2 billion per year ■ Caused by intrinsic(age, muscle weakness,gait, pmhx, cognitive impairments,meds) and extrinsicfactors (clothing,hazards,living conditions) ■ Many consequences– Physical,Mentaland Social ■ Main specialties:neuro, cardio,ENT The King’s Fund 2013 NHS England 2023SBA ■ A 35-year-old man presents with acute onset severe vertigo, nausea, and vomiting of vertigo. He denies hearing loss or tinnitus, but mentions that he recently had a cold. Neurological examination is normal, except for horizontal nystagmus. The symptoms have improved slightly but persist. What is the most likely diagnosis? A) Vestibular neuritis B) Benign paroxysmal positional vertigo (BPPV) C) Meniere's disease D) Labyrinthitis E) CerebellarstrokeSBA ■ A 35-year-old man presents with acute onset severe vertigo, nausea, and vomiting of vertigo. He denies hearing loss or tinnitus, but mentions that he recently had a cold. Neurological examination is normal, except for unilateral horizontal nystagmus. The symptoms have improved slightly but persist. What is the most likely diagnosis? A) Vestibular neuritis B) Benign paroxysmal positional vertigo (BPPV) C) Meniere's disease D) Labyrinthitis E) Cerebellarstroke Vertigo (peripheral causes) 1. Virallabyrinthitis Inflammationof the boy labyrinthof the inner ear (semicircularcanals, vestibuleand cochlea) 2. Vestibularneuronitis Acute inflammationof the vestibularnerve 3. Benignparoxysmalpositionalvertigo Tiny calcium crystals(otoconia) come loose fromtheir normallocation on the utricle. Crystalsbecome displaced into the semicircular canals 4.Menieresdisease Excessivebuildup of endolymph(fluid) in the inner ear, leading to dysfunctionof the vestibularand cochlear systems. SBA A 50-year-old male presents to the Emergency Department with sudden onset central chest pain that began an hour ago. He reports a recent fall at the gym. He has had some worsening shortness of breath on exertion over the last few months. He says his father died suddenly in middle age of an unknown cause. On examination, he has a harsh ejection systolic murmur loudest around the lower left sternal border. He is noted to have a biphasic pulse on palpation of his carotid. Electrocardiogram (ECG) shows signs of left ventricular hypertrophy. Which is the most likely diagnosis? 1) Aortic regurgitation 2) Aortic stenosis 3) Hypertrophic cardiomyopathy 4) Brugada syndrome 5) Pulmonary stenosis SBA A 50-year-old male presents to the Emergency Department with sudden onset central chest pain that began an hour ago. He reports a recent fall at the gym. He has had some worsening shortness of breath on exertion over the last few months. He says his father died suddenly in middle age of an unknown cause. On examination, he has a harsh ejection systolic murmur loudest around the lower left sternal border. He is noted to have a biphasic pulse on palpation of his carotid. Electrocardiogram (ECG) shows signs of left ventricular hypertrophy. Which is the most likely diagnosis? 1) Aortic regurgitation 2) Aortic stenosis 3) Hypertrophic cardiomyopathy 4) Brugada syndrome 5) Pulmonary stenosisHOCM Autosomal dominant disorder of muscle tissue ■ Left ventricle hypertrophy → decreasedcompliance → decreased cardiacoutput ■ Characteristic murmur? ■ Symptoms : exertional dyspnoea, angina, syncope, high risk of sudden cardiac death ■ Drugs to avoid? ■ Management (ABCD) Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemakerSBA ■ A 74-year-old man presents to the emergency department after a fall at home. past few months. She describes his gait as "shuffling". He has also experiencede short-term memory decline and recent episodes of urinary incontinence. What is the most appropriate definitive treatment for this patient? A) Oral acetazolamide therapy B) Ventriculoperitoneal (VP) shunt placement C) Deep brain stimulation D) Dopaminergic therapy (e.g., levodopa/carbidopa E) AntidepressantsSBA ■ A 74-year-old man presents to the emergency department after a fall at home. past few months. She describes his gait as "shuffling". He has also experiencede short-term memory decline and recent episodes of urinary incontinence. What is the most appropriate definitive treatment for this patient? A) Oral acetazolamide therapy B) Ventriculoperitoneal (VP) shunt placement C) Deep brain stimulation D) Dopaminergic therapy (e.g., levodopa/carbidopa E) AntidepressantsNormal Pressure Hydrocephalus ■ Reversiblecause of dementiain elderly ■ Presentswithtriad ■ Thoughtto be secondaryto reduced CSF absorptionat thearachnoidvilli ■ Ventriclesenlargewithoutsulcalatrophy ■ Mx: VP shuntSBA ■ A 72-year-old man presents with sudden onset of left-sided facial droop and difficulty speaking. His symptoms resolved completely within 20 minutes. He has a history of type 2 diabetes mellitus and smoking. On examination, his blood pressure is 160/95 mmHg, and there are no neurological deficits. A non- contrast CT head shows no acute abnormalities. What is the most appropriate initial treatment for this patient? A) Prescribe aspirin 75 mg daily and arrange outpatient follow-up in 1 week B) Start clopidogrel 75 mg daily and refer for elective carotid imaging C) Administer aspirin 300 mg immediately and arrange urgent assessment by a stroke specialist within 24 hours D) Initiate warfarin therapy and plan for outpatient MRI brain E) Admit for inpatient care and schedule carotid Doppler within 48 hoursSBA ■ A 72-year-old man presents with sudden onset of left-sided facial droop and difficulty speaking. His symptoms resolved completely within 20 minutes. He has a history of type 2 diabetes mellitus and smoking. On examination, his blood pressure is 160/95 mmHg, and there are no neurological deficits. A non- contrast CT head shows no acute abnormalities. What is the most appropriate initial treatment for this patient? A) Prescribe aspirin 75 mg daily and arrange outpatient follow-up in 1 week B) Start clopidogrel 75 mg daily and refer for elective carotid imaging C) Administer aspirin 300 mg immediately and arrange urgent assessment by a stroke specialist within 24 hours D) Initiate warfarin therapy and plan for outpatient MRI brain E) Admit for inpatient care and schedule carotid Doppler within 48 hoursTransient Ischemic Attack ■ A transientepisode of neurologicdysfunctioncausedby focal brain, spinal cord, or retinalischaemia,withoutacute infarction ■ Tissuebased definitionratherthantime based ■ Similar to a strokebut usually resolves in 1 hour ■ Potentialfeatures? ■ TIA mimics? Resolved TIA symptoms,Reviewed by specialist,Long-term secondary awaiting specialist reinitial 21 days when atprevention after 21 days within 24 hours risk of further events Aspirin Aspirin + Clopidogrel ClopidogrelSBA ■ A 25-year-oldwoman presentswitha historyof episodes whereshe experiencesa sudden risingepigastricsensation,followed by a senseof déjà vu and a brief period of staringblankly.Her partnerreports that during theseepisodes, she smacks her lips and appearsunresponsivefor about a minute.She has no memory of the events afterward.What is the most likely type of seizure she is experiencing? A) Absenceseizure B) Focal aware seizure C) Focal impaired awarenessseizure D) Generalisedtonic-clonicseizure E) Myoclonic seizureSBA ■ A 25-year-oldwoman presentswitha historyof episodes whereshe experiencesa sudden risingepigastricsensation,followed by a senseof déjà vu and a brief period of staringblankly.Her partnerreports that during theseepisodes, she smacks her lips and appearsunresponsivefor about a minute.She has no memory of the events afterward.What is the most likely type of seizure she is experiencing? A) Absenceseizure B) Focal aware seizure C) Focal impairedawareness seizure D) Generalisedtonic-clonicseizure E) Myoclonic seizureEpilepsy Brief,suddenlapsesin consciousnesswitha blank stare,often inchildren. Convulsive seizureswithstiffening (tonicphase)followed byjerking movements(clonicphase). Sudden,briefjerksor twitchesof muscles, typicallywithoutloss of consciousness. Suddenloss of muscle tone,causingcollapse or falls ("drop attacks") Suddenstiffeningof muscles, often affecting posture or causing falls.Epilepsy Location Features - Typical Seizure Type: May occur with or without Temporal Lobe impairment of consciousness or awareness. - Aura: Rising epigastric sensation, psychic or experiential phenomena (déjà vu, jamais vu), less commonly hallucinations (auditory, gustatory, olfactory). - Seizure Characteristics: Lasts ~1 minute, automatisms (lip smacking, grabbing, plucking) are common. - Motor Seizures: Head or leg movements, posturing, Frontal Lobe post-ictal weakness, Jacksonian march (progressive motor involvement). - Sensory Seizures: Paraesthesia (tingling or Parietal Lobe abnormal sensations). Occipital Lobe - Visual Seizures: Visual disturbances such as floaters or flashes. FALLS HISTORY BartSBA A 55-year-old patientpresentsto the clinicafter trippingand fallingat home. Thepatient denies dizziness or loss of consciousness.The patient’sregular medicationsincludeatorvastatin,and ramipril.gabapentin,dapagliflozinand metformin.How could the patient’sunderlyingconditionhave contributedto his fall? A. Orthostatichypotensioncausingsudden dizziness B. Impaired sensationleadingto difficulty in foot placement C. Sudden weaknessdue to muscleparalysis D. Vestibulardysfunctionaffecting balance E. Visualimpairmentfrom diabetic retinopathySBA 1 A 55-year-old patientpresentsto the clinicafter trippingand fallingat home. Thepatient denies dizziness or loss of consciousness.The patient’sregular medicationsincludeatorvastatin,and ramipril.gabapentin,dapagliflozinand metformin.How could the patient’sunderlyingconditionhave contributedto his fall? A. Orthostatichypotensioncausingsudden dizziness B. Impaired sensationleadingto difficulty in foot placement C. Sudden weaknessdue to muscleparalysis D. Vestibulardysfunctionaffecting balance E. Visualimpairmentfrom diabetic retinopathyMr Smith ■ 72-year-oldmale who presentedto A&E followinga fall ■ You are the F1 inA&E ■ Whatare you goingto ask him? ■ Whatis in a history?What is in a history? ■ PresentingComplaint Which are the ■ History of PresentingCompliant elements important ■ Past MedicalHistory in falls histories? ■ Drug History ■ Family History ■ Social History ■ Systems Review ■ ICE…What is in a history? ■ PresentingComplaint Target your questions ■ History of PresentingCompliant to narrow down ■ Past MedicalHistory differentials and ■ Drug History exclude causes ■ Family History ■ Social History ■ Systems Review ■ ICE…Presenting Complaint - Before ■ When and where did the fall happen?Anyprevious falls? ■ Whathappened before… – Chest pain, dizziness,palpitations – Did you know you were goingto fall? – Did you eat anything? – Trauma ■ During… ■ And after?Presenting Complaint - During ■ Whathappenedbefore… ■ During… – Loss of consciousness – D■d FOOSHcatchthemselves? – Can they remember episode? – Collateral history ■ Seizure activity, pale/flushed, how long were they down for? ■ And after?Presenting Complaint - After ■ Whathappenedbefore… ■ During… ■ And after? – How quickly were they up again? – P■inSOCRATES – Whendid they present to services? – Confusion(post-ictal),weakness,speech difficultyMr Smith ■ Mr. Smith describes feeling dizzywhilepreparing his morningcoffee at 5am. As he reachedfor the counterto steady himself, his foot caughton the edgeof a loose kitchen rug, causinghim to lose balanceand fall. He landedonhis left side, experiencingimmediatepain(8/10) in his hip and has minorbruising onhis left arm. ■ He deniesloss of consciousnessbut admits to "blackingout fora moment"beforethe fall. ■ This happenedat home and he was found by his neighborPast Medical History ■ Previous falls ■ Encounterswithfalls differentials – Epilepsy – Cardiac disease – Stroke/CVD risk factors – Age – Vestibularproblems – Visualproblems – MSK problems ■ Surgical historyand reactionsto anaesthetics ■ Otherpast medical history – if you’re admittinga patientyou need to know whatthey haveMr Smith PmHx ■ HTN ■ T2DM ■ Osteoarthritis(bilaterallyin his knees) ■ TIA 2 years prior ■ No past surgicalhistory ■ Mr Smith has additionallymentionedthat some people have said his memory is goinga littleDrug History Polypharmacy is a Y5 topic, but ■ Many drugs can increase risk of falls can be a good thing to mention ■ Always question allergies and compliance with medication as something to consider at this point – Nitrates – Diuretics – Anticholinergics – Antidepressants Affect falls via postural hypotension – L-dopa – Beta-blockers – Antihypertensives – BDZs – Digoxin – Sedatives – Opiates and codeine Affect falls via other mechanisms – Diabetic medication – AntipsychoticsMr Smith ■ DHx ■ Amlodipine10 mg once daily ■ Metformin 1,000 mg twicedaily ■ Clopidogrel75mg once daily ■ Atorvastatin80mg once daily ■ Gabapentin300 mg at night ■ MultivitaminsFamily history ■ Family historyof falls differentials – Age of onsetof conditions – By thisstagetry to come to your top differentials ■ General anaestheticreactionsMr Smith Fhx ■ Motherdied of stroke at age 80 – Rheumatoidarthritis ■ Fatherdied followingheartattackat 78 ■ No other past historyof noteSocial history A fall is a time to consider if a patient is coping well at home – probably not ■ VERY important ■ Home environment – ADLs – Carers/people in home environment - Who has patient got at home to look after them? – Stairs ■ Finances – Pension/benefits – Work and sick notes – Type of work patient does – DVLA rules ■ Drinking/smoking/drugs – Don’t be shy to ask – even if patient doesn’t ‘seem to be type’ – Important – Consider cessation and withdrawalMr Smith Shx ■ Occasionalalcoholuse (1-2 drinksper week) ■ No smokinghistory ■ Limitedmobility due to kneepain; uses a canefor walking ■ Lives in groundfloor flat on his own ■ Independentfor all ADLs – but orders food for delivery ■ Does not driveSystems review ■ Neurological ■ Audio-vestibular – stroke – focal neurology ■ GI – Epilepsy – automatisms during fall, – Fluid loss/gain post-ictal period – Movement disorders ■ MSK – Dementias? Which ones? – Osteoporosis ■ Visual – Arthritis – Double vision (stairs) ■ Endocrine – Cataract/macular – Diabetes – hypoglycaemia degeneration/glaucoma ■ Infection ■ Cardiac – Syncope ■ Blood – Orthostatic hypotension – perform – Anaemia lying-standing BP – B-symptomsICE ■ MOST IMPORTANT! ■ Listento thepatientand theywill give you the answers ■ BIG marks in OSCEs and rapportbuildingExaminations ■ A to E ■ CranialNerve, Upper limb/Lowerlimb neuro ■ Cardiovascular,respiratory,gastro ■ Inspectionof affected areas and MSK ■ Examineeverythingand anythingthat you thinkmay have contributedto the patient’ssituation.Mr Smith O/E ■ Vital Signs: BP 102/68 mmHg, HR 88 bpm, RR 16/min, SpO₂ 96% on room air, afebrile ■ General Appearance: Alert but appears fatigued; in mild distress due to pain, somewhat dry mucus membranes ■ Neurological Exam: Mildly decreased sensation in both feet; no focal deficits ■ Cardiovascular: Regular rhythm, no murmurs, Orthostatic drop in BP of 15mmHg ■ Musculoskeletal: Bruising and tenderness over the left hip; range of motion limited by pain; no obvious deformity ■ Gait: Unable to ambulate due to pain Investigations – elevated glucose and mildly elevated HbA1c, Garden III intracapsular fractureManagement ■ How are we goingto manageMr Smith? ■ Pain control ■ Bleep orthopaedicsto assesspatientand considerhipreplacement – hemiarthroplastyor THR ■ Get endocrinologyinput for glycaemic control ■ Review antihypertensivemedicationsand compliance/overuse ■ Occupationaland physiotherapyinputIn summary: Some major causes by system ■ C–rdVasovagal – Aortic Stenosis – Carotid Sinus Syndrome The whole history is important – Arrythmias ■ Neuro approach it as a timeline – Stroke/ TIAorders – Peripheral Neuropathy Intrinsic and extrinsic factors – Normal Pressure Hydrocephalus affect falls ■ ENT – Peripheral vertigo causes Management is holistic ■ V–suDoublevision – Cataracts etc. ■ M–K Osteoporosis – Arthritis – Foot deformities.eg. Bunions THANKS FOR WATCHING! Tutor 2: Bart Pleasefill out the feedback form on Medall and see you after the holidays! Have a lovely break!!