Thanks to everyone who contributed to the discussions about Mrs Bennett a 78 year old lady who had had some falls.
You can see the highlights of the discussion on Twitter in the storify.
This week’s question setter & expert was Dr Sana Mufti, ST5 Geriatrics & Internal Medicine, Newham University Hospital.
Information available at the start of the week:
Mrs Audrey Bennett is a 78 year old lady who has been referred to the Community Falls Clinic by her GP after complaining of 4 falls in the last 3 months.
Mrs Audrey Bennet tells you she has never fallen before but had her first fall 3 months ago and has had 2 falls in the last 2 weeks which prompted her to see her GP.
Her first fall was when she waiting for the bus. She was feeling well and after boarding the bus felt ‘giddy’ and the next thing she remembers is being helped up by fellow passengers. She sustained a small laceration to her forehead but did not seek medical attention as she felt well (though a bit shaken up).
Her second fall was while she walking to the shops. She thinks she probably tripped on a loose paving stone but says she can’t quite remember how she fell and again she sustained a facial injury.
She began to lose confidence after her 2 falls and would only go out if accompanied.
Her more recent 2 falls were within her own home. On both occasions she had been standing up and remembers feeling ‘dizzy’ and having palpitations before collapsing and waking up on the floor. She did not sustain any injuries.
She has a past medical history of treated hypertension, hypercholesteraemia and osteoarthritis of both knees.
She is currently taking amlodipine 10mg, bisoprolol 2.5mg, losartan 50mg, bendroflumethiazide 2.5mg and simvastatin 20mg. The bendroflumethiazide was started 4 months ago and her bisoprolol had recently been increased from 1.25mg. She takes paracetamol PRN.
She lives alone in a ground floor flat and is independent for all activities of daily living. A friend is helping with shopping since she is reluctant to go out alone. She does not require a mobility aid. She is an ex-smoker and does not drink any alcohol.
There is no significant family history of note.
Question 1: What further information would you obtain from history and examination in order to refine your differential diagnosis?
On review of systems, the only things of note are that she does not have any exertional chest pain or breathlessness but she does complain of feeling lightheaded when she stands up and since her falls, feels ‘off balance’ when walking.
She looks well hydrated. Her lying BP is 110/70mmHg and after 1 min standing drops to 90/50mmHg. Her pulse rate is 60bpm regular and normal in character and volume. Oxygen saturations are 98% on air. Her heart sounds are normal but she has an ESM heard loudest in aortic area which is non radiating. She has no peripheral oedema and her chest is clear. Her abdominal and neurological examination are normal.
Her routine blood tests are all within normal limits. Her ECG shows sinus bradycardia with first degree heart block. Her chest x-ray shows normal heart size and clear lung fields with a healed rib fracture on the right hand side.
Further questions discussed on Twitter:
Question 2: What investigations would you request?
Question 3: How would you manage Mrs Bennett?
Question 4: Which other ‘falls interventions’ would you consider addressing to decrease Mrs Bennett’s risk of falls and their complications?
1. Falls can be prevented and consequences minimalised
2. The importance of a clear detailed history and focussed examination when carrying out a ‘falls’ assessment
3. Importance of a thorough drug history (new/old drugs and compliance)
4. Appropriate investigations needed in falls work up
5. Falls are multifactorial and often several remediable factors contributing to falls
6. Reducing risk of falls requires multidisciplinary input (minor changes to multiple factors more powerful)
7. Assessment of bone health and primary prevention
- National Service Framework 6 (2001) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/198033/National_Service_Framework_for_Older_People.pdf
- NICE guidance 2004 http://guidance.nice.org.uk/CG161
- Fracture risk scoring http://www.shef.ac.uk/FRAX http://www.qfracture.org
- European Society of Cardiology (ESC) Guidelines on Syncope http://eurheartj.oxfordjournals.org/content/30/21/2631.full.pdf
Dr Sana Mufti, ST5 Geriatrics & Internal Medicine, Newham University Hospital, says:
This was an interesting scenario which brought out some important points with falls investigation and management.
Falls are an incredibly common presentation to Doctors in any specialty
- Falls are common in patients over 65 years and are considered one of the ‘Geriatric Giants’.
- They are a major cause of disability and leading cause of mortality resulting from injury in people > 75 in UK.
- Falling has an impact on quality of life, health and health care costs
- 1 in 3 people aged > 65 years experience a fall at least once a year – rising to 1 in 2 among > 80 year-olds
- The associated cost to NHS and private sector services are estimated at £908.9 million & 63% of these costs were incurred from falls in those aged > 75 years
- 95% of hip fractures are the result of a fall although only 5% of falls result in fracture
- The total annual cost of these fractures to the NHS has been calculated as £1.7 billion with many individuals losing independence and quality of life for which a cost cannot be estimated
- Most falls do not result in serious injury, but consequences include:
– Psychological problems (fear of falling)
– loss of confidence
– loss of mobility (social isolation / depression)
– increase in dependency and disability
– pressure-related injury
Falls are commonly multifactorial and there are often several remediable factors contributing to them. The literature describes more than 400 separate risk factors for falls! Falls can be prevented and consequences minimalized with careful assessment and multidisciplinary intervention.
Falls History and Examination
The key to differentiating the cause of a fall is a detailed and thorough history supported by a focussed examination and appropriate investigations. Spending time on the history is crucial as often investigations will show anomalies but without clinical correlation it is difficult to say whether they are contributing to the falls (e.g. aortic stenosis on an echocardiogram may have nothing to do with falls related to postural instability in someone with a first presentation of Parkinson’s disease)
Looking at the case of Mrs AB we can see the cause of her falls is not immediately apparent from the history and her description of how she fell is vague. This is a very common scenario when taking a falls history.
Important questions to ask here would be asking her to expand on what she means by ‘dizzy’ and ‘giddy’ (e.g. vertigo/light-headedness/unsteady/etc). It is important to establish if she remembers falling through the air and whether she lost consciousness. From the history it seems she did lose consciousness in the first and third and fourth fall. The second fall is less clear though often when people say ‘I must have tripped’ it is important to establish if they did trip or whether they lost consciousness and asking whether they remember falling through the air is a useful discriminating question.
One needs to establish any symptoms pre- and post fall to establish whether the fall is related orthostatic hypotension, cardiac syncope or vasovagal syncope or more rarely seizure. These include chest pain, light-headedness, palpitations, sweating, nausea, visual or hearing loss and phase of recovery. Urinary incontinence and jerking of limbs is not necessarily related to a seizure and can happen in vasovagal syncope. Here, a witness history would be helpful if available.
Reviewing the history provided it seems the cause of Mrs AB’s falls could be either orthostatic hypotension (‘giddy’ and ‘dizzy’ prior to falls, standing when falls occurred; postural BP drop of 20mmHg on clinical examination and on multiple drugs for hypertension with recent changes in medications) or cardiogenic (ESM and sinus bradycardia on ECG) or neurocardiogenic.
Other important questions to ask in a falls history (risk factors) are muscle weakness (specifically hip which is an independent risk factor); polypharmacy (including timeline of medications); poor balance; visual impairment; fear of falling; urinary incontinence; cognitive impairment; alcohol intake; joint pains; history of any neurological diagnosis or symptoms of sensory/motor neuropathies and history of previous falls, causes and interventions made.
Routine investigations in a patient who has fallen are basic blood tests (FBC, U&E, CRP) and if these show any abnormality or the history points to a specific underlying disease process, more detailed tests may be needed such as B12, folate, ferritin, thyroid function and calcium/vitamin D. Postural BPs must be carried out as per guidelines (BP after lying for 5 mins then measured at 1, 3 and 5 minutes standing and any symptoms noted. A systolic drop of >20mmHg is significant). An ECG should also always be done to look for ischaemia or any conduction abnormalities.
Depending on your differential diagnosis, other investigations may include 24 Hr (or longer) cardiac monitoring; 24 hr BP monitor; Echocardiogram; Tilt Table Testing with carotid sinus massage and CT Brain / MR Brain.
In the case of Mrs AB I would repeat her postural blood pressures as per guidance discussed above and ask if she had symptoms on standing. If she did, the first step would be to rationalise the treatment for her hypertension, perhaps stopping the bendroflumethiazide and either reducing or stopping her bisoprolol (due to bradycardia). There is no formula when reducing antihypertensives but it is usual to stop any drugs that are non prognostic or those known to have more side effects. For example, if she had a history of IHD, ACEI/AR2B and B-blockers are important prognostic drugs so these would be stopped last. Diuretics tend to cause dehydration and are only helpful in symptomatic heart failure so it is usual to stop these first. We would continue to reduce her medications until her BP improved with no significant postural drop. If her symptoms resolved and she had no further falls no further investigations are required as her diagnosis would be orthostatic hypotension exacerbated by polypharmacy.
In this case it can be argued we need to rule out cardiac syncope given the history, ESM on examination and sinus bradycardia with 1st degree heart block on ECG. There is no right or wrong answer here but if she has a significant symptomatic postural BP drop this is the likely cause of her falls (especially if her falls cease once it has been corrected) and should be corrected first. It maybe useful to get an echocardiogram to assess for aortic stenosis but this could be more routine and part of a holistic work up. If her falls did not improve with correction of her BP, the next step would be prolonged cardiac monitoring and echocardiogram. If these were normal, we would then go on to do tilt table testing with carotid sinus massage to look for neurocardiogenic syncope (see ESC guidance on syncope).
Other Falls Interventions
Correcting any underlying medical cause of falls is not the only intervention to make in someone who falls. Falls are multifactorial and reducing risk of falls requires multidisciplinary input (minor changes to multiple factors is more powerful). Falls often happen when there is an internal/external stressor or both that causes the ‘fall threshold’ to reduce.
Mrs AB has developed a fear of falling and had stopped going out alone. This is an independent risk factor for falls and has led to social isolation and increased dependence on friends to help out. She also has a history of osteoarthritis.
She would benefit from strength and balance training with physiotherapist as well as a falls group with other people who have fallen.
Other falls interventions include:
– Environmental assessment and modification – OT home visit – Rugs, Rails, Furniture height etc.
– Reducing stressors – e.g. modifying risk / adjusting lifestyle to avoid falls. Appropriate help
– Teaching how to get up (strategies taught by physio)
– Alarms (pull cords, pendant, falls detectors)
– Supervision (family / carer visits).
– Change of accommodation : NOT a panacea but in some cases may reduce risk / consequences
Osteoporosis Detection and Management
One intervention that is often overlooked is osteoporosis detection and treatment. 95% of hip fractures are the result of a fall although only 5% of falls result in fracture. Hip fractures are very serious causing disability, morbidity and mortality (Approximately one third are dead at one year).
Bone health is something that is uniformly done poorly and is often missed even after a non-hip fracture. Adcal D3 should be prescribed to everyone over 65 years who falls or is at risk of falls. Using FRAX tool or QFracture tool, osteoporosis risk should be assessed and either bone protection (such as a bisphosphonate) prescribed or DEXA scan organised.
To summarise, falls are an extremely important topic and are very common in the over 65 population. They are complex and challenging and often multifactorial in cause and require a thorough history with specific falls -related questions as well as focussed examination. It is important to organise relevant investigations to support your diagnosis which should be apparent from your history and examination. Intervention is multidisciplinary and falls interventions should be tailored to and agreed with the individual. Bone health is often missed and should be routinely assessed before a fracture occurs as by then, it’s often too late!