Medicine of the older adult for PLAB 1

An 82 year old woman has fallen three times in two months, each time shortly after standing up from a chair. She feels lightheaded on rising. She takes amlodipine, bendroflumethiazide, tamsulosin, amitriptyline and zopiclone. Her lying blood pressure is 138/78 mmHg and standing is 108/66 mmHg at one minute. What is the SINGLE most likely diagnosis?

1. Cardiac arrhythmia Sudden collapse with no warning and rapid full recovery, sometimes during exertion, and it needs an ECG in every faller. A 30 mmHg systolic drop on standing while on five contributing drugs raises it.
2. Falls A person coming to rest on the ground unintentionally, with contributors that are usually multiple rather than singular. A 30 mmHg systolic drop on standing while on five contributing drugs fits.
3. Benign paroxysmal positional vertigo (BPPV) Brief rotational vertigo triggered by head position, diagnosed by the Dix-Hallpike and treated with the Epley manoeuvre. A 30 mmHg systolic drop on standing while on five contributing drugs suggests it.
4. Vasovagal syncope A prodrome of nausea, sweating and greying vision with an identifiable trigger, and slow recovery with fatigue afterwards. A 30 mmHg systolic drop on standing while on five contributing drugs argues against it.
5. Postural hypotension correct Correct. A 30 mmHg systolic drop with symptoms on rising, and falls that happen specifically on standing up. The mechanism is written into the history and confirmed at the bedside.

The point: A fall is a presentation, not a diagnosis. Ask what the patient was doing, whether there was warning, whether they lost consciousness, and whether anybody saw it. Look for the treatable contributors: postural hypotension, polypharmacy, visual impairment, cognitive impairment, infection, arrhythmia and environmental hazards. Every older person who falls needs a multifactorial assessment, a medication review and a lying and standing blood pressure. Four or more medicines independently raises risk.

Source: NICE NG249 — Falls: assessment and prevention in older people and in people 50 and over at higher risk NICE · tier 1, national regulator or guidance

An 82 year old woman has fallen three times in two months, each time shortly after standing up from a chair. She feels lightheaded on rising. She takes amlodipine, bendroflumethiazide, tamsulosin, amitriptyline and zopiclone. Her lying blood pressure is 138/78 mmHg and standing is 108/66 mmHg at one minute. What is the SINGLE most appropriate initial investigation?

1. Blood tests including full blood count, renal function and calcium Screens for anaemia, electrolyte disturbance and hypercalcaemia as contributors. A 30 mmHg systolic drop on standing while on five contributing drugs makes it supportive.
2. Medication review Sedatives, antihypertensives, diuretics, anticholinergics, opioids and hypoglycaemics all contribute, and four or more medicines raises risk independently. A 30 mmHg systolic drop on standing while on five contributing drugs makes it high-yield.
3. CT head For a fall with head injury on an anticoagulant, a reduced conscious level, or a focal deficit. A 30 mmHg systolic drop on standing while on five contributing drugs indicates it.
4. Multifactorial falls assessment Gait and balance, muscle strength, vision, cognition, continence, footwear, home hazards and medication. The evidence supports the package rather than any single component. A 30 mmHg systolic drop on standing while on five contributing drugs makes it the standard.
5. Lying and standing blood pressure correct Correct. Five minutes lying, then at one and three minutes standing. It takes a few minutes, it costs nothing, and in a faller it is the highest-yield measurement there is. It is also the one most often omitted.

The point: A fall is a presentation, not a diagnosis. Ask what the patient was doing, whether there was warning, whether they lost consciousness, and whether anybody saw it. Look for the treatable contributors: postural hypotension, polypharmacy, visual impairment, cognitive impairment, infection, arrhythmia and environmental hazards. Every older person who falls needs a multifactorial assessment, a medication review and a lying and standing blood pressure. Four or more medicines independently raises risk.

Source: NICE NG249 — Falls: assessment and prevention in older people and in people 50 and over at higher risk NICE · tier 1, national regulator or guidance

An 82 year old woman has fallen three times in two months, each time shortly after standing up from a chair. She feels lightheaded on rising. She takes amlodipine, bendroflumethiazide, tamsulosin, amitriptyline and zopiclone. Her lying blood pressure is 138/78 mmHg and standing is 108/66 mmHg at one minute. What is the SINGLE most appropriate immediate management?

1. Stop or reduce the culprit medication correct Correct. Every one of her five drugs contributes: amlodipine and bendroflumethiazide lower blood pressure, tamsulosin causes postural drop, amitriptyline is anticholinergic and sedating, and zopiclone is sedating. Deprescribing is more effective here than anything that could be added, and it is the intervention most likely to be skipped.
2. Strength and balance training The intervention with the best evidence for preventing further falls, delivered as a supervised programme rather than as advice to exercise. A 30 mmHg systolic drop on standing while on five contributing drugs makes it first line.
3. Treat the postural drop Review the medication first, then hydration, compression and advice on rising slowly, with fludrocortisone or midodrine only under specialist advice. A 30 mmHg systolic drop on standing while on five contributing drugs indicates it.
4. Refer for cardiac monitoring For unexplained collapse with no prodrome, an abnormal ECG, or a fall during exertion. A 30 mmHg systolic drop on standing while on five contributing drugs raises that.
5. Bone protection with calcium, vitamin D and a bisphosphonate For osteoporosis or after a fragility fracture. A 30 mmHg systolic drop on standing while on five contributing drugs makes it necessary.

The point: A fall is a presentation, not a diagnosis. Ask what the patient was doing, whether there was warning, whether they lost consciousness, and whether anybody saw it. Look for the treatable contributors: postural hypotension, polypharmacy, visual impairment, cognitive impairment, infection, arrhythmia and environmental hazards. Every older person who falls needs a multifactorial assessment, a medication review and a lying and standing blood pressure. Four or more medicines independently raises risk.

Source: NICE NG249 — Falls: assessment and prevention in older people and in people 50 and over at higher risk NICE · tier 1, national regulator or guidance