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 A sudden collapse with no warning and a quick, full recovery, sometimes during exercise, and every faller needs a heart tracing to check for this. Here, a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs points elsewhere.
2. Falls A person ending up on the ground without meaning to, usually caused by more than one thing at once rather than a single cause. It does not fit a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs.
3. Benign paroxysmal positional vertigo (BPPV) A brief spinning feeling brought on by moving the head, checked for with the Dix-Hallpike test and treated with the Epley manoeuvre. But a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs does not point to it.
4. Vasovagal syncope A build-up of feeling sick, sweating and vision greying out, with a clear trigger, followed by a slow recovery and feeling washed out afterwards. That does not match a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs.
5. Postural hypotension correct Correct. A 30 mmHg drop in the top number with symptoms on getting up, and falls that happen specifically on standing. The cause is written into the history and confirmed at the bedside.

The point: A fall is something that has happened, not a diagnosis on its own. Ask what the patient was doing, whether there was any warning, whether they lost consciousness, and whether anyone saw it happen. Look for causes that can be treated: a drop in blood pressure on standing, taking too many medicines, poor eyesight, memory or thinking problems, infection, an abnormal heart rhythm, and hazards at home. Every older person who falls needs a full assessment covering all these areas, a review of their medicines, and their blood pressure checked lying down and standing up. Taking four or more medicines raises the risk of falling on its own.

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 plays a part: amlodipine and bendroflumethiazide lower blood pressure, tamsulosin causes a drop on standing, amitriptyline is sedating and has anticholinergic effects, and zopiclone is sedating too. Cutting back on these works better here than adding anything new, and it is the step most likely to be missed.
2. Strength and balance training The treatment with the best evidence for stopping further falls, given as a supervised programme rather than just advice to exercise more. That does not match a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs.
3. Treat the postural drop Review the medicines first, then look at fluid intake, compression stockings, and advice on standing up slowly, with drugs like fludrocortisone or midodrine used only on specialist advice. But a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs does not point to it.
4. Refer for cardiac monitoring For a collapse with no clear cause, no warning beforehand, an abnormal heart tracing, or a fall during exercise. It does not fit a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs.
5. Bone protection with calcium, vitamin D and a bisphosphonate For weak, brittle bones or after a fracture from a minor fall. Here, a 30 mmHg drop in the top blood pressure number on standing, while on five contributing drugs points elsewhere.

The point: A fall is something that has happened, not a diagnosis on its own. Ask what the patient was doing, whether there was any warning, whether they lost consciousness, and whether anyone saw it happen. Look for causes that can be treated: a drop in blood pressure on standing, taking too many medicines, poor eyesight, memory or thinking problems, infection, an abnormal heart rhythm, and hazards at home. Every older person who falls needs a full assessment covering all these areas, a review of their medicines, and their blood pressure checked lying down and standing up. Taking four or more medicines raises the risk of falling on its own.

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

A 79 year old man collapsed without warning while walking to the shops. Bystanders say he was pale and unresponsive for about 20 seconds, then recovered fully within a minute with no confusion. He has had two similar episodes. His ECG shows a bifascicular block and his lying and standing blood pressures are normal. What is the SINGLE most likely diagnosis?

1. Vasovagal syncope A build-up of feeling sick, sweating and vision greying out, with a clear trigger, followed by a slow recovery and feeling washed out afterwards. But a collapse with no warning and immediate full recovery, with a block in the heart's electrical pathway does not point to it.
2. Urinary tract infection Often blamed for a fall but often not the real cause, since having bacteria in the urine without symptoms is common over 65, and treating it does not stop falls. Here, a collapse with no warning and immediate full recovery, with a block in the heart's electrical pathway points elsewhere.
3. Falls A person ending up on the ground without meaning to, usually caused by more than one thing at once rather than a single cause. It does not fit a collapse with no warning and immediate full recovery, with a block in the heart's electrical pathway.
4. Postural hypotension A drop in blood pressure of 20 mmHg (top number) or 10 mmHg (bottom number) on standing, with symptoms on getting up, often caused by the patient's own medicines. That does not match a collapse with no warning and immediate full recovery, with a block in the heart's electrical pathway.
5. Cardiac arrhythmia correct Correct. No warning, a brief loss of consciousness during exercise, an immediate full recovery with no confusion, and it has happened more than once. That combination points at the heart, and the block found on the heart tracing explains how.

The point: Fainting caused by the heart happens with no warning, can happen during exercise or without warning at all, and recovery is immediate and complete. Vasovagal fainting has a build-up of symptoms first, and leaves the patient feeling washed out. A seizure leaves the patient confused afterwards. A double block in the heart's electrical pathway, combined with fainting, suggests the heart's normal rhythm is cutting out completely from time to time, and it needs urgent referral to a heart specialist.

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