A precise diagnosis is essential first. If aortic stenosis is severe, the patient should be referred to a cardiologist for consideration of valve replacement. Transaortic valve implantation has extended the option of valvular repair to include patients not previously considered robust enough for open heart surgery. The patient should be advised to avoid sudden strenuous exertion in the meantime.
Admission is necessary if MI or arrhythmia is suspected. If there is postural hypotension, consider discontinuing or reducing the dose of any offending medication. The patient should be educated regarding avoidance of precipitating events. Compression hosiery should be used.
Aspirin and statin should be given for hindbrain TIA.
CASE 6.2 – An 82-year-old woman presents with recurrent falls.
A1: What is the differential diagnosis?
There are multiple causes, including:
poor vision
postural hypotension
polypharmacy
neurological dysfunction – previous stroke, cervical myelopathy, vitamin B12 deficiency
arthritis/osteomalacia
arrhythmia – AF.
A2: What features in the history support the diagnosis?
Poor vision: the fall occurred at night when environmental hazards are more difficult to see and avoid.
Postural hypotension: the fall occurred as the patient was getting out of bed to go to the toilet. She is on a lot of medications that can impair postural blood pressure control – a diuretic, an angiotensin-converting enzyme (ACE) inhibitor and amitriptyline (a tricyclic antidepressant with anticholinergic properties).
Polypharmacy: postural hypotension:
impaired balance and cognition caused by temazepam, opiate analgesic and tricyclic antidepressant
muscle weakness; diuretic-induced hypokalaemia.
Neurological dysfunction: brisk reflexes are suggestive of upper motor neuron dysfunction. Common causes at this age include stroke disease, cervical myelopathy and occasionally vitamin B12 deficiency.
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As a result of the history of falls and the finding of cognitive impairment, a chronic subdural haematoma should also be considered.
Atrial fibrillation: poorly controlled (rapid) ventricular rate on exertion causing syncope. AF might also be a manifestation of sick sinus syndrome, predisposing to supraventricular tachycardia or bradycardia.
A3: What additional features in the history would you seek to support the potential diagnoses?
Poor vision: access to spectacles, ability to read or identify objects, adequacy of lighting in the home.
Postural hypotension: dizziness or falls when upright, with associated symptoms of faintness or syncope, and rapid recovery when recumbent.
Polypharmacy: concordance with medication regimen and any potential to exceed the intended dosing schedule.
Neurological dysfunction: history suggestive of previous stroke or TIA.
Neck arthritis: giddiness on head movement and pain radiating to shoulders and upper limbs (cervical spondylitic radiculopathy) suggest cervical myelopathy as a potential cause of falling.
Enquire about diet, previous gastric surgery, bowel (terminal ileal) disease or resection, anaemia and symptoms of sensory neuropathy in suspected vitamin B12 deficiency.
Fluctuating alertness: confusion or consciousness with a history of falls and head injuries (even trivial) should highlight the possibility of subdural intracranial bleeding.
Bone pains and muscle weakness: in a housebound patient with poor diet, these point to osteomalacia.
Cardiac arrhythmia: recurrent episodes of dizziness or syncope unrelated to posture or activity with prompt recovery suggest an intermittent cardiac rhythm disturbance.
A4: What other features would you look for on clinical examination?
Poor vision: Snellen chart to assess visual acuity, examination of eyes for common causes of visual loss in older people (i.e. refractive disorder), cataracts, glaucoma, macular degeneration, diabetic retinopathy.
Postural hypotension: lying and standing blood pressure.
Neurological disorders: thorough central nervous system (CNS) examination essential. Focal upper motor neuron signs suggestive of stroke or subdural haematoma. Up-going plantar responses, consistent with cervical myelopathy; peripheral neuropathy and posterior column dysfunction (joint position/vibration sense) suggest vitamin B12 deficiency.
Arthritis/osteomalacia: joint examination, back pain, muscle weakness.
A5: What investigations would you perform?
The following tests are necessary:
lying and standing blood pressure
ECG
plasma urea, creatinine and electrolytes (U&Es) and glucose
full blood count (FBC) (and vitamin B12/folate levels if macrocytic anaemia present)
radiograph of painful bones and significantly arthritic joints
vitamin D, calcium, albumin and alkaline phosphatase (ALP; for osteomalacia).
Other tests might be indicated after preliminary assessment and investigation, including:
cervical spine radiograph with option to proceed to magnetic resonance imaging (MRI) cervical spine if cervical myelopathy is probable and surgery is a realistic option
computed tomography (CT) of the brain
thyroid function.
A6: What treatment options are available?
Vision: occupational therapist home visit to remove environmental hazards and improve lighting.
Assess for spectacles and ophthalmic referral as needed.
Postural hypotension and polypharmacy: review the need for and doses of all medications.
Neurological dysfunction: beyond the scope of this case scenario.
Osteomalacia: calcium and vitamin D supplements.
Atrial fibrillation: discuss the need for rhythm or rate control – options include cardioversion, digoxin, beta-blockers and amiodarone. If the patient has a bradyarrhythmia, they will require assessment for cardiac pacemaker. Owing to the risk of further falls, anticoagulation with warfarin is often not appropriate without very careful assessment of the ongoing risks. Always involve the patient, family and general practitioner (GP) in such discussions.
CASE 6.3 – A 78-year-old man who lives alone is brought to A&E after being found on the floor at home by his neighbour.
A1: What is the differential diagnosis?
pneumonia
dehydration
parkinsonism
head injury with intracranial bleed or contusion.
A2: What features in the history support the diagnosis?
Hypostatic pneumonia and dehydration often complicate a long period of immobility after a fall.
Aspiration pneumonia should also be considered.
The generalized muscle cog-wheel rigidity is suggestive of parkinsonism. Reflexes can be difficult to elicit in this situation. Spasticity caused by cerebrovascular disease would more usually be associated with hyperreflexia and up-going plantar responses. Parkinsonism might be a result of idiopathic Parkinson’s disease or secondary to other causes such as medication (e.g. neuroleptics such as haloperidol or risperidone) or vascular (arteriosclerotic). The patient’s unkempt state suggests a chronic insidious decline before this acute presentation. Parkinson’s disease and parkinsonism can present in this way.
Head injury is obvious on examination, but the severity is difficult to assess. A subdural haematoma (acute or chronic) must be considered in this setting.
A3: What additional features in the history would you seek to support the potential diagnoses?
Further history from family, neighbours and so on is essential to establish the time course and pattern of the patient’s decline and any history of previous falls. An accurate medication history is required, from the GP’s records if necessary. Any suggestion of alcohol abuse is important. As always, details of past medical history are essential, such as a history of stroke disease, vascular dementia, and previous psychiatric history requiring neuroleptic medication.
A4: What other features would you look for on clinical examination?
Assessment of conscious level and airway is essential because the patient is at risk of airway obstruction and aspiration.
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Signs of weight loss or lymphadenopathy (tuberculosis [TB]) and clubbing (bronchial carcinoma) should be looked for. The rigidity of parkinsonism is usually of lead-pipe or cog-wheel type. A pill-rolling resting tremor may also be present, but not invariably so.
Evidence should be sought of urinary outflow obstruction (enlarged bladder), faecal impaction (rectal examination), bony injuries (hip, skull) and pressure sores, which can be overlooked in this setting.
A5: What investigations would you perform?
Additional investigations include:
arterial oxygen saturation/blood gases
blood and sputum cultures (for pneumonia)
calcium (confusion caused by hypercalcaemia)
urea, creatinine, electrolytes and creatinine kinase (for dehydration, kidney failure, rhabdomyolysis)
ECG (for arrhythmias)
radiographs of skull and sites of other apparent bony injuries
CT of head (for acute or chronic subdural haematoma).
A6: What treatment options are available?
The following treatment options are available:
rehydration with monitoring of urine output
oxygen therapy as directed by O2 saturation or arterial blood gas (ABG) measurements
broad-spectrum antibiotics for hypostatic/aspiration pneumonia (e.g. benzylpenicillin, levofloxacin and metronidazole – but consult local antibiotic guidelines)
discontinuation of any drugs likely to cause parkinsonism
if idiopathic Parkinson’s disease is suspected, gradual introduction of L-dopa-based medication (e.g.
co-careldopa) once resuscitation completed.
OSCE counselling cases
OSCE COUNSELLING CASE 6.1 – What advice would you give the following patient?
The daughter has a valid point, but you will need to explain that to prevent further fractures measures are needed to reduce the risk of falling in addition to a consideration of treatment for osteoporosis.
The patient would benefit from a multidisciplinary assessment to identify remediable medical illnesses that might precipitate falls (e.g. cardiovascular disease, medications, poor eyesight, Parkinson’s disease).
Advice from a physiotherapist or occupational therapist on measures to enhance fitness and safety at home, and to secure help if further falls supervene, is also essential.
If the patient is aged 75 years or older, osteoporosis can be assumed in the setting of a low trauma fracture. Having excluded secondary causes of osteoporosis (e.g. thyrotoxicosis, steroid therapy, multiple myeloma, hyperparathyroidism), treatment for age-associated osteoporosis should be considered. In this setting, calcium and vitamin D supplements are helpful and relatively safe, although it is prudent to measure the plasma calcium level before and 6–8 weeks after initiating treatment. A regular bisphosphonate is also indicated, providing the requirements for safe and effective oral dosing can be followed. Oesophageal and peptic ulcer disease and renal impairment will require caution with respect to bisphosphonate therapy. Thorough discussion with the patient is essential before initiating treatment.
OSCE COUNSELLING CASE 6.2 – ‘What is the underlying condition, and how has it come about?’
The likely diagnosis is osteomalacia. Lack of exposure to sunlight, poor diet if socially isolated, poor health, and enhanced metabolism of vitamin D as a result of treatment with phenytoin (a liver enzyme inducer) may have precipitated the condition. Diseases causing malabsorption and chronic renal failure can also predispose to osteomalacia.
You need to look for proximal muscle weakness, bony tenderness (pseudo-fractures or Looser’s zones on radiograph), and skeletal deformities such as kyphosis and bowing of the limbs. Significant hypocalcaemia can precipitate tetany with a positive Chvostek sign (spasm of the facial muscles on tapping over the branches of the facial nerve in front of the ear) and Trousseau’s sign (spasm of the hand and forearm muscles after compression of the forearm).
The blood level should be checked for 25-hydroxy-vitamin D, and vitamin D supplements should be given either orally or intramuscularly. An adequate calcium intake should be provided, if necessary with oral calcium supplements (1 g/day). There should be a thorough discussion with the patient about the risks and benefits of changing to an alternative anticonvulsant such as sodium valproate.
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IMMOBILITY
Questions
Clinical cases
For each of the case scenarios given, consider the following:
CASE 6.4
Q1: What is the differential diagnosis?
Q2: What features in the history support the diagnosis?
Q3: What additional features in the history would you seek to support the potential diagnoses?
Q4: What other features would you look for on clinical examination?
Q5: What investigations would you perform?
Q6: What treatment options are available?
CASE 6.5
Q7: What investigations would you perform?
Q8: What treatment options are available?
Q9: What are the likely causes of his immobility?
Q10: What can be done to improve the situation at home?
CASE 6.6
Q11: What treatment options are available?
Q12: In addition to regular medical and nursing attention, which members of the multidisciplinary team ought to be involved with care?
Q13: What medical complications might supervene during the next 4–6 weeks?
CASE 6.4 – A 74-year-old man who has difficulty walking is referred to the elderly medicine day hospital.
The patient is confined to his chair unless assisted to stand. He cannot get into bed at night. His past history includes neck surgery for cervical spondylosis. He has hypertension treated with nifedipine. He is obese, his legs are oedematous and he is incontinent of urine. He has ulceration and cellulitis affecting his lower legs. A CNS examination reveals normal cognition and cranial nerves, but weak arms and legs (power 4/5), brisk reflexes bilaterally and up-going plantar responses. His feet are warm but foot pulses are impossible to assess owing to oedema.
CASE 6.5 – You have been called to see a 72-year-old man who lives alone at home.
The district nurse has become increasingly concerned about his health. The patient has been
housebound for some time but is now unable to rise from his chair. He is a large man and his left hip is very painful. There is no history of a fall. He is unkempt and his clothes smell of urine. He is a heavy smoker, and he is breathless and wheezy with a chronic cough. His legs are swollen and blistered.
Detailed examination is difficult but reveals signs of airflow obstruction, cyanosis, elevated JVP and peripheral oedema. Movement at the left hip is restricted and painful. He is very reluctant to leave his home.
CASE 6.6 – A 68-year-old previously active woman is unable to walk or stand having sustained a stroke (left middle cerebral artery territory infarction) 3 weeks previously.
The patient has a dense right hemiparesis, homonymous hemianopia and sensory disturbance. She is also dysphasic and has difficulty swallowing. Recovery has been complicated by aspiration pneumonia.
She has a urinary catheter and needs regular toileting. She is in AF, and her blood pressure is 142/78 mmHg. She is reluctant to engage with her programme of rehabilitation.
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