Introduction
Case history: Vascular Parkinsonism
Case history: Polymyalgia rheumatica (PMR)
Case history: Parkinson’s disease with significant postural drop
Conclusion
References

 

Introduction

One in three adults over 65 years who live at home will have at least one fall in a year and 50% of these individuals will have multiple falls.1

This can have serious consequences as every year 3.4 million people suffer serious injury and possibly even death. After a hip fracture, 50% of patients don’t return to their baseline level of independence. Hence, the psycho-social implications associated with reduced confidence and isolation also need to be considered.2

The term ‘mechanical fall’ is an ambiguous term that is becoming increasingly common. Some clinicians attribute it to extrinsic, environmental factors whereas others use it to categorise aetiologies that haven’t been fully explored nor excluded. Use of this term prevents accurate diagnosis, treatment and increases risk of future falls.3 The following case summaries explore underlying diagnoses and learning points in three patients provisionally given a diagnosis of ‘mechanical fall’.

 

Case history: Vascular Parkinsonism

A 66-year-old woman presented to the emergency department with left-sided facial droop, slurred speech and three falls in the past 24 hours without loss of consciousness. She had a background of type 2 diabetes, hypertension, ischaemic heart disease with multiple stents, transient ischaemic attack, chronic kidney disease, urinary incontinence and osteoporosis.

On examination, we elicited full power and normal sensation. However, she had cogwheel rigidity in the upper limbs, which guided confirmation of more subtle signs such as hypomimia, bradykinesia and dysphonia. Collateral history revealed that the patient was ataxic and often ‘slipped out of her chair’. MRI showed multiple microhaemorrhages; stable from previous imaging.

The patient was diagnosed with vascular Parkinsonism; with an element of cognitive impairment driven by arteriopathy. The challenge in this patient was control of vascular risk factors and anticoagulation in the context recurrent falls. Furthermore, trial of Parkinsonian medication posed risks such as confusion and postural hypotension. Learning points are highlighted in Box 2.

 

BOX 1: TIME: AN ACRONYM FOR CAUSES OF FALLS4
Therapeutics: gait, balance, mobility, muscle weakness, perceived functional ability, fear of falling

Iatrogenic: Benzodiazepines, Antidepressants, Antipsychotics, Antiepileptics, Antihypertensives

Medical: Visual impairment, cognitive and neurological impairment, incontinence, cardiovascular pathology, osteoporosis risk

Environmental: Home hazards

Case history: Polymyalgia rheumatica (PMR)

A previously independent 89-year-old woman presented to the emergency department with multiple falls over recent months without loss of consciousness. She suffered from arthritis, diverticular disease and Meniere’s disease. She reported dizziness and weakness in her legs. Further history revealed joint pain, specifically shoulder stiffness worse in the morning. Furthermore, there were no focal neurological signs on examination.

A diagnosis of Polymyalgia Rheumatica was made and the patient commenced on steroids. The crux of this case was detailed history taking and consideration of multiple aetiologies for this patient’s falls. It was important to consider immediate side effects of steroids such as hypertension, hyperglycaemia and electrolyte disturbances as well as long-term sequale such as osteoporosis and gastric erosion.6

 

Learning

PMR is a rheumatological condition affecting patients over 50 years. It causes shoulder and pelvic girdle pain and stiffness. There can also be synovitis of the proximal joints.7 Symptoms are usually worse in the morning and develop rapidly over weeks. Diagnosis is with a raised erythrocyte sedimentation rate (ESR) and excellent response to steroid therapy; although up to 50% of patients suffer from its side effects.8

Ultrasound may show features of subdeltoid bursitis in keeping with the predominant musculoskeletal features characteristic of PMR. Giant cell arteritis is a closely related syndrome and medical emergency. Arterial inflammation causes visual loss, headache, scalp tenderness and jaw claudication. Complications include complete blindness, thoracic aortic aneurysm and dissection.8,9

 

Case history: Parkinson’s disease with significant postural drop

A 85-year-old man presented to A&E with left-sided weakness, facial droop and recent history of recurrent falls without loss of consciousness. His past medical history included deep vein thrombosis, heart failure and a permanent pace maker. On examination full power and normal sensation was elicited. However, there was rigidity of the upper limbs; which guided confirmation of more subtle signs such as hypomimia and bradykinesia. Since an MRI was contraindicated, the patient was clinically diagnosed with multiple system atrophy (MSA) with an element of postural hypotension. The challenge in this patient was symptom control and prevention of future falls.

 

Learning

This refers to a group of neurological diseases that affect movement; manifesting as bradykinesia, tremor and rigidity. MSA is classified as a ‘Parkinson plus syndrome’ and needs to be distinguished from Idiopathic Parkinson’s disease due to differences in treatment and prognosis.

Degeneration of the central nervous system leads to symptoms of autonomic failure found in MSA such as postural hypotension, dual incontinence and impotence. There may also be cerebellar signs, dysphagia and stridor due to lack of abduction of the vocal cords.10 T2 diffusion weighted magnetic resonance imaging shows putamen atrophy in MSA.11 The final hallmark is a poor response and deterioration despite treatment with levodopa. Hence, it is important to address symptoms of orthostatic hypotension with head position, elastic stockings, fludrocortisone and desmopressin.10

 

BOX 2: VASCULAR PARKINSONISM VERSUS PARKINSON’S DISEASE5
Vascular Parkinsonism Parkinson’s disease
Main symptoms Falls, incontinence, vascular risk factors Bradykinesia, festination
Localisation Lower limbs Upper limbs
Tremor Postural Resting
Gait Parkinsonian- ataxic
(Wide base with variable stride length)
Short shuffling
MRI Subcortical infarcts/white matter ischaemia Volume change in substantia nigra
Management Poor/limited response to Levodopa Levodopa, dopamine agonists, monoamine oxidase inhibitors
MEDICAL ENVIRONMENTAL SENSORY & LOCOMOTOR
Cognitive and neurological:
stroke/dementia/Parkinson's
  • Review and discontinue psychotropic medication
Home hazards:
rugs/slippery floors/poor lighting
  • Bath aids, raised toilet, grab rails
Gait, balance and mobility
  • Strength and balance exercises
Cardiovascular:
syncope/arrhythmias/postural hypotension
  • Consider pacing if carotid sinus hypersensitivity
  • Review antihypertensive medication
Mobility aids
rugs/slippery floors/poor lighting
  • Walking stick, chair lift
Visual impairment
  • Assess acuity and correct refractive error
  • Cataract operation if indicated
Renal:
urinary incontinence/UTI
  • Bladder diaries
  • Urodynamic testing
Falls alarm
rugs/slippery floors/poor lighting
  • Bed and chair monitors
  • Emergency button/wristband
Previous falls
  • Frequency, nature, context
Osteoporosis:
Fragility fracture/glucocorticoids /smoking/excess alcohol/low BMI
  • Fracture risk assessment in women >65 and men >75 years without risk factors OR >50 years with risk factors
  • FRAX risk assessment tool
  • Calcium and vitamin D supplements
  • Bisphosphonates
Respite care
  • Falls prevention programme
  • Education and information
 

Conclusion

Although ageing increases the risk of falls, prevention is key. NICE guidelines recommend a multi-factorial approach to risk assessment in order to implement multi-modal interventions. Risk factors for falls and appropriate interventions can be categorised into medical, environmental and locomotor factors.4 Such assessment is recommended in patients presenting with a fall, recurrent falls or problems with gait and balance; usually in a specialist falls service.

 

Saraswati Aryasomayajula
Foundation year 2 doctor, General Practise, Luton and Dunstable Hospital

Sakthivel Sethuraman
Locum Consultant in Stroke and Geriatric Medicine, Luton and Dunstable Hospital

Johnson Philippanathan
Specialty Registrar in Stroke and Geriatric Medicine, Luton and Dunstable Hospital  

Conflict of interest: none declared

 


References

1. NHS Choices. Falls. Available from: http://www.nhs.uk/ conditions/Falls/Pages/Introduction.aspx [Accessed 26 September 2017]

2. Age UK. Stop falling: Start saving lives and money http:// www.ageuk.org.uk/Documents/EN-GB/Campaigns/Stop_ falling_report_web.pdf?dtrk=true [Accessed 26 September 2017]

3. Sri-on J, Tirrell GP, Lipsitz LA, Liu SW. Is there such a thing as a mechanical fall? Am J Emerg Med 2016; 34(3): 582–85

4. NICE. Falls in older people: assessing risk and prevention. Available from: https://www.nice.org.uk/guidance/cg161 [Accessed 26 September 2017]

5. Winikates J, Jankovic J. Clinical Correlates of Vascular Parkinsonism. Arch Neurol 1999; 56(1): 98102

6. Buchman AL. Side effects of corticosteroid therapy. J Clin Gastroenterol 2001; 33(4): 289–94

7. Soubrier M, Dubost JJ, Ristori JM. Polymyalgia rheumatic: diagnosis and treatment. Joint Bone Spine 2006; 73(6):599-605

8. Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet 2008; 372(9634): 234–45

9. Nothnagl T, Leeb BF. Diagnosis, differential diagnosis and treatment of polymyalgia rheumatic. Drugs Aging 2006; 23(5): 391-402

10. Rehman HU. Multiple system atrophy. Postgraduate Medical Journal 2001; 77: 379–82

11. Schocke MF, Seppi K, Esterhammer R et al. Diffusionweighted MRI differentiates the Parkinson variant of multiple system atrophy from PD. Neurology 2002; 58(4): 575–80