Serving an ageing population is one of the biggest challenges faced by the NHS. Falls are a common presentation in this cohort where the cause is often multi-factorial and reversible. We as clinicians need to dig deeper in our histories, observe more closely in our examinations and broaden our differentials to ensure we don’t slip up.
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’.
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
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
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
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.
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|
(Wide base with variable stride length)
|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:
rugs/slippery floors/poor lighting
|Gait, balance and mobility
rugs/slippery floors/poor lighting
rugs/slippery floors/poor lighting
Fragility fracture/glucocorticoids /smoking/excess alcohol/low BMI
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.
Foundation year 2 doctor, General Practise, Luton and Dunstable Hospital
Locum Consultant in Stroke and Geriatric Medicine, Luton and Dunstable Hospital
Specialty Registrar in Stroke and Geriatric Medicine, Luton and Dunstable Hospital
Conflict of interest: none declared