For Student

An 82-year-old woman presents with recurrent falls.

The patient is housebound. Her most recent fall occurred while getting up to go to the toilet at
night. She has arthritis, heart failure and poor vision as a result of macular degeneration, and she
has had a previous hip replacement. She receives treatment with furosemide, ramipril, co-codamol,
amitriptyline and temazepam. She is very frail. The main findings on examination are: abbreviated
mental test 6/10, vision – large print only, kyphotic spine, brisk reflexes bilaterally, peripheral
oedema, clear lung fields and normal jugular venous pressure (JVP), heart rate 112/min, atrial
fibrillation (AF), blood pressure sitting 114/62 mmHg, mitral regurgitation.

Tasks:
1. What is the differential diagnosis?
2. What features in the history support the diagnosis?
3. What additional features in the history would you seek to support the potential diagnoses?
4. What other features would you look for on clinical examination?
5. What investigations would you perform?
6. What treatment options are available?
Student’s name
For examiner

An 82-year-old woman presents with recurrent falls.

The patient is housebound. Her most recent fall occurred while getting up to go to the toilet at
night. She has arthritis, heart failure and poor vision as a result of macular degeneration, and she
has had a previous hip replacement. She receives treatment with furosemide, ramipril, co-codamol,
amitriptyline and temazepam. She is very frail. The main findings on examination are: abbreviated
mental test 6/10, vision – large print only, kyphotic spine, brisk reflexes bilaterally, peripheral
oedema, clear lung fields and normal jugular venous pressure (JVP), heart rate 112/min, atrial
fibrillation (AF), blood pressure sitting 114/62 mmHg, mitral regurgitation.
Task 1 (2.0) - There are multiple causes, including: poor vision postural hypotension
polypharmacy neurological dysfunction – previous stroke, cervical myelopathy, vitamin B12
deficiency arthritis/osteomalacia arrhythmia – AF.
Task 2 (2.0) - 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 angiotensinconverting 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. Falls 145 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.
Task 3 (1.0) 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.
Task 4 (1.0) 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.
Task 5 (2.0) 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.
Task 6 (2.0) 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.