Fits, Faints and Funny Turns - SCGH Kate Ingram Geriatrician
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Fits, Faints and Funny Turns
Kate Ingram
Geriatrician
SCGH
84 year old man presents to ED after falling overnight and being found the next morning by a carer on the floor in his hallway. After being treated for hypothermia, dehydration, rhabdomyolysis and renal failure you take a history of the events of last night. He tells you he got up to go to the toilet and was on his way back to bed when he felt dizzy and collapsed. Not sure if he lost consiousness
What are the Possible Explanations? • Postural hypotension • Post micturition syncope • Cardiac syncope
Outline • Syncope • Dizziness • Vertigo
• Elderly often have poor recall as to whether they lost consiousness • Collateral history is essential
Taking a History
• What are you going to ask the patient ?
– Preceding dizziness, palpitations, sweating, chest pain
– History of postural dizziness
– Previous episodes of syncopal falls. What were they
doing at the time? Always whilst upright?
– Injuries suggestive of LOC eg facial/ head injuries
– Recent changes to medications?What are you going to ask the witness? • Observed pallor, sweating • Length of LOC • Pulse at the time?? (otherwise ambulance pulse and BP is next best thing) • Exclude features of seizures – Tongue biting, incontinence – Prolonged recovery – Seizure activity
Syncope
• 40% of adults have had a syncopal episode
• Elderly patients are more likely to have a
cardiac cause (up to 30%)
• Collateral history is essential
– Elderly frequently cannot recall whether they did
have LOCCauses of Non Cardiac Syncope
• Neurally mediated * most common
• Vasovagal
• Carotid Sinus syncope
• Orthostatic hypotension
• Primary autonomic failure
• Secondary autonomic failure
• Volume depletion
• Situational syncope
– Cough
– Micturition
– Defaecation
– Post prandialCardiac Syncope • Increased risk with age • Associated with high mortality • Causes – Arrhythmias- VT, VF, CHB, bradycardias – Structural problems- HOCM, AS
Antipsychotics Cause Tachyarrythmia
How far to investigate? • History, examination, lying and standing BP and ECG gave a diagnosis in 66% with diagnostic accuracy of 88% (Van Dyck 2008) • If exclude patients with suspected or certain heart diseaswe it rules out cardiac cause of syncope in 97%. • Suspicious ECG findings – VT – Widened QRS complex – Sinus bradycardia
Mrs NM 85 yrs, lives at home alone 4 falls, resulting in #s in past, LOC at least on some occasions Admitted with CCF ECG…
Who needs further investigations? • Syncope with no warning symptoms • Syncope during exercise • Preceding palpitations • Syncope in the supine position • Frequent or injurious syncope • Features suggestive of seizure
Specialised Investigations
• Echocardiography
• Ambulatory ECG monitoring
– 24 hour has a low yield (4- 19%)
– Implantable loop recorder has much higher
yield (33- 55%)
• Carotid sinus massage
• Head up tilt table testingMedications- Antipsychotics • respiradone, olanzepine, haloperidol, quetiapine • Increases risk of falls • Increased mortality rate if used in demented patients 2.3 Vs 3.5% (JAMA 2005) • Respiradone has FDA black box warning in USA
Driving • If unexplained syncope no driving for 4 weeks • If there is an adequate prodrome, and no history of syncope whilst seated then should be OK
Vertigo • The illusion of movement • Most common cause is Benign (Paroxysmal) Positional Vertigo • Hall Pike +ve • Treatment- Epleys Manoeuvre • Beware of stemetil- Parkinsonism
Causes of Vertigo
Cause Symptoms Management
Benign Positional Vertigo Few seconds of vertigo on Epleys positioning
looking up manoevre
Viral labyrinthitis Acute onset of vertigo, N & Supportive initially,
V, settles over days to vestibular rehab during
weeks. Recent viral illness recovery
Menieres disease Episodic vertigo lasting Serc, ENT review, vestibular
days. Also deafness, aural rehab
fullness, tinnitis
Brainstem or cerebellar Vertigo, diplopia, facial Stroke management,
stroke droop etc vestibular rehab
Vestibular migraine Younger patients, Migraine management
preceding aura, headache
Acoustic neuroma Insidious onset unilat Surgical resection
deafness, vertigo, facial
droopMechanism –What does the Debri do?
• Otolithic debri (Otoconia) make their way into the semicircular canal and
either Float freely within the Endolymph or are Fixed to the Cupula.
Modified from Parnes et al 03. CMAJ 169, 681 - 693Dix Hallpike (Posterior & Anterior SemiCircular Canal)
Parnes et al 03. CMAJ 169, 681 - 693
A. Long Sitting B. Supine
Rotate Cx Spine 45o 20 – 30o Cx ExtensionVestibular Assessment
• History
• Examination
– Gait
– Hall- Pikes
– Eye movements
• saccades and pursuit
• ? nystagmus
– Head Thrust Test/ Vestibulo- Occular Reflex
– Other tests: head shaking, marching eyes closed
• Positive in vestibular rather than brainstem causesVertigo- Further Investigations
• Audiometry
• Caloric testing
• Electro/ video nystagmography
• MRI
– Internal auditory canals or cerebellumPeripheral Vs Central Vertigo
(Harrison’s, Walker MF and Daroff RB)
Sign/ Symptom Peripheral (Labyrinth or Central (Brainstem or
Vestibular Nerve) Cerebellum)
Direction of nystagmus Unidirectional (fast phase Bi or unidirectional
opposite lesion)
Purely horizontal Uncommon May be present
nystagmus
Purely vertical or purely Never present May be present
torsional nystagmus
Visual fixation (eg on Inhibits nystagmus No inhibition
finger)
Tinnitis and /or deafness Often present Usually absent
Associated other None Common (eg double vision,
neurological abnormalities slurred speech)
Common causes BPPV, labyrinthitis, Strokes, MS, tumours
Menieres, labyrinthine
ischemiaCauses of Dizziness
• Much more vague, non specific symptom!
• Causes
40% peripheral vestibular lesion eg BPV, Menieres
10% brainstem pathology
15% psychiatric
25% postural hypotension, presyncope, leg weakness/
instability
10% unknownWorkup for Dizziness • Good history, including collateral history • Look at medications • Examination – Lying and standing BP – Pulse, ECG – Neuro signs- esp nystagmus, hearing, facial droop, coordination – Special manoevres- Hall Pikes, VOR, walking on spot • Investigations – If suspicious of brainstem/ cerebellar lesion- MRI
Case- Mrs KC 95 year old, living alone, supportive daughter, frail ++ Seeing Falls Specialist at home for falls and poor mobility Referred in for urgent medical assessment for subacute decline- fatigue, worsening mobility, poor appetite & wt loss, incontinence Functional outcomes confirm deteriorating Timed Up and Go s 28- 51 secs
PMH -Polymyalgia Rheumatica- quiescent
-OA- TKRs
-Urge urinary incontinence- KEMH
-Macular degeneration
-TIA and ? Seizure x 1 10 years agoMedications prednisolone 5 mg solifenacin 5 mg vitamin D 2 tabs phenytoin 200mg thyroxine 125 mcg nexium 20mg perindopril plus 5/125mg actonel
• Examination – BP 130 systolic lying- 80 mmHg standing, dizzy ++ – Hypovolaemic • Investigations – B12 120 (Low) – Vitamin D 117 – ESR and CRP normal – TSH 0.22 (low) – Sodium 124 (Low)
Management -stop vesicare, phenytion, perindopril plus -load with B12 -reduce thyroxine -stop actonel, continue with calcium & vit D -wean prednisolone
Review at 4 months • No further falls • Mobility improving with Falls Specialist- TUG improved 54- 23 secs • No return of PMR symptoms • Sodium normalised
Case 2- Mrs M 78 years, lives with husband in own home Poor mobility for years due to spinal degenerative arthritis 3 year history of falls- 4 in last month
• Other symptoms – Deteriorating memory, concentration – Urinary incontinence • PMH – IHD- stents 3 months ago – Depression- stable now – Laminectomy
Case 2 Mrs M- Medications Aspirin • Nortriptyline 50mg Clopidegrel • Dothiepin 150mg Carvedilol • Oestrone 0.625mg Monoplus 20/12.5 • Atorvastatin Spironolactone • Meloxicam
Examination • BP 90/40 lying, 70/40 standing • Very unsteady gait, tending to fall backwards • MMSE 23/30 • Right trendelenberg gait with gluteal tenderness (post fall)
Management • Physio program for gluteal muscle tear (on U/S) • Sodium was low (120) so stopped thiazide diuretic • Reduced monopril dose • In conjunction with psychiatrist weaned both tricyclic antidepressants • Stop Mobic- panadol instead • Vitamin D low (13) so loaded and continued on vitamin D supplements.
Progress • ‘Today Mrs M looks like a completely different person’ • No falls, steady gait, improved memory • Now bright and reactive, planning holiday! • Resolved urinary incontinence
You can also read
