Fits, Faints and Funny Turns. Kate Ingram Geriatrician SCGH

Transcription

1 Fits, Faints and Funny Turns Kate Ingram Geriatrician SCGH

2 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

3 What are the Possible Explanations? Postural hypotension Post micturition syncope Cardiac syncope

4 Outline Syncope Dizziness Vertigo

5 Elderly often have poor recall as to whether they lost consiousness Collateral history is essential

6 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?

7 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

8 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 LOC

9 Causes 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 prandial

10

11 Cardiac Syncope Increased risk with age Associated with high mortality Causes Arrhythmias- VT, VF, CHB, bradycardias Structural problems- HOCM, AS

12 Antipsychotics Cause Tachyarrythmia

13 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 <50/ min Long or short QT interval

14 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

15

16 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

17 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 testing

18 Medications- 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

19 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

20 Vertigo The illusion of movement Most common cause is Benign (Paroxysmal) Positional Vertigo Hall Pike +ve Treatment- Epleys Manoeuvre Beware of stemetil- Parkinsonism

21 Causes of Vertigo Cause Symptoms Management Benign Positional Vertigo Viral labyrinthitis Menieres disease Brainstem or cerebellar stroke Vestibular migraine Acoustic neuroma Few seconds of vertigo on looking up Acute onset of vertigo, N & V, settles over days to weeks. Recent viral illness Episodic vertigo lasting days. Also deafness, aural fullness, tinnitis Vertigo, diplopia, facial droop etc Younger patients, preceding aura, headache Insidious onset unilat deafness, vertigo, facial droop Epleys positioning manoevre Supportive initially, vestibular rehab during recovery Serc, ENT review, vestibular rehab Stroke management, vestibular rehab Migraine management Surgical resection

22 Modified from Parnes et al 03. CMAJ 169, Mechanism 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.

23 Dix Hallpike (Posterior & Anterior SemiCircular Canal) Parnes et al 03. CMAJ 169, A. Long Sitting Rotate Cx Spine 45 o B. Supine o Cx Extension

24 Vestibular 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 causes

25 Vertigo- Further Investigations Audiometry Caloric testing Electro/ video nystagmography MRI Internal auditory canals or cerebellum

26 Sign/ Symptom Direction of nystagmus Purely horizontal nystagmus Purely vertical or purely torsional nystagmus Visual fixation (eg on finger) Peripheral Vs Central Vertigo (Harrison s, Walker MF and Daroff RB) Peripheral (Labyrinth or Vestibular Nerve) Unidirectional (fast phase opposite lesion) Uncommon Never present Inhibits nystagmus Central (Brainstem or Cerebellum) Bi or unidirectional May be present May be present No inhibition Tinnitis and /or deafness Often present Usually absent Associated other neurological abnormalities Common causes None BPPV, labyrinthitis, Menieres, labyrinthine ischemia Common (eg double vision, slurred speech) Strokes, MS, tumours

27 Causes 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% unknown

28 Workup 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

29 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 declinefatigue, worsening mobility, poor appetite & wt loss, incontinence Functional outcomes confirm deteriorating Timed Up and Go s secs

30 PMH -Polymyalgia Rheumatica- quiescent -OA- TKRs -Urge urinary incontinence- KEMH -Macular degeneration -TIA and? Seizure x 1 10 years ago

31 Medications prednisolone 5 mg solifenacin 5 mg vitamin D 2 tabs phenytoin 200mg thyroxine 125 mcg nexium 20mg perindopril plus 5/125mg actonel

32 Examination BP 130 systolic lying- 80 mmhg standing, dizzy ++ Hypovolaemic Investigations B (Low) Vitamin D 117 ESR and CRP normal TSH 0.22 (low) Sodium 124 (Low)

33 Management -stop vesicare, phenytion, perindopril plus -load with B12 -reduce thyroxine -stop actonel, continue with calcium & vit D -wean prednisolone

34 Review at 4 months No further falls Mobility improving with Falls Specialist- TUG improved secs No return of PMR symptoms Sodium normalised

35 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

36 Other symptoms Deteriorating memory, concentration Urinary incontinence PMH IHD- stents 3 months ago Depression- stable now Laminectomy

37 Case 2 Mrs M- Medications Aspirin Clopidegrel Carvedilol Monoplus 20/12.5 Spironolactone Nortriptyline 50mg Dothiepin 150mg Oestrone 0.625mg Atorvastatin Meloxicam

38 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)

39 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.

40 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