Falls and Syncope — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Mrs Margaret Hughes, 82 years old, lives alone in her own single-storey home. [1]

Presenting complaint: Three falls in the past six months, assessed in the outpatient falls clinic. [1]

History of the presenting complaint: The first fall occurred three months ago, when Mrs Hughes got out of bed at 6 am to go to the toilet; she felt lightheaded as she stood, took two steps, and fell to her knees, without loss of consciousness. She bruised her hip but did not seek medical attention. The second fall, six weeks ago, was identical — lightheaded on standing from bed in the morning, and she fell against the doorframe. Her daughter, who visited that afternoon, persuaded her to see the general practitioner. The third fall, two weeks ago, occurred when she turned quickly in her kitchen to answer the phone; she lost her balance and fell sideways, again without injury or loss of consciousness. [1]

She describes no chest pain, palpitations, dyspnoea, or neurological symptoms at the time of the falls. She has noticed that she feels lightheaded whenever she stands quickly, and she has begun to limit her activity — she no longer walks to the shops because she is afraid of falling. She sleeps poorly and takes a temazepam most nights. [1]

Past history:

• Hypertension, diagnosed 20 years ago
• Type 2 diabetes, diagnosed 15 years ago, with a sensory neuropathy in both feet
• Osteoarthritis of both knees
• Neuropathic pain in the feet, worse at night
• Cataract in the left eye, under review
• No history of ischaemic heart disease, stroke, or structural heart disease [1]

Current medications:

• Doxazosin 4 mg at night
• Hydrochlorothiazide 25 mg in the morning
• Amitriptyline 25 mg at night
• Temazepam 10 mg at night
• Metformin 500 mg twice daily
• Paracetamol 1 g as needed (two to three times daily) [1]

Social history: She is a widow of four years. She lives alone in her own single-storey home with two steps at the front entrance. She has one daughter who visits weekly and helps with her shopping. She drove until three months ago but has stopped because she is afraid. She does not smoke and drinks alcohol rarely. She is independent in her basic activities of daily living but has reduced her housework and her walking. [1]

Examination findings (trainee elicits):

• Alert, oriented, conversational. MoCA 26 out of 30 (points lost on recall and on the trail-making task).
• Supine blood pressure 152/88, heart rate 72 and regular. On standing for 1 minute: 128/76, lightheaded. On standing for 3 minutes: 118/72, heart rate 80, still lightheaded — a systolic drop of 34 mmHg with symptoms.
• Cardiovascular examination: no murmurs, no signs of heart failure, pulse regular, no carotid bruits.
• Neurological examination: reduced joint position sense and vibration sense at the toes bilaterally (sensory neuropathy); normal power, tone, and reflexes; no parkinsonism; no cerebellar signs.
• Gait: slow, short-stride, cautious, with a single-point stick. Timed Up and Go test 17 seconds; turns in four steps; tandem gait impaired.
• Musculoskeletal: osteoarthritis of both knees; rises from the chair by pushing off with her arms. [1]

Investigations:

• Full blood count, urea and electrolytes, liver function tests: all normal. HbA1c 58 mmol/mol.
• Vitamin D 42 nmol/L (mild deficiency).
• 12-lead ECG: normal sinus rhythm, 72 beats per minute, normal intervals, no conduction abnormality, no ischaemia, no LVH. [1]

Candidate's long-case presentation (SASPOP)

"Mrs Margaret Hughes is an 82-year-old widow who lives alone and presents with three falls in six months — two on getting out of bed in the morning with a clear orthostatic prodrome, and one when she turned in her kitchen — none with loss of consciousness. [1]

Her past history includes hypertension, type 2 diabetes with a sensory neuropathy, osteoarthritis, neuropathic pain, and a left cataract. Her medications are doxazosin, hydrochlorothiazide, amitriptyline, temazepam, metformin, and paracetamol as needed. [1]

On examination she has drug-induced orthostatic hypotension — a systolic drop of 34 mmHg with symptoms on standing — a slow cautious gait with a Timed Up and Go of 17 seconds, reduced joint position sense at the toes from diabetic neuropathy, and a mild cognitive impairment with a MoCA of 26. Her ECG is normal. [1]

Her main problems are:

1. Drug-induced orthostatic hypotension — the dominant acute mechanism
2. Multifactorial gait and balance impairment — sensory neuropathy, osteoarthritis, sarcopenia, a left cataract
3. Polypharmacy — four of her five regular drugs are STOPP criteria targets
4. Environmental hazards at home — the front steps, the kitchen turn
5. Fear of falling and activity restriction, with driving cessation [1]

My integrated plan is to conduct a systematic STOPP/START medication review as the first and most effective intervention — stop the doxazosin, stop or reduce the hydrochlorothiazide, stop the amitriptyline and switch to gabapentin or duloxetine for her neuropathic pain, and taper and stop the temazepam — and then re-check the orthostatic blood pressure after the washout, reserving fludrocortisone or midodrine for persistent symptomatic orthostatic hypotension. I would refer her for a supervised strength and balance exercise programme (the Otago Exercise Programme or a community tai chi class), arrange an occupational therapy home hazard assessment, refer her for cataract surgery assessment, address her fear of falling with a graded re-activation plan, treat her mild vitamin D deficiency, and screen her bone health with a DEXA. I would review her at 3 months with a repeat Timed Up and Go and orthostatic blood pressure and a falls diary." [1]

Discussion questions

Q1: "Why do you say the orthostatic hypotension is drug-induced rather than from autonomic neuropathy?" [1]

"Both contribute, but the drugs are the dominant and the reversible mechanism. Her diabetes is long-standing and she has a peripheral sensory neuropathy, so she has some degree of autonomic involvement — but her orthostatic heart rate response is preserved (a rise of 8 beats per minute), which is against a severe autonomic neuropathy (in autonomic failure the heart rate does not rise with the drop). More tellingly, four of her five regular drugs are known to cause or worsen orthostatic hypotension — doxazosin is an alpha-blocker that blocks the vasoconstrictor response to standing, hydrochlorothiazide reduces intravascular volume, amitriptyline has alpha-1 antagonist activity, and temazepam impairs the central autonomic response. The STOPP/START criteria version 2 (O'Mahony 2015, PMID 25324330) flag all of these. The Freeman 2011 consensus (PMID 21431947) classifies drug-induced orthostatic hypotension as the commonest cause in older adults. My expectation is that withdrawing the causative drugs will substantially improve or resolve the orthostatic drop, and the test of that hypothesis is a repeat orthostatic blood pressure after the washout — if it resolves, the cause was the drugs; if it persists, the autonomic neuropathy is the contributor and I would then add pharmacotherapy." [1]

Q2: "How do you justify stopping her antihypertensives when her seated blood pressure is 152/88?" [1]

"The principle is that the harm of the orthostatic hypotension (the falls, with the risk of a hip fracture or a head injury) outweighs the benefit of tight blood-pressure control in an 82-year-old with symptomatic postural drops. The HYVET trial treated patients over 80 to a target of 150/90 or less, and the benefit was real but modest — and the trial excluded patients with significant orthostatic hypotension. Her seated blood pressure of 152/88 is just above the HYVET target, and her standing blood pressure of 118/72 with symptoms is the problem I am treating. I would stop the doxazosin and the hydrochlorothiazide, re-check her seated and standing blood pressures after the washout, and only re-introduce a non-posturally active agent (such as amlodipine) at a low dose if her seated blood pressure is consistently and significantly above target and she has no orthostatic drop. The goals of care — to prevent falls and maintain her independence — take precedence over a blood-pressure number." [1]

Q3: "She has stopped driving because of her fear of falling. How do you address driving in an older patient with falls?" [1]

"Driving is both a safety and a legal issue, and I would address it directly and compassionately. First, I would clarify the medical question — her falls are non-syncopal and her cardiovascular and neurological examinations are normal, so there is no clear medical contraindication to driving from a syncope perspective. The ESC 2018 syncope guideline (PMID 29392118) provides specific guidance on driving after syncope — for private drivers, the restriction is generally a few months of symptom freedom for reflex syncope, longer for unexplained or cardiac syncope — but her problem is falls, not syncope, and the relevant question is whether her gait and her cognition allow her to safely operate a car. Her MoCA of 26 and her impaired gait raise a concern. In Australia, there is a legal obligation to report certain medical conditions to the licensing authority, and the requirements differ by state; her falls and her cognitive impairment are reportable in most states. I would counsel her and her daughter honestly, document the advice, and recommend a formal on-road driving assessment if there is any doubt. I would pair the conversation with a plan for alternative transport — community transport, her daughter, a taxi subsidy scheme — to preserve her autonomy and her social engagement, because losing the car is often the trigger for social isolation, depression, and functional decline in an older person." [1]

Q4: "What is the single most effective intervention you can offer her?" [1]

"The single most effective intervention is the structured medication review and deprescribing — it is the highest-yield, the safest, the cheapest, and the most rapidly reversible intervention for her drug-induced orthostatic hypotension. The second most effective is the supervised strength and balance exercise programme, which the 2019 Cochrane review (Sherrington, PMID 30703426) showed reduces falls by about 23 percent across community-dwelling older adults and by up to 35 percent with the Otago programme in adults over 80 (Campbell 1997, PMID 9366737). If I had to choose only one, I would choose the medication review, because her dominant acute mechanism is the drug-induced orthostatic drop, and removing the cause is always more effective than adding a countermeasure. In practice I would do both, in parallel — the medication review to remove the acute driver, and the exercise to rebuild her strength and balance and address her fear of falling." [1]

DCE Short Case — Gait and the Timed Up and Go

Examiner instruction: "This 79-year-old man has been referred with falls. Please examine his gait." [1]

Systematic examination routine

1. Prepare — confirm identity, introduce, explain, ensure usual footwear and walking aid, position in a clear corridor or long room.
2. Observe sitting — posture, balance, any tremor or abnormal movement.
3. Stand from the chair — without using the arms if possible; observe the push-off, the number of attempts, the balance on rising.
4. Timed Up and Go test — sit in a standard armchair; on the word 'go', rise, walk 3 metres at usual pace to a mark, turn, walk back, sit down. Time the task (Podsiadlo 1991, PMID 1991946). Less than 10 seconds normal; greater than 12 to 14 seconds impaired mobility and increased fall risk; greater than 30 seconds high dependency.
5. Observe the gait — step length, step height, symmetry, arm swing, base, cadence, rhythm, stability, and any freezing or festination.
6. Observe the turn — count the steps (more than three is abnormal).
7. Observe the sit-down — control on landing (a 'plop' suggests weakness).
8. Balance — Romberg (feet together, eyes open then closed); tandem gait (heel-to-toe along a line).
9. Focused neurological examination — parkinsonism, cerebellar signs, sensory neuropathy (joint position and vibration at the toes), proximal muscle weakness.
10. Cardiovascular examination — including orthostatic blood pressure. [1]

Key signs this patient demonstrates

• Uses a single-point stick; rises from the chair by pushing off with both arms (proximal lower-limb weakness).
• Timed Up and Go 17 seconds (impaired mobility, increased fall risk).
• Gait is slow, short-stride, cautious, with a reduced arm swing; not shuffling, wide-based, or hemiparetic.
• Turns in four steps with mild instability.
• Tandem gait impaired — loses balance after three steps.
• Romberg positive (sways with eyes closed, stable with eyes open) — indicates a proprioceptive component.
• Reduced joint position and vibration sense at the toes bilaterally — a diabetic sensory neuropathy.
• No bradykinesia, rigidity, or tremor (no Parkinson disease).
• Cardiovascular examination and orthostatic blood pressure normal. [1]

Presentation template

"I examined the gait of this 79-year-old man referred for falls. He uses a single-point stick. He rises from the chair by pushing off with both arms, indicating proximal lower-limb weakness. His Timed Up and Go test takes 17 seconds, which is abnormal and indicates impaired mobility and increased fall risk. His gait is slow, short-stride, and cautious with a reduced arm swing — but not shuffling, wide-based, or hemiparetic. He turns in four steps with mild instability. His tandem gait is impaired. His Romberg is positive, and he has reduced joint position and vibration sense at the toes, consistent with a diabetic sensory neuropathy. There are no features of parkinsonism. [1]

The picture is of a multifactorial gait and balance impairment — a sensory ataxia from diabetic neuropathy, mild proximal muscle weakness, and a cautious gait from a fear of falling — without a single discrete neurological or cardiovascular cause. I would complete the falls assessment with a medication review, an orthostatic blood pressure measurement, and an ECG, and I would refer him for a supervised strength and balance exercise programme and an occupational therapy home hazard assessment." [1]

Discussion

Q: "What single test most increases your predictive value for fall risk at the bedside?" [1]

"The Timed Up and Go test (Podsiadlo 1991, PMID 1991946). It takes under a minute, requires only a chair and a watch, and it captures the four components that matter for falls — the strength to rise, the gait to walk, the balance to turn, and the control to sit down — in a single timed task. A time greater than 12 to 14 seconds identifies impaired mobility and increased fall risk; a time greater than 30 seconds identifies high dependency. It is sensitive to change, so it also tracks the response to intervention. In a busy clinic or a DCE short case it is the single most efficient and informative bedside test of fall risk." [1]

Q: "How would you distinguish a Parkinson disease gait from a vascular parkinsonism gait?" [1]

"Parkinson disease produces a flexed posture, a slow short-stride shuffling gait with a reduced arm swing, a reduced step height, freezing on initiation, and festination with a multi-step turn; there is typically a resting tremor, bradykinesia, rigidity, and an asymmetric onset. Vascular parkinsonism ('lower-body parkinsonism') produces a predominantly lower-limb, symmetric, broad-based shuffling gait with a preserved arm swing, no resting tremor, a poor levodopa response, and commonly cognitive impairment and pyramidal signs; the MRI shows confluent white-matter hyperintensities. The distinction matters because vascular parkinsonism does not respond to levodopa, and the management is vascular risk-factor control and falls prevention." [1]

Q: "How do you decide which falls patient needs an echocardiogram?" [1]

"The decision is driven by the history and the ECG, not by the fall itself. An echocardiogram is indicated when there is clinical or ECG suspicion of structural heart disease — a murmur on auscultation, a history of heart failure or myocardial infarction, syncope on exertion (which is a high-risk ESC red flag), an abnormal ECG (bifascicular block, prior infarct, LVH, long QT, Brugada pattern), or recurrent unexplained syncope with any of these features. In a patient like this man, whose falls are non-syncopal and whose cardiovascular examination and ECG are normal, an echocardiogram is not indicated — it would be low-yield and an inappropriate use of resources. The ESC 2018 syncope guideline (PMID 29392118) is explicit that routine echocardiography in syncope without clinical suspicion is not recommended. The test I WOULD do in any falls patient is the orthostatic blood pressure — it is the bedside equivalent of an echocardiogram for the orthostatic mechanism, and it is positive in a large proportion of older fallers." [1]