Falls and Syncope in Older Adults — Written Clinical Reasoning

SAQ 1 — Multifactorial Falls with Drug-Induced Orthostatic Hypotension in a Polypharmacy Patient (20 marks, 30 minutes)

Prompt: Outline your integrated assessment and management plan for this patient, including the diagnostic reasoning, the systematic medication review, the non-pharmacological falls-prevention interventions, the role of pharmacotherapy for the orthostatic hypotension, and the communication with the patient and her daughter. Justify each decision with reference to evidence and guideline recommendations. [1]

Model Answer

Diagnostic reasoning and problem framing (3 marks): [1]

This woman has a multifactorial falls syndrome with at least three distinct, interacting mechanisms. The first is drug-induced orthostatic hypotension, confirmed at the bedside — a systolic drop of 34 mmHg with symptoms (lightheadedness) on standing (the Freeman 2011 consensus threshold is a systolic drop of 20 mmHg or diastolic drop of 10 mmHg within 3 minutes, PMID 21431947) — and her morning falls map directly to this mechanism. The second is a gait and balance impairment from the combination of diabetic sensory neuropathy (reduced joint position sense), osteoarthritis of the knees, and age-related sarcopenia, demonstrated objectively by a slow Timed Up and Go of 17 seconds (greater than 12 to 14 seconds is abnormal and indicates increased fall risk, Podsiadlo 1991). The third is an environmental hazard — the front steps and the turn in the kitchen. The fourth is polypharmacy: she is on five regular drugs, and four of them (doxazosin, hydrochlorothiazide, amitriptyline, temazepam) are independently associated with falls in older adults and are identified by the STOPP/START criteria version 2 (O'Mahony 2015, PMID 25324330) as potentially inappropriate in this context. [1]

The problems I will address in an integrated plan are: [1]

1. Drug-induced orthostatic hypotension — the dominant acute mechanism, and the most rapidly reversible.
2. Multifactorial gait and balance impairment (sensory neuropathy, osteoarthritis, sarcopenia) — the modifiable substrate.
3. Polypharmacy — the underlying pharmacological driver.
4. Environmental hazards at home and at the entrance.
5. Fear of falling and activity restriction — a perpetuator that must be addressed explicitly.
6. Diabetes with end-organ complications (autonomic and sensory neuropathy) — a contributor to monitor longitudinally. [1]

The systematic medication review (5 marks): [1]

This is the single highest-yield intervention I can make, and I will apply the STOPP/START criteria version 2 (O'Mahony 2015, PMID 25324330) systematically: [1]

• Doxazosin (alpha-blocker) — STOP. It is a potent cause of orthostatic hypotension and is a STOPP criterion in an older patient with falls. If her blood pressure needs treatment, I would prefer a less posturally active agent (a low-dose dihydropyridine calcium channel blocker such as amlodipine, titrated cautiously with orthostatic BP checks) — but my first action is to stop the alpha-blocker, not to replace it reflexively, and to re-check her blood pressure standing and supine after the washout.
• Hydrochlorothiazide — STOP or REDUCE. The diuretic contributes to volume depletion and to the morning postural drop; in a patient with drug-induced orthostatic hypotension it is part of the cause. I would stop it, re-check the blood pressure, and address any residual hypertension with a non-postural agent if needed.
• Amitriptyline — STOP and switch. Amitriptyline is a tricyclic with alpha-1 antagonist and anticholinergic activity, both of which worsen orthostatic hypotension and cognition; it is a high-priority STOPP target in an older patient with falls. For her neuropathic pain I would switch to gabapentin or pregabalin, started at a low dose and titrated cautiously, with an acknowledgement that these too can increase falls and require monitoring — or to duloxetine, which is effective for diabetic neuropathic pain and has a lower postural and anticholinergic burden.
• Temazepam — STOP (with a taper). Benzodiazepines increase falls by impairing balance and reaction time and are a STOPP criterion in any patient with a history of falls. I would taper it over 2 to 4 weeks (to avoid withdrawal) and address the insomnia with non-pharmacological measures — sleep hygiene, cognitive behavioural therapy for insomnia, management of nocturia (which is contributing to her getting out of bed in the morning and to the postural drop).
• Metformin — continue. It is appropriate for her type 2 diabetes and is not a falls-risk drug; I would ensure her diabetes is well controlled and screen for hypoglycaemia. [1]

The principle is deprescribing first — there is rarely a reason to add a drug to a falling patient, and there is almost always a reason to remove one. I would not initiate pharmacotherapy for the orthostatic hypotension until I have removed the causative drugs and re-tested. [1]

Non-pharmacological falls-prevention interventions (4 marks): [1]

• A supervised strength and balance exercise programme. This is the single best-evidenced non-pharmacological intervention. The 2019 Cochrane review of exercise for preventing falls in community-dwelling older people (Sherrington 2019, PMID 30703426) found a 23 percent reduction in fall rate with exercise as a single intervention, with balance and functional exercises reducing the rate by 24 percent and multi-component programmes by up to 34 percent. I would refer her to a physiotherapist-led programme — the Otago Exercise Programme (Campbell 1997, PMID 9366737) is the prototype for older adults in their own homes and reduced falls by 35 percent in adults over 80 — or to a community tai chi programme, which reduces falls by about 19 to 43 percent (Lomas-Vega 2017). The programme must CHALLENGE balance and provide more than 3 hours per week to be effective.
• An occupational therapy home hazard assessment. Effective in higher-risk groups such as those with prior falls or visual impairment (Gillespie 2012 Cochrane). The OT will address the loose rugs, the lighting (especially on the path to the bathroom at night), the grab rails, the two front steps (a rail and improved lighting), and the footwear (slip-on shoes are a hazard).
• Vision assessment. If she has a cataract or uncorrected refractive error, I would refer for cataract surgery (which reduces falls) and to an optometrist; I would specifically counsel against wearing multifocal or bifocal glasses outdoors, as they impair edge-contrast discrimination at the ground and increase outdoor falls.
• Podiatry and footwear review. Her diabetic neuropathy makes foot care important; supportive lace-up shoes with a non-slip sole are safer than slip-ons. [1]

The role of pharmacotherapy for the orthostatic hypotension (3 marks): [1]

After the causative drugs have been withdrawn and the patient has been re-assessed, if the orthostatic hypotension persists and remains symptomatic, I would add a stepwise pharmacological regimen (Freeman 2011 consensus, PMID 21431947): [1]

• Non-pharmacological first: increase salt and fluid intake (2 to 3 litres of water and up to 10 g of salt per day, cautioning against heart failure); waist-high compression garments to reduce venous pooling; elevate the head of the bed 10 to 20 cm to reduce nocturnal diuresis; advise her to sit on the edge of the bed for several minutes before standing.
• Fludrocortisone 0.1 mg orally daily, titrated to 0.2 mg twice daily — a mineralocorticoid that expands plasma volume. I would monitor for supine hypertension, peripheral oedema, hypokalaemia, and heart failure, all of which are common in older adults.
• Midodrine 2.5 to 5 mg three times daily — an alpha-1 agonist — as an alternative or add-on. It is contraindicated in ischaemic heart disease (she has no history of ischaemic heart disease but I would confirm with an ECG and a cardiac history) and causes piloerection and urinary retention; the last dose should be before late afternoon to avoid supine hypertension. [1]

I would explicitly recognise that supine hypertension is the unsolved paradox of treating orthostatic hypotension in older adults — I would treat the standing hypotension during the day and accept a degree of supine hypertension at night, or use a short-acting antihypertensive at bedtime if the supine pressures are very high. [1]

Communication with the patient and her daughter (3 marks): [1]

I would frame the falls as a treatable geriatric syndrome, not an inevitable part of ageing — this shifts the conversation from fatalism to action and improves adherence. I would explain that the medications she has been taking for very real problems (her blood pressure, her nerve pain, her sleep) are contributing to her falls, and that the plan is to carefully withdraw them one at a time, with monitoring, in partnership with her GP. I would address the fear of falling explicitly — patients restrict activity believing it is protective, when the opposite is true; I would negotiate a graded re-activation plan with the physiotherapist that rebuilds her confidence alongside her strength. I would involve her daughter, who is her informal carer and her source of collateral history, in the home-safety plan and in recognising the warning signs. I would discuss driving — if she drives, her falls and her orthostatic hypotension have implications for her safety and her legal obligation to the licensing authority; I would pair the conversation with a plan for alternative transport to preserve her autonomy. And I would set realistic expectations — the goal is to reduce the frequency and severity of falls and to maintain her independence, not to eliminate falls entirely; the trajectory will be measurable at the 3-month review with a repeat Timed Up and Go and a falls diary. [1]

Prognosis and follow-up (2 marks): [1]

I would arrange a 3-month review with a repeat Timed Up and Go, a repeat orthostatic blood pressure (standing and supine), a medication review, and a falls diary. The combination of drug withdrawal, exercise, and home hazard reduction is effective — multifactorial interventions reduce falls by about 25 percent in community-dwelling older adults at risk. I would also ensure her osteoporosis risk is assessed and treated if indicated (a DEXA and a FRAX score), because the consequence of a fall that we most want to prevent is a hip fracture. I would give her and her daughter a clear safety-net plan — what to do if she falls again, when to call an ambulance (a head injury on warfarin, a suspected fracture, a prolonged period on the floor), and the falls clinic contact. [1]

SAQ 2 — Exertional Syncope from Severe Aortic Stenosis (10 marks, 15 minutes)

Prompt: A 76-year-old man is brought to the emergency department after an episode of loss of consciousness while walking up a steep hill. He developed central chest tightness and breathlessness followed by syncope; he recovered rapidly on the ground. He has a 3-year history of exertional chest tightness and a progressive reduction in his exercise tolerance. On examination his blood pressure is 135/85, his pulse is regular at 78 with a slow-rising character, and there is a loud (grade 4/6) ejection systolic murmur at the right second intercostal space radiating to the carotids, with a delayed and weak radial pulse. His ECG shows left ventricular hypertrophy with strain. Outline your diagnostic reasoning, the investigations you would arrange, and the management. [1]

Model Answer

Diagnostic reasoning (2 marks): [1]

This man has exertional syncope in the context of severe aortic stenosis, until proven otherwise. The clinical syndrome is classic: exertional chest tightness, exertional dyspnoea, and now exertional syncope — the three cardinal symptoms of severe symptomatic aortic stenosis, each of which carries an ominous prognosis without valve replacement. The physical signs corroborate: a slow-rising, weak radial pulse (pulsus parvus et tardus), a loud ejection systolic murmur at the right upper sternal border radiating to the carotids, and left ventricular hypertrophy with strain on the ECG. According to the 2018 ESC syncope guidelines (Brignole 2018, PMID 29392118), syncope during exertion is one of the high-risk 'red-flag' features that mandates urgent cardiac investigation and admission, because it indicates a cardiac cause with a high one-year mortality. Syncope in severe aortic stenosis reflects the inability of the cardiac output to rise with the demand of exercise across a fixed obstruction — the cerebral perfusion falls and the patient loses consciousness. The differential includes hypertrophic cardiomyopathy (also a dynamic or fixed outflow obstruction causing exertional syncope) and pulmonary hypertension, but the murmur, the pulse character, and the ECG point to aortic stenosis as the leading diagnosis. [1]

Investigations (3 marks): [1]

• Echocardiogram — urgent. This is the diagnostic test: it quantifies the aortic valve area, the mean transvalvular gradient, the peak velocity, and the left ventricular function. Severe aortic stenosis is defined by an aortic valve area less than 1.0 cm squared (or less than 0.6 cm squared per metre squared indexed), a mean gradient greater than 40 mmHg, or a peak velocity greater than 4 m per second. The echo will also identify any coexisting left ventricular dysfunction, which is a key determinant of the timing and the type of intervention.
• 12-lead ECG — already done; shows left ventricular hypertrophy with strain, consistent with pressure overload from the stenotic valve.
• Blood tests — troponin (to exclude an acute coronary syndrome as a contributor), renal function and electrolytes, full blood count, and BNP or NT-proBNP (a marker of decompensation and a prognostic indicator).
• Coronary angiography — before any valve intervention, to exclude coexisting coronary artery disease that would need revascularisation at the same operation; the patient is a 76-year-old with exertional chest tightness, and coronary disease is common in this group.
• I would NOT arrange a CT brain, carotid Dopplers, or an EEG — the ESC 2018 guideline explicitly advises against routine neurological imaging in syncope, and the diagnosis here is cardiac. [1]

Management (3 marks): [1]

• Admit for monitoring and risk stratification — the patient has a high-risk cardiac syncope and is at risk of sudden death.
• Urgent cardiology referral for consideration of aortic valve replacement. In a 76-year-old with severe symptomatic aortic stenosis, the choice is between surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI), guided by the surgical risk score (the STS or EuroSCORE), the patient's frailty, the anatomy of the aortic annulus and iliofemoral access, and the patient's preferences. TAVI is preferred in older patients with a high or intermediate surgical risk and suitable anatomy.
• Symptomatic medical management while awaiting the intervention — cautious use of a beta-blocker for the angina (with great caution, as over-suppression of the heart rate in aortic stenosis can worsen the obstruction and the syncope), avoidance of vasodilators and nitrates (which reduce preload and can precipitate syncope), and avoidance of vigorous exertion until the valve is replaced.
• Prognosis — without valve replacement, the median survival after the onset of exertional syncope in severe aortic stenosis is less than 2 years, and the risk of sudden death is high; with successful valve replacement, the symptom relief and the prognosis are excellent. [1]

Communication and shared decision-making (2 marks): [1]

I would explain the diagnosis, the prognosis, and the options to the patient and his family in plain language — that the valve in his heart has narrowed, that this is the cause of his chest pain and his blackout, that the treatment is a valve replacement, and that the choice between a surgical and a keyhole (TAVI) approach will be made by the heart team in discussion with him. I would explain the risks and the benefits of each approach and involve him in the decision. I would advise him not to drive in the interim and to avoid exertion, and I would arrange close follow-up. The key communication principle is that severe symptomatic aortic stenosis is a treatable, time-critical condition, and the prognosis with treatment is far better than the prognosis without — the conversation should convey both the seriousness and the optimism. [1]