Falls and Syncope Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

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

Her past history includes hypertension, type 2 diabetes, osteoarthritis, and neuropathic pain. Her medications are doxazosin 4 mg at night, hydrochlorothiazide 25 mg daily, amitriptyline 25 mg at night, temazepam 10 mg at night, metformin, and paracetamol as needed. [1]

On examination, her supine blood pressure is 152/88 and on standing for 3 minutes it is 118/72 with symptoms of lightheadedness — a systolic drop of 34 mmHg, consistent with drug-induced orthostatic hypotension. Her Timed Up and Go takes 17 seconds with a slow, short-stride gait. Her MoCA is 26 out of 30. She has reduced joint position sense at the toes from diabetic neuropathy. Her ECG is normal. [1]

Her main problems are:

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

My integrated plan is to conduct a systematic STOPP/START medication review first — 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 — because the medication review is the single most effective and safest intervention and the orthostatic hypotension is drug-induced. I would then re-check the orthostatic blood pressure after the washout and only consider fludrocortisone or midodrine if the drop persists and is symptomatic. I would refer her for a supervised strength and balance exercise programme — the Otago Exercise Programme or a community tai chi class — because exercise is the best-evidenced non-pharmacological intervention and reduces falls by about 23 percent. I would arrange an occupational therapy home hazard assessment to address the front steps, the lighting, the loose rugs, and the footwear. I would address the fear of falling explicitly with a graded re-activation plan. And I would screen for osteoporosis with a DEXA, because the consequence of a fall that we most want to prevent is a hip fracture. I would review her at 3 months with a repeat Timed Up and Go and orthostatic blood pressure and a falls diary." [1]

Examiner probing questions and model answers

Q1: "You propose stopping the doxazosin and the hydrochlorothiazide. What will you do about her blood pressure?" [1]

"My first action is to stop the posturally active drugs, not to replace them reflexively — the orthostatic hypotension is causing her falls, and the harm of the falls (a hip fracture, a head injury) outweighs the benefit of tight blood-pressure control in an 82-year-old. After a washout period I would re-check her blood pressure both standing and supine. If her seated and supine blood pressures are consistently above target — say, above 150 systolic — and she has no orthostatic drop, I would introduce a non-posturally active agent, starting with a low-dose dihydropyridine calcium channel blocker such as amlodipine 2.5 mg, titrated cautiously with standing and supine blood-pressure checks at each visit. The evidence is that in older adults, less is often more in blood-pressure management — the HYVET trial treated patients over 80 to a target of 150/80, and the benefit was real but modest; the harms of over-treatment, especially orthostatic hypotension and falls, are equally real. The principle is to treat the seated blood pressure but never at the cost of a disabling orthostatic drop." [1]

Q2: "How confident are you that exercise works, and what would you actually prescribe?" [1]

"I am confident — the evidence is high-certainty. The 2019 Cochrane review by Sherrington (PMID 30703426) pooled 108 randomised trials and 23,407 participants and found that exercise as a single intervention reduces the rate of falls in community-dwelling older people by about 23 percent, with balance and functional exercises reducing the rate by 24 percent and multi-component programmes by up to 34 percent. The two features that make a programme effective are that it CHALLENGES balance — walking alone is not enough — and that it provides more than 3 hours of exercise per week. The Otago Exercise Programme, which is a home-based, physiotherapist-supervised set of lower-limb strength and balance exercises with a walking plan, reduced falls by 35 percent in adults over 80 in the original Campbell trial (BMJ 1997, PMID 9366737) and the benefit was sustained at 2 years (PMID 10604501). Tai chi reduces the rate of falls by about 19 to 43 percent in meta-analysis (Lomas-Vega 2017). So for Mrs Hughes I would refer her to a physiotherapist-led Otago programme or a community tai chi class, and I would set a clear prescription — 30 minutes of balance and strength work, three times a week, progressing in difficulty as she improves, plus a daily walk." [1]

Q3: "How do you decide between a tilt table test, a Holter monitor, and an implantable loop recorder in syncope?" [1]

"The choice is driven entirely by the clinical suspicion and the frequency of the events, not by a reflex panel. The ESC 2018 syncope guideline (Brignole 2018, PMID 29392118) is explicit on this. The initial evaluation of any patient with syncope is history, physical examination including orthostatic blood pressure, and a 12-lead ECG — that triad alone yields a suspected or certain diagnosis in 60 to 70 percent of cases. After that, the choice of test depends on the suspected mechanism. A carotid sinus massage is for a patient over 40 with unexplained syncope compatible with a reflex origin — and I would do it before a tilt test in most older adults. A tilt table test is for suspected reflex syncope when the history is atypical, for suspected delayed orthostatic hypotension, or for distinguishing syncope from psychogenic pseudosyncope — the ESC has downgraded it to a lower class of recommendation. Ambulatory ECG monitoring is for suspected arrhythmic syncope, and the duration of the monitor is chosen by the frequency of the events: a Holter for daily events, an external loop recorder for weekly events, and an implantable loop recorder for monthly or less frequent events. The implantable loop recorder is the highest-yield investigation for recurrent unexplained syncope in older adults after a negative initial work-up, because it monitors for up to 3 years and captures the rhythm at the moment of an event — it is cost-effective and often diagnostic when everything else has failed. An echocardiogram is for suspected structural heart disease, an abnormal ECG, or syncope on exertion; an EP study is for suspected arrhythmic syncope with structural heart disease. The tests I would NOT order reflexively are a CT brain, carotid Dopplers, and an EEG — they are low-yield in unexplained syncope without focal neurology and the ESC guideline explicitly advises against them." [1]

Q4: "What is the difference between carotid sinus hypersensitivity and carotid sinus syndrome?" [1]

"The distinction is the symptoms, not the reflex. Carotid sinus hypersensitivity is the asymptomatic reproduction of a cardioinhibitory or vasodepressor response during carotid sinus massage — an asystolic pause greater than 3 seconds or a systolic blood-pressure drop greater than 50 mmHg. It is present in up to 40 percent of older adults and is NOT, on its own, a diagnosis; it is a normal variant of ageing. Carotid sinus syndrome is the diagnosis when the carotid sinus massage REPRODUCES the patient's spontaneous symptoms — that is, the lightheadedness or syncope that they have been having in real life. The diagnostic test requires both the reflex AND the reproduction of the spontaneous symptoms. The reason the distinction matters is the management: a patient with recurrent spontaneous syncope that is reproduced by carotid sinus massage with a dominant cardioinhibitory response (a long asystolic pause) has carotid sinus syndrome and is treated with a permanent dual-chamber pacemaker, which halves the recurrence of syncope. A patient with an incidental asymptomatic reflex on carotid sinus massage is not diagnosed with anything and does not need a pacemaker — that is the trap. The carotid sinus massage is contraindicated in a patient with a recent TIA or stroke or a carotid bruit, and it is performed under continuous ECG and blood-pressure monitoring." [1]

Q5: "How would you manage her fear of falling?" [1]

"The fear of falling is both a consequence and a perpetuator of falls, and I address it explicitly because it is often the difference between a patient who re-engages with life and one who becomes housebound. The fear causes activity restriction, which causes deconditioning and sarcopenia, which causes further falls — a vicious cycle. I screen for it with the Falls Efficacy Scale or simply by asking about her confidence in everyday activities. The management is a graded re-activation plan, built around the exercise programme — I negotiate small, achievable increases in activity (a walk to the letterbox, then to the corner) and pair it with the strength and balance work that objectively improves her postural stability. As her balance and her confidence improve together, the fear recedes. I also address the environmental hazards that amplify the fear (the lighting, the grab rails, the front steps) through the OT home assessment, because a safer home restores confidence. And I frame the whole conversation around what she CAN do, not what she must avoid — the goal is to maintain her independence and her quality of life, and avoiding all activity defeats that goal. I would avoid a benzodiazepine for the anxiety — it would worsen her falls risk." [1]

DCE Short-Case Viva — Gait and the Timed Up and Go Test

Examiner instruction: "This 79-year-old man is referred for assessment of falls. Please examine his gait." [1]

Candidate's examination routine (narrated)

"I would begin by confirming the patient's identity, introducing myself, explaining what I am going to do, and ensuring he is comfortable and is wearing his usual footwear and uses his usual walking aid. I would ask him to walk in a clear corridor or a long room. [1]

First, I observe him sitting — is he comfortable and balanced, is he leaning to one side, is there a tremor or abnormal movement? [1]

I then ask him to stand from the chair without using his arms if possible — the ability to rise from a chair without using the arms is a test of proximal lower-limb strength, and the need to push off with the arms, or to make several attempts, indicates quadriceps weakness, a key falls risk factor. [1]

I time the Timed Up and Go test: I ask him to sit in a standard armchair, to rise on the word 'go', to walk 3 metres at his usual and safe pace to a mark on the floor, to turn, to walk back, and to sit down again. The original validation by Podsiadlo and Richardson (1991, PMID 1991946) showed that an independent older adult completes this in less than 10 seconds; a time greater than 12 to 14 seconds indicates impaired mobility and increased fall risk; and a time greater than 30 seconds indicates high dependency and a need for assistance with most activities of daily living. [1]

As he walks I observe the components of the gait: the step length (a short shuffling step suggests Parkinson disease, vascular gait, or a fear of falling), the step height (a foot-drag or a low step suggests a foot-drop or a pyramidal weakness), the symmetry (a hemiparetic gait is asymmetric), the arm swing (reduced in Parkinson disease), the base (wide-based suggests cerebellar or sensory ataxia), the cadence and the rhythm, and the stability. As he turns, I count the steps — more than three steps to turn is abnormal and suggests postural instability. As he returns and sits, I observe the control on sitting down — a 'plop' into the chair suggests proximal muscle weakness or loss of control. [1]

After the gait, I assess balance: I ask him to stand with his feet together, first with his eyes open and then with his eyes closed — the Romberg test. A loss of balance when the eyes are closed but not when they are open indicates a proprioceptive loss, which fits with his diabetic neuropathy. I then ask him to walk heel-to-toe along a straight line — the tandem gait — which tests balance more than gait. [1]

I would complete the assessment with a focused neurological examination — for parkinsonism (bradykinesia, rigidity, tremor), for cerebellar signs, for a sensory neuropathy (joint position and vibration sense at the toes), and for proximal muscle weakness — and a cardiovascular examination including orthostatic blood pressures, looking for a postural drop." [1]

Presentation template (model answer)

"I examined the gait of this 79-year-old man who has been referred for falls. He uses a single-point stick. He rises from the chair by pushing off with both arms — indicating some 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 and short-stride with a reduced arm swing and a mildly flexed posture, but it is not shuffling, wide-based, or hemiparetic. He turns in four steps with mild instability. His tandem gait is impaired — he loses balance after three steps. His Romberg is positive — he sways and almost falls when his eyes are closed but is stable with them open, indicating a proprioceptive component. He has reduced joint position sense and vibration sense at the toes bilaterally, consistent with a diabetic sensory neuropathy. There is no bradykinesia, rigidity, or tremor to suggest Parkinson disease. His cardiovascular examination and orthostatic blood pressures are normal. [1]

The picture is of a multifactorial gait and balance impairment — a sensory ataxia from diabetic neuropathy, mild proximal muscle weakness from disuse, and a cautious gait from a fear of falling — without evidence of a single discrete neurological or cardiovascular cause. I would assess his medications for drug-induced contributors, refer him for a supervised strength and balance exercise programme, arrange an occupational therapy home hazard assessment, and screen his bone health to reduce the consequence of any future fall." [1]

Examiner discussion

Q: "What is the most discriminating bedside test in the falls short case?" [1]

"The Timed Up and Go test (Podsiadlo 1991, PMID 1991946). It is quick (under a minute), requires no equipment beyond a chair and a watch, and it tests the four components that matter for falls — the strength to rise from a chair, 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 an increased fall risk; a time greater than 30 seconds identifies high dependency. It correlates well with the Berg Balance Scale and with the Barthel Index, and it is sensitive to change, so it is also the test I use to follow the response to intervention. In a DCE short case, performing and reporting a TUG demonstrates both the assessment and the interpretation in a single act." [1]

Q: "How does the gait of Parkinson disease differ from the gait of vascular parkinsonism?" [1]

"Parkinson disease produces a classic gait: a flexed posture, a slow, short-stride, shuffling gait with a reduced or absent arm swing, a reduced step height, a hesitation on initiation ('freezing'), and a festination (an accelerating, shortening stride) with a turn that requires multiple small steps. There is typically a resting tremor, bradykinesia, rigidity, and a loss of postural stability on the pull test, and the gait and the signs are largely asymmetric at the onset. Vascular parkinsonism ('lower-body parkinsonism') produces a predominantly lower-limb, symmetric gait with a broad-based, shuffling, short-stride pattern, a preserved arm swing, an absence of a resting tremor, a poor or absent response to levodopa, and cognitive impairment and pyramidal signs are common. The MRI shows confluent white-matter hyperintensities in vascular parkinsonism and is normal in early Parkinson disease. The distinction matters because vascular parkinsonism does not respond to levodopa and the management is risk-factor control and falls prevention." [1]

Q: "What is the role of vitamin D in falls prevention?" [1]

"The role has been substantially downgraded. The 2018 USPSTF recommendation (Grossman, PMID 29710141) found no net benefit of routine vitamin D supplementation for the primary prevention of falls in community-dwelling older adults without documented deficiency — the evidence from the large trials (including the VITAL trial) showed no reduction in falls with routine supplementation. The current practice is to measure a vitamin D level in patients with risk factors for deficiency (housebound, dark-skinned, malnourished, osteoporotic, renal impairment) and to supplement to sufficiency (a level greater than 50 nmol per litre) if deficient — but not to prescribe routine vitamin D for falls prevention. I would still check Mrs Hughes's level, because she is housebound and has osteoporosis risk, and I would treat her to sufficiency for her bone health — but I would not present the vitamin D as the falls intervention; the falls interventions are the exercise, the medication review, and the home hazard reduction." [1]