Prepared by Erin Ong Wan Feng
Supervised by Prof Tan Kit Mun
Title: Complexities of an Older Person with Recurrent Falls and Syncope
Mr G was a 76-year-old man with the following comorbidities, followed up by a primary care clinic:
Essential Hypertension
Type 2 Diabetes Melitus
Dyslipidaemia
Infrarenal Aortic Aneurysm post-surgical repair in 2018
Peripheral vascular disease with left critical limb ischemia underwent angioplasty in 2017
Medication history:
T. amlodipine 5mg OD
T. telmisartan 20mg OD
T. metoprolol 50mg BD
T. empagliflozin 25mg OD
T. aspirin 100mg OD
T. gliclazide MR 120mg OD
T. metformin 1g BD
T. atorvastatin 20mg ON
T linagliptin 5mg OD
He was referred to the geriatric medicine team by the medical admissions unit for hyperactive delirium and recurrent falls. He also demonstrated aggressive behaviour of hitting his neighbouring patient with a jug at 3am upon ward admission leading to 4-point restraint and intramuscular haloperidol by the on-call team.
History of Presenting Illness:
Mr G was brought to the emergency department via ambulance following an unwitnessed fall at home injuring his neck as he fell backwards. The patient reported that upon waking up and walking out of his bedroom, he accidentally stepped on a plastic mat in his room and slipped. He fell backwards and subsequently experienced pain at the back of his neck post-fall.
Collateral history from his daughter:
The patient lived with his wife, but since she passed away just 3 weeks ago; he has been living alone. His daughter who was the sole caregiver; lives in a different residence but would visit him regularly and monitor him remotely via CCTV as she is working full-time. She noticed that the patient had a memory decline since 2020 as he started to become non-compliant with his medications and clinic appointments. Otherwise, he was still able to manage the house and the various home chores including looking after his wife who was also becoming increasingly frail with cognitive impairment. Therefore, it did not occur to her that he was already having significant memory issues severe enough to seek medical attention at that time.
Following the recent death of his wife, the patient started to have a low mood with mention of also wanting to die to follow his wife. His daughter started receiving phone calls at 3 am from the patient asking for rice and food. She would need to pack and deliver food to him and manage his medications or clinic appointments. Otherwise, the patient would read his newspaper daily and manage himself alone at home including his basic activities of daily living independently.
His daughter suspects patient has been having recurrent unwitnessed falls but not reported to her throughout the years as they have been non-injurious. She then showed us several CCTV videos that captured the patient suddenly experiencing 20 second loss of consciousness resulting him falling backwards, eyes rolled up and brief myoclonic jerks while reading the newspaper on his usual lazy chair. He regained full consciousness spontaneously and went back to reading his newspaper. There was no post-ictal drowsiness. The patient’s current injurious fall was not captured as it occurred in the kitchen not under the surveillance of the CCTV. After the patient’s admission, his daughter went back to the patient’s house to assess how he recently fell. She suspected that the patient fell backwards in the kitchen while cutting a mango, hitting the rack behind him therefore injuring his neck.
Admission Progress:
In the emergency department, the patient was alert and conscious with no remarkable neurological findings other than tenderness over the posterior region of his neck limiting his neck movements. Other systems examination was normal as well. His non-contrasted CT brain showed compression fractures at C4-C6 and T1 vertebrae, as well as old lacunar infarcts at the right corona radiata, left thalamus and pons with no intracranial bleed. Blood parameters including thyroid function and electrolytes were normal other than mild acute renal impairment due to dehydration.
A referral to spine orthopaedics team was made and further evaluation with MRI cervical spine revealed atlanto-axial instability with marginal osteophytes. There were no cervical fractures seen. He was advised for cervical collar for the atlantoaxial instability with oral analgesia.
Following admission to the medical admissions unit, patient had aggressive behaviour towards nursing staff and the neighbouring patient, resulting in him being placed in four-point restraint and antipsychotics initiated by the psychiatry liaison team.
A neuromedical team referral was made to exclude the possibility of seizures to explain the hyperactive delirium and falls. Electroencephalography (EEG) was done while the patient was not orientated, but able to follow simple commands although occasionally aggressive. The EEG was reported diffuse theta slowing consistent with mild diffuse cortical dysfunction. No epileptiform discharges were seen. Coincidentally the ECG lead showed junctional tachycardia alternating with 1st degree heart block and short sinus pauses.
Chest Xray (left) and CT brain plain (right) on admission
ECG showing prolonged PR interval with bifasicular block
MRI Cervical spine
The geriatric medicine team assessment revealed the following issues:
Recurrent Falls with atlanto-axial instability secondary to probable cardiac syncope
Hyperactive delirium with possible underlying major neurocognitive disorder
Possible depression with psychosis due to bereavement
Financial and long-term placement difficulties
The patient was transferred to the geriatric medicine ward for further management of his hyperactive delirium and to expedite the investigation and treatment for falls with syncope.
An urgent referral to the cardiology team was made for HOLTER assessment and pacemaker insertion.
HOLTER report:
- atrial tachycardia (max 140 bpm) and a few episodes of sinus bradycardia (min 40)
- sinus pause longest 1.8s
- low burden PVCs (including bigeminy) 0.4%
Echocardiography report:
LVEF 60%, left ventricular hypertrophy with normal left ventricular size and systolic function. No regional wall motion abnormality seen. Reduced right ventricular systolic function. Both atrial sizes normal. Trivial mitral, pulmonary and tricuspid regurgitation. Mild aortic regurgitation.
The final diagnosis upon review by the cardiac electrophysiologist:
Bifasicular block with 1st degree atrioventricular delay
Concomitant sinus node dysfunction (tachybradycardia syndrome)
An early inpatient single chamber pacemaker insertion was arranged for the patient but there was delay as he required the help of the medical social worker for financial assistance. His single chamber pacemaker was successfully inserted without any complications 10 days after the cardiac diagnosis was obtained.
During his stay in the geriatric medicine ward, he was referred to the multidisciplinary team of physiotherapists, occupational therapist, nurses and dietitian. With the collaborative efforts, his hyperactive delirium resolved and antipsychotics were discontinued. His gait and stability were assessed and with active inpatient physiotherapy sessions he improved from requiring a two-wheel
rollator to walking with a stick requiring supervision.
His mini mental state examination baseline score of 12 had improved to 16. Modified Barthel Index score improved from 55 to 75 (mild dependency). Elder mobility scale (EMS) improved from 8/20 to 15/20. Falls safety measures and carer training was also taught to his daughter.
Discharge plans:
The patient was successfully discharged back to his own home well after a total of 30 days of hospitalization. Upon discharge, he was independently ambulant with a walking stick, only needing supervision with a mild dependency level. He will be cared for by a domestic helper and monitored remotely via CCTV by his daughter. He was given an early geriatric medicine clinic appointment, bone mineral density outpatient appointment, pacemaker clinic check and spine orthopaedics clinic in 1 month.
Medications on discharge:
T aspirin 100mg OD
T metformin 500mg BD
T linagliptin 5mg OD
T calcium carbonate 500mg OD
T bisoprolol 1.25mg OD
Cholecalciferol powder 50,000unit weekly for 8 weeks then monthly after
Syrup lactulose 15mls PRN
Questions:
What were Mr. G’s falls risk factors upon presentation?
What are the differences and similarities in clinical features between syncope and seizures?
During his early Geriatrics clinic review, what would be the other issues of concern that needs to be addressed and managed further?
What do you think of his medications before the admission and at the point of discharge?
What is the process of reducing medications called?
What are possible cardiac and cardiovascular complications of antipsychotics?
What are the red flags or signs/symptoms suggestive of cardiac syncope
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