ANSWER 87
There are a number of possibilities to explain falls in the elderly. Some more information in
the history about the circumstances of these falls would be helpful. On further enquiry, it
emerges that the falls are most likely to occur when he gets up from bed first thing in the
morning. The afternoon events have occurred on getting up from a chair after his post-lunch
doze. These circumstances suggest a possible diagnosis of postural hypotension. This was
verified by measurements of standing and lying blood pressure – the diagnostic criteria are
a drop of 15 mmHg on standing for 3 min. This showed a marked postural drop with blood
pressure decreasing from 134/84 to 104/68 mmHg. This is most likely to be caused by the
antihypertensive treatment; both the alpha-blocker which causes vasodilatation and the
diuretic might contribute. Another possible candidate for a cause of the postural hypoten-
sion is the diabetes which could be associated with autonomic neuropathy. In this case the
diabetes is not known to have been present for long and there is evidence of only very mild
peripheral sensory neuropathy. Diabetic autonomic neuropathy is usually associated with
quite severe peripheral sensory neuropathy, with or without motor neuropathy.
The ECG shows evidence of sino-atrial node disease or sick sinus syndrome. Clinically, it
is easily mistaken for atrial fibrillation because of the irregular rhythm and the variation
in strength of beats. The ECG shows a P-wave with each QRS complex although the
P-waves change in shape and timing. It may be associated with episodes of bradycardia
and/or tachycardia which could cause falls. This might be investigated further with a 24-h
ambulatory recording of the ECG.
Coughing bouts can cause falls through cough syncope. The positive intrathoracic pressure
during coughing limits venous return to the heart. The cough is usually quite marked and he
might be expected to remember this since he gives a good account of the falls otherwise.
Syncope can occur in association with micturition. Neck movements with vertebrobasilar
disease, poor eyesight and problems with balance are other common causes of falls in the
elderly. A neurological cause, such as transient ischaemic episodes and epilepsy, is less likely
with the lack of prior symptoms and the swift recovery with clear consciousness and no neuro-
logical signs.
Another diagnosis which should be remembered in older people who fall is a subdural
haematoma. Symptoms may fluctuate, and this might be considered and ruled out with a
computed tomography (CT) scan of the brain.
The doxazosin should be stopped and another antihypertensive agent started if necessary.
This might be a beta-blocker, long-acting calcium antagonist or angiotensin converting-
enzyme (ACE) inhibitor, although all these can cause postural drops in blood pressure. His
symptoms all disappeared on withdrawal of the doxazosin. The blood pressure rose to
144/86 mmHg lying and 142/84 mmHg standing, indicating no significant postural
hypotension, with reasonable blood-pressure control.
- Falls in the elderly are a symptom in need of a diagnosis.
- Postural hypotension is a common side-effect of diuretics, vasodilators or other anti-
hypertensive therapy. Lying and standing blood pressures should be measured if this is
suspected. - Autonomic neuropathy in diabetes is associated with significant peripheral sensory
neuropathy.