Name:
A 65-Year-Old with Falls
Description:
A 65-Year-Old with Falls
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Duration:
T00H06M15S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
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CATHY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy. And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Harrison's Podclass. This is Episode 8: A 65-Year-Old Man with Falls. I'll read the question. A 65-year-old man presents complaining of frequent falls and gait abnormalities. He first noticed the difficulty about 6 months ago.
CATHY: He has a history of hypertension, hypothyroidism, and hyperlipidemia. His current medications include amlodipine, 10 mg daily, simvastatin 20 mg daily, and levothyroxine 75 mcg daily. On neurologic examination, you observe his gait to be wide-based with short shuffling steps. He has difficulty rising from his chair and initiating his gait. Upon turning, he takes multiple steps and appears unsteady. However, his cerebellar testing is normal, including heel-to-shin and Romberg testing.
CATHY: He has no evidence of sensory deficits in the lower extremities, and strength is five out of five throughout all tested muscle groups. He shows no evidence of muscle spasticity on passive movement. His neurologic examination is consistent with which of the following causes: a) alcoholic cerebellar degeneration; b) communicating hydrocephalus; c) neurosyphilis; d) multiple system atrophy; or e) lumbar myelopathy.
CATHY: Cathy, what do you think is causing the falls and the gait disturbance in this patient?
CATHY: The chief complaint of falls is always difficult, and it can be a really common complaint especially to primary care offices. It's important to distinguish falls from syncope or presyncope which tends to be more acute in onset. And in thinking about our patient, who is older with multiple comorbidities-- we heard about hypertension and hyperlipidemia which puts him at risk for vascular disease including stroke-- he has a much more subacute time course, so I really don't think that this would be syncope or presyncope.
CATHY: The history that was provided makes it sound like it primarily is a gait disorder and a problem with walking, and we hear about an abnormal neuro exam. So, I think that that's the most likely etiology. But it's important to remember that things like arthritis, fatigue, or frailty, especially in older patients, could present similarly.
CHARLIE: What do you take from the neurologic exam in this patient?
CATHY: So, the pertinent positives in this case are important to group together and then sort of compare them to what we have as negatives in this case. The first one-- difficulty rising from a chair-- when I see this, I think about patients who probably have a primary motor weakness, especially in the proximal muscles. On exam, when you're looking at a patient, you'll see that the patients will use their arms or other muscles to try and help themselves get up.
CATHY: But this can also occur if people have sensory deficits or coordination problems. I would group the other positives together. So, difficulty initiating his gait and turning, a wide-based gait and short shuffling steps-- these to me are typical of gait apraxia where he really cannot plan the appropriate movements and put them together. The negatives in this case are also really important. So, here we heard about that he has no muscle weakness, no cerebellar signs, no sensory problems, and no muscle spasticity, and the absence of those findings is also important.
CHARLIE: So, based on the positives and negatives you've just mentioned, what do you conclude from this examination? What is your kind of neurologic diagnosis?
CATHY: So, this is typical of a frontal gait disorder or gait apraxia, and the most common causes are cerebrovascular disease and communicating hydrocephalus. The patient that we heard mentioned here is at risk for cerebrovascular disease, and that's the most common. But we don't hear about that as one of the answer choices. Communicating hydrocephalus is the other most common cause, and that is what I would go with in this case. And remember the classic triad which is wacky, wobbly, and wet, where people have mental status changes, gait apraxia or unsteadiness, and also urinary incontinence.
CHARLIE: So, option B-- communicating hydrocephalus-- is the best answer of those listed for the patient's gait apraxia. Why don't we go with some of the other diseases mentioned here, and talk about why they're not consistent with this presentation.
CATHY: Alcoholic cerebellar degeneration-- option A, and multiple system atrophy-- option D, both present with signs of cerebellar ataxia and can involve the gait. Some of the exam findings that are mentioned here, like wide-based gait, unsteadiness with turning, are similar to what can be seen in cerebellar ataxia, but there are multiple differences. So, gait initiation is usually normal in patients with cerebellar ataxia, and they will present with notable cerebellar findings such as dysmetria which is picked up on finger-to-nose testing or heel-to-shin testing.
CATHY: In our case, these physical exam findings were absent. In patients with cerebellar ataxia, you would expect them to be abnormal.
CHARLIE: Also, I would say that falls in these patients are typically a late event. Usually, they'll have some neurologic findings that present them to the physician before they progress all the way to falls. Cathy, what steered you away from the other answers?
CATHY: Neurosyphilis and lumbar myelopathy are examples of sensory ataxia, which can present with falls, but again, the gait pattern in these conditions is different. So typically, those patients will have a narrow-based gait, and they tend to look down while walking. Gait initiation is usually normal which was not present in this case. And on exam, you would usually see a positive Romberg test where the patient would be very unsteady.
CHARLIE: So, this case highlights the differences in various gait ataxias and the importance of a detailed neurologic examination, including having the patient stand up and walk in front of you. That component of the exam, which is very simple and very quick, can help you distinguish from central, cerebellar, motor, and sensory causes of falls, and also, help you diagnose gait abnormalities.
CATHY: To learn more about this, you can read Harrison's Internal Medicine chapter on cardinal manifestations of disease, Disorders of the Gait.
CHARLIE: Thank you! ♪ (music) ♪