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]