Vertigo and the Increased Risk for Fall Injuries One in three older adults fall each year

Vertigo and the Increased Risk for Fall Injuries One in three older adults fall each year. There are approximately 2.5 million falls among older adults treated in emergency departments. (Patel, 2018) The risk for falls threatens the safety of seniors daily lives and independence tremendously. Due to this fear of falling older adults will limit their daily activities and social enjoyments which can result in further physical decline. The patient is a seventy-year-old Caucasian male who was admitted to the emergency department of The University Medical Center on April 29, 2018 after sustaining a fall while exercising at the gym. The patient has stated that he has not had any history of syncope or seizures. After the patient was admitted to the Emergency Room (ER) the patient was found to be bleeding from the back of his head as well as from the right side of his forehead. The patient was diagnosed with syncope and collapse upon admission as well as benign positional vertigo (BPV). The patient has a history of hypothyroidism, chronic anemia, essential hypertension, chronic kidney disease stage III, obsessive compulsive disorder, anxiety, and gastroesophageal reflux disease (GERD). He did not have a history of falls. The patient had an unsteady gait but was fully ambulatory. The combination of an unsteady gait, syncope and vertigo may have contributed to the recent fall resulting in the patients head injury. The patient had a minimal surgical history. He had a Dupuytren contracture release, but the date and age of occurrence is unknown. The patient has denied smoking and use of illegal drugs. However, he does admit to having two nine-ounce glasses of wine per day. The patient was previously admitted to The University Medical Center in August 2017 and was treated for hypertension. In November 2016, the patient was hospitalized due to sleep problems, changes in urination output, and swelling of feet and ankles. At that time, he was diagnosed with chronic kidney disease. He was also admitted to the hospital in December 2014 and treated for GERD. According to Seunggu Han, MD there are no major risk factors for BPV, but there are some indications that it could be an inherited condition. There are also some other conditions that could make some people more prone to developing BPV. These include prior head injuries, osteoporosis, diabetes, and an inner ear condition. (Han, 2018) The patient is an elderly Caucasian male who has lived in Metairie, LA for his entire life. He currently resides in the Oak Lawn area of Metairie. The patient frequently talks about his apartment and how he needs to be stable in order to climb the two flights of stairs to get to his home. The patient has stated he has been compliant with all of medications prescribed for his hypertension and obsessive-compulsive disorder. The attends church every Sunday at a local Presbyterian church. The patient graduated from Tulane when he was twenty-one with a degree in political science. He then went on to complete his law degree at Loyola University New Orleans College of Law. He has been working as a criminal defense attorney since he graduated at the age of 24. The patient is extremely knowledgeable and seems to understand his diagnosis well. The patient is still a practicing lawyer, although he has decreased his workload in anticipation for retirement. The patient is insured by Blue Cross Blue Shield, which covers most of his hospital expenses. According to his benefits plan they will cover inpatient hospital care for 175 per day up to 875 per admission. His plan will also cover his emergency room visit for 125 per day. (Blue Cross Blue Shield, 2018) The patient is a widower who has one child. His son and daughter-in-law are the patients main support system. The son visited the patient alone on the first day I had him and on the second day the patients daughter-in-law came with her husband. During the time that the son was there he helped his father to the restroom and helped him slowly sit up and move to the couch. The patients son states that the patient has always been a strong and athletic person. The patient was always the sole provider for the family when the son still lived at home. His mother was a stay at home mother and did not work. Since the patient has not been able to do many things on his own since he has been in the hospital the patient shows signs of powerlessness. The patients son has said that his father is complaining of having to sit in his room all day and not be able to walk around on his own. On April 29, 2018, the patient was admitted to the emergency department at The University Medical Center after a fall that resulted in a laceration to the back of the head as well as to the patients right forehead. A peripheral IV was inserted into the patients left antecubital upon admission. In order to monitor for changes in the level of consciousness (LOC), that may be secondary to the patients head injury, mental status was evaluated every hour on the first day and once a shift there after. For the entirety of the hospital stay the patient stayed oriented to person, place, time, and situation. Disorders of vestibular function are characterized by a condition called vertigo, in which an illusion of motion occurs. With vertigo, the person may be stationary and the environment in motion or the person may be in motion and the environment stationary. Persons with vertigo frequently describe a sensation of spinning, to-and-fro motion or falling. Vertigo can result from central or peripheral vestibular disorders. Vertigo due to peripheral vestibular disorders tends to be severe in intensity and episodic or brief in duration. In contrast, vertigo due to central vestibular causes tends to be mild and constant and chronic in duration. Motion sickness is a form of normal physiologic vertigo. Hyperventilation, which commonly accompanies motion sickness, produces changes in blood volume and pooling of blood in the lower extremities that lead to postural hypotension and sometimes to syncope. (Porth, 2016) There are some certain types of vertigo that resolve without treatment. Drugs can relieve some symptoms including antihistamines or antiemetics to reduce motion sickness and nausea. Sometimes inner surgery is carried out to treat patients with intractable benign paroxysmal positional vertigo. The surgeon inserts a bone plug into the inner ear to block the area where vertigo is being triggered. The plug prevents this part of the ear from responding to particle movements inside the semicircular canal of the inner ear or head movements that could lead to vertigo. (MacGill, 2017) Clinical manifestations include balance problems and lightheadedness, a sense of motion sickness, nausea and vomiting, tinnitus, a feeling of fullness in the ear, and headache. (MacGill, 2017) Dizziness can increase your risk of falling and injuring yourself. Experiencing dizziness while driving a car or operating heavy machinery can increase the likelihood of an accident. You may also experience long-term consequences if an existing health condition that may be causing your dizziness goes untreated. (Dizziness, 2018) Vertigo is fairly common, with an estimated incidence of 107 per 100,000 per year and a lifetime prevalence of 2.4 percent. It is thought to be extremely rare in children but can affected adults of any age, especially seniors. The vast majority of cases occur for no apparent reason, with many people describing that they simply went to get out of bed one morning and the room started to spin. However, associations have been made with trauma, migraine, inner ear infection or disease, diabetes, osteoporosis, intubation (presumably due to prolonged time lying in bed) and reduced blood flow. There may also be a correlation with ones preferred sleep side. (Woodhouse, 2018) Syncope is a brief lapse in consciousness accompanied by a loss of postural tone. The causes of syncope can be cardiovascular or non-cardiovascular. The most common cause of syncope is cardio neurogenic syncope, or vasovagal syncope. In cardio neurogenic syncope, the increase in venous pooling that occurs in the upright position reduces venous return to the heart. This results in a sudden, compensatory increase in ventricular contraction. This is mistaken by the brain as a hypersensitive state, and consequently sympathetic stimulation is withdrawn. This produces a paradoxic vasodilation and bradycardia. The end results are bradycardia, hypotension, cerebral hypoperfusion, and syncope. (Lewis, 2016) This test uses a magnetic field and radio waves to create cross-sectional images of the patients head and body. A doctor can use these images to identify and diagnose a range of conditions. An MRI may be performed to rule out other possible causes of vertigo. (Mayo Clinic, 2015) The results of the patients MRI found a mass in the patients frontal lobe. A biopsy was done and the mass was found to be benign and believed to not be the cause of the patients vertigo. A head CT is often performed initially upon admission to the emergency department for vertigo. This is often performed to exclude a central cause. (Lawhn-Heath, 2012) The results of the patients CT found a mass in the patients frontal lobe. A biopsy was done, and the mass was found to be benign and believed to not be the cause of the patients vertigo. The CBC is a blood test that is used to evaluate the status of red blood cells, white blood cells, and platelets. (Lewis, 2016) The basic metabolic panel is a group of blood tests that provides information about your bodys metabolism. (Case-Lo, 2017) Table 1 represents the patients current labs during the clinical rotation, it also provides an explanation to why the lab values are abnormal. Table 1 Lab5/35/4Normal Rage with unitsWhy abnormal CBC (Italics are included in a CBC with Diff)RBC3.30 (L)3.31 (L)4.50-5.90 106/uLWhy abnormal A low RBC count is most likely caused by the patients chronic anemia. Could also be due to the patients CKD since erythropoietin is produced in the kidneys (Pagana, 441) Consequences Tiredness, SOB, headache, dizziness Hgb11.1 (L)11.1 (L)13.5-17.5 gm/dLWhy abnormal A low Hgb count is most likely caused by the patients chronic anemia. Could also be due to the patients CKD since erythropoietin is produced in the kidneys (Pagana, 283) Consequences Tiredness, SOB, headache, dizzinessHct31.9 (L)31.9 (L)40.0-51.0Why abnormal A low Hct count is most likely caused the patients chronic anemia. Could also be due to the patients CKD since erythropoietin is produced in the kidneys (Pagana, 280) Consequences Tiredness, SOB, headache, dizzinessBMP/Chem 7 (Italics are included in a CMP)BUN26.0 (H)27.0 (H)7.0-25.0 mg/dLWhy abnormal The patients high BUN level could be due to the patients chronic kidney disease stage III (Pagana, 513) Consequences Fluid retention, fatigue/tiredness, high blood pressureCreatinine1.87 (H)1.82 (H)0.70-1.40 mg/dLWhy abnormal A high creatinine level is most likely caused by the patients chronic kidney disease stage III (Pagana, 190) Consequences Fluid retention, fatigue/tiredness, high blood pressureEGFR non AA41 (L)43 (L)89 mL/minWhy abnormal The patients low EGFR level could be due to the patients chronic kidney disease stage III (Pagana, 194) Consequences Fluid retention, fatigue/tiredness, high blood pressureEGFR AA36 (L)37 (L)89 mL/minWhy abnormal The patients low EGFR level could be due to the patients chronic kidney disease stage III (Pagana, 194) Consequences Fluid retention, fatigue/tiredness, high blood pressure The patient was ordered to remain in bed and only allowed up with assistance. The patient was also instructed to sit up slowly and sit on the edge of the bed for a few minutes before fully standing. The patient was put on a cardiac diet that was low in sodium and low in fat. The patient was referred to a physical therapist in order to treat his dizziness and balance dysfunction. The physical therapists performed passive physical therapy for the patients balance, which included canalith repositioning and activity modification. They also worked on the patients balance, core strength, gait training, and visual tracking exercises. Amlodipine was administered daily to treat the patients hypertension. Amlodipine is an antihypertensive that inhibits the transport of calcium into myocardial and vascular smooth muscle cells resulting in inhibition of excitation. (Vallerand, 2016) A chewable aspirin was administered to the patient once daily in order to thin out the patients blood and prevent clots. Aspirin is an antipyretic that decreases platelet aggregation. (Vallerand, 2016) The patient was given atorvastatin daily in order to lower his high cholesterol. Atorvastatin is a lipid lowering agent that inhibits 3-hydroxy-3-methylglutaryl-coenzyme A reductase which catalyzes an early step in the synthesis of cholesterol. (Vallerand, 2016) The patient received duloxetine once daily in order to treat his OCD and anxiety. Duloxetine is an antidepressant that inhibits serotonin and norepinephrine reuptake into the CNS which then lowers the patients anxiety and OCD. (Vallerand, 2016) Heparin was administered to the patient three times daily in order to prevent DVT and pulmonary emboli. Heparin is an anticoagulant that potentiates the inhibitory effect of antithrombin on factor Xa and thrombin to prevent blood clots. (Vallerand, 2016) The patient received levothyroxine once daily to resolve his symptoms of hypothyroidism. Levothyroxine is a replacement hormone that substitutes for endogenous thyroid hormones. (Vallerand, 2016) Meclizine was administered to the patient twice daily to relieve his dizziness and vertigo. Meclizine is an antihistamine and antiemetic. It decreases excitability of the middle ear labyrinth and depresses conduction in middle ear vestibular-cerebellar pathways. (Vallerand, 2016) Melatonin was administered once a day before bed time in order to relieve the patients insomnia. Melatonin is a sedative/hypnotic that is supplemented for the hormone melatonin secreted from the pineal gland. (Vallerand, 2016) The patient must be able to ambulate without becoming dizzy. According to research from UpToDate patients with vertigo should undergo balance rehabilitation. Balance rehabilitation will help the patients brain adjust its response to changes in the vestibular system. The therapy can also help train the eyes and other senses to learn how to adapt. These exercises can be performed at home. The patient will start by focusing on an object with a blank background and move his head slowly to the right and left and up and down. The patient will perform this exercise for several minutes two to three times per day. (Furman, 2017) The patient has trouble standing or walking because of his vertigo, so he understands that he is at risk for falling. The patient was taught to get rid of hazards in his home in order to reduce the risk of falls. The patient understood the teaching and was able to state back that he would remove slippery rugs, loose electrical cords, and will avoid walking in unfamiliar areas that are not lighted. (Furman, 2017) Y, B8L 1(IzZYrH9pd4n(KgVB,lDAeX)Ly5otebW3gpj/gQjZTae9i5j5fE514g7vnO( ,[email protected] /[email protected] 6Q