An 80-year-old man comes to the office due to generalized weakness and intermittently feeling "dizzy" and unsteady over the past year. He fell 9 months ago when he tripped over a step. The patient has had no syncope or chest pain and has not attempted to use any mobility aids. History is notable for hypertension, type 2 diabetes mellitus, hypercholesterolemia, osteoarthritis, coronary artery disease, and gastroesophageal reflux disease. Current medications include metformin, glipizide, hydrochlorothiazide, aspirin, atenolol, simvastatin, and omeprazole. The patient does not use tobacco or alcohol.
Blood pressure is 150/90 mm Hg and pulse is 68/min. There are no orthostatic changes. BMI is 30 kg/m². Examination shows normal jugular venous pressure, clear lung fields, and normal S1 and S2. The abdomen is soft and nontender. There is no tenderness to palpation of the lower back. There are symmetric joint deformities of both knees and generalized arthritic changes in both hands. Cranial nerve examination is normal. Muscle power is 4/5 in both upper and lower extremities. Pinprick and light touch sensations are mildly decreased in both feet. Achilles reflexes are absent bilaterally.
Complete blood count, basic metabolic panel, and vitamin D levels are normal. Hemoglobin A1c is 8.2%. ECG shows normal sinus rhythm and old Q waves in lateral leads.
Which of the following is the most effective strategy to decrease this patient's risk for falls?

Question

Quizplus · Accepted Answer

11ec193a_9943_12db_853d_c3464db1609a_MD0002_00 This elderly patient with multiple comorbid conditions and nonspecific weakness and dizziness on ambulation without focal neurologic deficits or diagnostic findings (aside from mild peripheral neuropathy) is likely experiencing disequilibrium. Disequilibrium, a nonspecific sensation of impaired balance that occurs with ambulation, is common in older individuals with multiple chronic disorders and increased fall risk. The etiology is likely multifactorial and includes peripheral neuropathy, muscle weakness, arthritis, medication side effects, cerebellar dysfunction (ataxia), cervical spondylosis, Parkinsonism, and visual impairment. Disequilibrium should be differentiated from vertigo (a sense of spinning or movement) and presyncope (lightheadedness, acute "closing in" of vision, or orthostatic dizziness). Management usually requires a multidisciplinary program including regular exercise, physical therapy, and occupational therapy. A home fall risk assessment should be conducted. Nonessential medications should be discontinued. Although vitamin D supplementation is sometimes advocated, it is probably not helpful in the absence of overt deficiency. (Choice A) Pacemaker implantation is indicated for symptomatic bradycardia, usually due to heart block or chronotropic incompetence. Symptoms are typically described as "blacking out" or syncope/presyncope. This patient has no bradycardia and no conduction block noted on ECG. (Choice B) Education on fall prevention may be provided in the context of a comprehensive fall risk assessment. However, this patient will likely need balance and strengthening exercise, and the home exercise education is best provided in a supervised physical therapy program. (Choice C) Although a hemoglobin A1c target of <7 is appropriate for most adults, elderly patients with functional impairment or complex comorbidity are usually managed to a less stringent standard (eg, <8.5%). Tight control would increase the risk of hypoglycemia and possibly contribute to falls. (Choice D) Current recommendations regarding blood pressure control in patients age >80 are mixed, although most experts recommend a target of <140/90 mm Hg for patients with diabetes or chronic kidney disease. However, tight blood pressure control is associated with an increased risk of falls. Educational objective: Disequilibrium is a nonspecific sense of weakness or imbalance with ambulation. It is common in elderly patients with multiple comorbid conditions. Contributing factors may include cerebellar dysfunction, cervical spondylosis, Parkinsonism, peripheral neuropathy, medication side effects, arthritis, muscle weakness, and visual impairment. Management usually requires a multidisciplinary program including regular exercise, physical therapy, and occupational therapy. __________ References: Disequilibrium and its management in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/19842350)

An 80-Year-Old Man Comes to the Office Due to Generalized