The prevalence of Neurally Mediated Syncope in older patients presenting with unexplained falls

AimsTo determine the prevalence and clinical significance of carotid sinus syndrome (CSS) and vasovagal syncope (VVS), the two common types of Neurally Mediated Syncope (NMS), in a cohort of older patients with unexplained falls.MethodsPatients presenting with unexplained and accidental falls were identified from 200 consecutive admissions of falls in patients aged 65 years and older admitted to the Rapid Assessment Medical Unit (RAMU) in a teaching hospital. A sample of unexplained and accidental fallers underwent carotid sinus massage (CSM) and tilt table testing (TTT) as per a standardised protocol. Baseline characteristics, clinical variables and the prevalence of NMS were compared between the two groups.ResultsFalls were unexplained in 26% of patients. The prevalence of NMS was 24% (5/21) among patients with unexplained falls who underwent assessment for NMS, whereas it was nil (0/17) in patients with accidental falls (P = 0.050). The prevalence of previous falls was significantly higher in patients with unexplained falls (P = 0.0025), but all other baseline characteristics were similar between the two groups.ConclusionFalls are unexplained in a significant number of older patients presenting to acute hospitals. The assessment of unexplained fallers for NMS is clinically important as this may be aetiologically related in nearly a quarter of these patients.     

Cognitive screening of older patients in a teaching hospital: the impact of the Rapid Assessment Medical Unit (RAMU)

Background: The Rapid Assessment Medical Unit (RAMU) is a short stay processing ward for general medical patients. Aim: To evaluate the impact of the RAMU on cognitive screening of older medical patients. Method: Audit of documentation of cognition using a validated screening tool in the medical records of 500 patients aged 70 years and older. Their admission records under general medicine in the preceding 12 months were also reviewed. Results: Administration of the Abbreviated Mental Test (AMT) was attempted in 81% of patients. In 64.6% it was completed. 29% had impaired cognition on screening. A validated screening tool for cognitive assessment was recorded only in 7.6% of patients before the RAM U was opened. Conclusion: The work practice and procedural changes in the RAMU appear to have a positive impact on cognitive screening. This observation may suggest that evidence based clinical guidelines could be successfully implemented in a model similar to the RAMU.     

Sentinel lymph node biopsy in renal malignancy: The past,present and future

Sentinel lymph node biopsy (SLNB) is now an established technique in penile and pelvic cancers, resulting in a lower mortality and morbidity when compared with the traditional lymph node dissection. In renal cancer however, despite some early successes for the SLNB technique, paucity of data remains a problem, thus lymph node dissection and extended lymph node dissection remain the management of choice in clinically node positive patients, with surveillance of lymph nodes in those who are clinically node negative. SLNB is a rapidly evolving technique and the introduction of new techniques such as near infra-red fluorescence optical imaging agents and positron emission tomography/computed tomography scans, may improve sensitivity. Evidence in support of this has already been recorded in bladder and prostate cancer. Although the lack of large multi-centre studies and issues around false negativity currently prevent its widespread use, with evolving techniques improving accuracy and the support of large-scale studies, SLNB does have the potential to become an integral part of staging in renal malignancy.     

Neurally mediated syncope and unexplained or nonaccidental falls in the elderly

Falls and syncope are among the leading causes for which older patients seek hospital admissions. The prevalence of unexplained or nonaccidental falls is high in this group. The clinical spectrum of falls and syncope has been shown to overlap significantly in the elderly. Carotid sinus syndrome and vasovagal syncope, the two common examples of neurally mediated syncope (NMS), have been increasingly recognised as important attributable causes for unexplained falls and syncope. However, in clinical practice NMS is not widely investigated as a cause of fall and is likely to be underdiagnosed.     

Management of chronic kidney disease in the elderly

Both chronic kidney disease (CKD) and end-stage renal disease are strongly age related. Although the morbidity and mortality of CKD have significantly improved in recent years because of a greater understanding of its pathophysiology and evidence-based approach to management, the application of this evidence to the elderly CKD patients is often fraught with difficulty. This is because, besides age, the clinical and biological variables that are widely prevalent in the elderly, such as multiple co-morbidities, functional impairments and polypharmacy, and quality of life and functional outcome measures, which are pertinent to this age group, have generally not been incorporated into the available evidence. This paper reviews the current evidence with a view to providing a framework for diagnosing and managing CKD in the elderly. Special references are made to age-related physiological changes in the renal system, assessment of renal function, and management of metabolic complications and end-stage renal disease.     

Subarachnoid haemorrhage in Plasmodium falciparum malaria

A 41 year old man with cerebral malaria was found to have numerous bilateral retinal haemorrhages and very high parasitaemia. Despite intensive treatment his condition deteriorated and he died. Autopsy showed subarachnoid haemorrhage, which has not been previously described in cerebral malaria.     

Pitfalls in managing falls

Falls are common in the elderly and one of the most common reasons for older people to seek medical help. To illustrate the diagnostic dilemmas of this common clinical problem, we present a case study of a woman with a history of recurrent falls.