Abstract & Commentary
Synopsis: A standardized work-up will reveal a cause for drop attacks in 90% of cases.
Source: Parry SW, Kenny RA. J Am Geriatr Soc. 2005;53:74-78.
A drop attack is a sudden collapse without loss of consciousness. Elderly women seem to suffer more frequently than men. Parry and Kenny conducted a study of 93 consecutive patients presenting to the Royal Victoria Infirmary emergency department and its Falls and Syncope Service in Newcastle Upon Tyne, United Kingdom, with 3 or more unexplained attacks. Their goal was to ascribe diagnoses to these patients following a standardized assessment. The assessment included a detailed history and physical exam with attention paid to the neurologic, skeletal, cardiovascular systems. Testing included visual acuity, Mini-Mental State Exam (MMSE), gait, balance, electrocardiogram (ECG), carotid sinus massage (CSM), orthostatic blood pressure (BP), biochemical profile, and complete blood count. Gait was addressed by the Get Up and Go Test,1 which requires patients to stand up from a chair, walk a short distance, turn around, return, and sit down again. Balance was measured by the one-legged stand test,2 which requires patients to stand on one leg for 5 seconds. Should the initial work-up have proved unfruitful, a tilt table test with or without nitroglycerin provocation and 24-hour ambulatory ECG and BP monitoring were ordered. If the history or physical suggested another diagnosis, then echocardiogram, cervical spine x-rays, hip x-rays, brain imaging, electroencephalogram, electrophysiologic studies, or toxicology studies were ordered.
Since a drop attack is a symptom and not a diagnosis, it was important to have a strict definition of what constitutes a drop attack, to avoid including other conditions (for instance, a seizure). Parry and Kenny defined it as follows: ". . .a sudden fall event whereby the patient landed on the ground or another lower level, with no prodrome, no awareness of loss of consciousness, and no overt extraneous triggering event such as a slip or a trip." They also defined what constituted a diagnosis; once a risk factor was detected, there had to be an association of symptoms with a positive test or physical exam, or a 50% reduction in drop attacks after addressing the risk factor or disease.
Inclusion criterion was age 55 or older. Excluded were patients with syncope, myocardial infarction, stroke, infection, malignancy, electrolyte abnormality, gastrointestinal hemorrhage, fracture, head injury, or a MMSE score < 15. Because CSM was an important part of the work-up, patients with a relative contraindication to CSM (for instance, transient ischemic attack in the previous 3 months) were also excluded. The 93 patients were an average age of 77, 75% female, and 80% living independently in private homes and were followed for 18 months. On entry, these patients averaged 6 drop attacks.
A diagnosis was made in 84 patients (90%). Cardiovascular disorders accounted for the largest group of diagnoses (53%), followed by neurological disorders (29%), and gait and balance problems (17%). Carotid sinus hypersensitivity was diagnosed in 37 patients, vestibular disorders in 9, orthostatic hypertension in 5, visual impairment in 5, cerebrovascular disease in 5, vasovagal syncope in 3, sick sinus syndrome in 2, and congestive heart failure and atrial fibrillation in 1 a piece.
Other disorders were diagnosed infrequently (1 or 2 occurrences each). Sixty-eight patients had only one diagnosis, 17 had two, and 3 had three. Polypharmacy was a contributing risk factor in 28%. History, physical exam, and initial testing made the diagnosis in most patients. Ambulatory BP and ECG monitoring helped very infrequently.
Comment by Allan J. Wilke, MD
If you are thinking that drop attacks and their work-up look suspiciously like syncope and its work-up, welcome to the club! As an editorialist noted, "The distinctions between falls, dizziness, syncope, and cardiovascular disease have become increasingly blurred."3 In 2001, Internal Medicine Alert reviewed4 a study by Sarasin5 that detailed a work-up of syncope that looks very similar to this one. Drop attacks seem to be syncope without the loss of consciousness, but Parry and Kenny hint at a subtler explanation. They point to several articles where elders who were undergoing CSM had unconsciousness and were amnesic for the loss of conciousness.
The patients in this study may not be similar to those in your practice. They were recruited from a falls and syncope clinic and had experienced multiple drop attacks before entering the study.
Proceeding on a work-up of a patient with multiple drop attacks is more than reasonable. These patients are elderly females for the most part and prone to grievous injury from falls. What to do with the patient who presents with a first drop attack? At the very least, a detailed, directed history and physical and some testing (gait and balance testing, orthostatic BPs, CBC, and basic metabolic profile) are warranted with more extensive testing if the work-up suggests a diagnosis or the problem persists.
Dr. Wilke, Associate Professor of Family Medicine, Medical College of Ohio, Toledo, OH, is Associate Editor of Internal Medicine Alert.
1. Mathias S, et al. Arch Phys Med Rehabil. 1986;67: 387-389.
2. Vellas BJ. J Am Geriatr Soc. 1997;45:735-738.
3. Rich MW. J Am Geriatr Soc. 2005;53:161-162.
4. Wilke AJ. Internal Medicine Alert. 2001;23:147-149.
5. Sarasin FP, et al. Am J Med. 2001;111:177-184.