1.5 Reflective exercise: Falls risk in Parkinson’s
Read over Mr Smith’s history. On direct questioning he does admit to having had one fall.
Think about what you have learned in Section 1 regarding factors which make someone with Parkinson’s more likely to fall. Remember that falls risk can be increased both by Parkinson’s factors and other more general factors. There are several things mentioned in the text which may increase Mr Smith’s falls risk. In your reflective log, identify as many as you can, and suggest how to reduce their impact. Write down anything else you would like to check.
Mr Smith is a 74 year old man diagnosed with idiopathic Parkinson’s who has been seen in clinic for the last 8 years. He is taking sinemet 125mg four times a day. He was diagnosed with prostate cancer last year and is now on anti-androgen hormone treatment. He had polymyalgia rheumatica 3 years ago and had steroid treatment for 18 months. He has some back pain. He drinks 3 units of red wine daily. He suffers with constipation, which is easily managed with aperients. He is hypothyroid on monitored replacement therapy. He takes bendroflumethiazide for hypertension, zopiclone to aid sleep, as well as aspirin 75mg for secondary cardiovascular disease prevention. He comes to clinic and it is noted that he is shuffling more than he used to and now uses a stick to walk. Coming through the door he gets ‘stuck’ and freezes. There is no ‘wearing off’ phenomenon. On examination he is wearing bifocal glasses, but his eye movements are normal. He has Hoehn and Yahr stage 3 Parkinson’s and has a moderately stooped posture. He has moderate bradykinesia and rigidity of his upper and lower limbs, more evident on the left than the right, and no red flags to suggest an alternative diagnosis to idiopathic Parkinson’s. He weighs 57kg and is 1.59m tall. He reports his main problem as feeling ‘really unsteady’ and as a result he is less confident leaving the house to do his weekly shop. He has not fallen.
Discussion
You may have noted the following factors:
- He is 74, and falls grow more common with age.
- He has Parkinson’s, which affects balance and gait.
- He is on dopaminergic medication. So while adequate treatment is necessary to maximise motor control, you would want to consider whether the drugs were negatively affecting his cognition and if they were making him dyskinetic or contributing to postural hypotension.
- Other medications associated with falls are sedatives (zopiclone) and antihypertensives (bendroflumethiazide) as well as alcohol intake.
- He demonstrates clear gait abnormality (shuffling steps) and freezing of gait, which is a potent risk factor for falling.
- His posture is abnormal (stooped) and he reports being unsteady.
- Bifocal glasses are an established risk factor for falls, as the magnifying section distorts the image in the lower field of vision.
1.4 Management of patients who are at risk of falls