From the Guidelines
Drop attacks are sudden falls without loss of consciousness, typically caused by a temporary loss of muscle tone, and the most effective management strategy is to identify and address the underlying cause, with treatment options including medications, physical therapy, and lifestyle modifications, as supported by the 2019 American Heart Association and American Red Cross focused update for first aid 1.
Causes of Drop Attacks
Drop attacks can be due to various conditions, including:
- Vestibular disorders, such as Tumarkin's otolithic crisis or Ménière's disease
- Cardiac issues, such as arrhythmias
- Seizures or neuromuscular problems
- Orthostatic intolerance, including postural orthostatic tachycardia syndrome (POTS) 1
Treatment Options
Treatment depends on the specific diagnosis, and may include:
- Medications, such as diazepam 2-5mg or meclizine 25mg for vestibular-related drop attacks
- Diuretics, such as hydrochlorothiazide 25mg daily, or a low-salt diet for Ménière's disease-related attacks
- Pacemaker implantation for cardiac-related drop attacks caused by arrhythmias
- Anti-seizure medications, such as levetiracetam (500-1500mg twice daily), for seizure-related attacks
Prevention and Management
Physical therapy focusing on balance training and fall prevention strategies is important regardless of cause, and home safety modifications, such as removing trip hazards and installing grab bars, can prevent injuries. Additionally, recognizing the signs and symptoms of presyncope, such as pallor, sweating, lightheadedness, visual changes, and weakness, and using physical counterpressure maneuvers (PCMs) can help prevent syncope 1.
Key Considerations
The underlying mechanism of drop attacks varies by cause, and a thorough medical evaluation is necessary to determine the underlying cause and develop an effective treatment plan. The 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope provides a comprehensive framework for evaluating and managing syncope, including drop attacks 1.
From the Research
Definition and Causes of Drop Attacks
- Drop attacks encompass both falls and transient loss of consciousness, but the term is not clearly defined 2
- The most common causes of drop attacks are cardiovascular, with vestibular dysfunction also being a common cause, especially in the elderly 2
- Other potential causes of drop attacks include epilepsy, functional neurological disorder, cataplexy, and hydrocephalic attacks 2
Diagnostic Approach
- A systematic investigative approach can achieve an attributable diagnosis in the majority of cases 3
- The diagnostic evaluation should include a comprehensive battery of investigations, with particular attention to traditional and more recently identified risk factors for drop attacks 3
- Understanding the neurophysiologic basis of posture can be significantly helpful in arriving at the appropriate diagnosis 4
Specific Causes of Drop Attacks
- Cardiovascular syncope is the most common cause of drop attacks in the elderly 5
- Benign hereditary chorea caused by TITF1 gene mutations can present with recurrent drop attacks in early childhood 6
- Drop attacks can also be caused by severe epilepsies, movement disorders, cataplexy, and psychiatric disorders in children 6
Clinical Characteristics
- Drop attacks are often associated with high levels of morbidity and healthcare resource utilization, especially in older adults 3
- Patients with drop attacks may have a history of soft tissue injuries or fractures secondary to the attacks 3
- The clinical picture and patient's history are the most important factors in arriving at the appropriate diagnosis 4