Differential Diagnosis for Recurrent Falls with Pre-symptoms of Lightheadedness in an Old Female

Single Most Likely Diagnosis

• Orthostatic Hypotension: This condition is characterized by a significant drop in blood pressure upon standing, leading to lightheadedness and potentially falls. It is common in the elderly due to age-related changes, medication side effects, or volume depletion.

Other Likely Diagnoses

• Vestibular Disorders: Conditions such as benign paroxysmal positional vertigo (BPPV) can cause vertigo and lightheadedness, increasing the risk of falls.
• Cardiovascular Conditions: Atrial fibrillation, heart block, or other cardiac arrhythmias can lead to reduced cardiac output, causing lightheadedness and falls.
• Neurological Conditions: Early signs of Parkinson's disease, normal pressure hydrocephalus, or peripheral neuropathy can affect balance and gait, predisposing to falls.
• Medication Side Effects: Many medications, especially sedatives, antihypertensives, and antidepressants, can cause dizziness or lightheadedness as a side effect.

Do Not Miss Diagnoses

• Cardiac Arrest or Myocardial Infarction: Although less likely, these conditions can present with lightheadedness before a fall and are immediately life-threatening.
• Stroke or Transient Ischemic Attack (TIA): Sudden onset of lightheadedness accompanied by other neurological deficits could indicate a stroke or TIA.
• Severe Anemia or Hypoglycemia: Both conditions can cause lightheadedness and are potentially life-threatening if not promptly addressed.

Rare Diagnoses

• Autonomic Dysfunction: Conditions like pure autonomic failure or multiple system atrophy can lead to orthostatic hypotension and lightheadedness.
• Inner Ear Disorders: Meniere's disease or labyrinthitis can cause vertigo and lightheadedness, though they are less common causes of recurrent falls.

Investigations to Rule Out Diagnoses

• Orthostatic Vital Signs: Measure blood pressure and heart rate in supine, sitting, and standing positions to diagnose orthostatic hypotension.
• Electrocardiogram (ECG): To evaluate for cardiac arrhythmias or conduction abnormalities.
• Blood Tests: Complete blood count (CBC) to check for anemia, blood glucose to rule out hypoglycemia, and electrolyte panel.
• Imaging Studies: Consider head CT or MRI if a stroke or TIA is suspected, or if there are focal neurological deficits.
• Vestibular Function Tests: If a vestibular disorder is suspected, tests like the Dix-Hallpike maneuver or electronystagmography may be useful.
• Medication Review: Assess the patient's medication list for potential contributors to lightheadedness and consider adjustments.