Brief Reports Treatment of Drop Attacks with Nifedipine: A Case Report James W. M old, M D Oklahoma City, Oklahoma Drop attacks are sudden, unexpected, nonsyncopal patient described in this case report experienced fre­ falls, which are not preceded or accompanied by loss quent drop attacks that were effectively prevented of consciousness, dizziness, lightheadedness, or loss with nifedipine. Possible pathophysiologic mecha­ of balance. They can be a manifestation o f epilepsy, nisms are discussed and the relevant literature is re­ brain stem tumors, and a variety of other conditions. viewed. In the elderly, they have been associated with verte­ brobasilar insufficiency, cervical spondylosis, or both. Key words. Drop attacks; falls; vertebrobasilar insuffi­ However, the specificity and etiology o f drop attacks ciency; geriatrics; aged; drug therapy. ( / Fam P ract have come under some scrutiny in recent years. The 1995; 41:91-94) . Drop attacks have been defined by Sheldon1 as “ sudden gree and of unknown etiology.11-14 A variety of other unexpected falls to the ground, usually while standing or causative factors have been reported, including medica­ walking, and often following neck movement, in an oth­ tions (eg, clozapine),15 muscular dystrophy,16 colloid erwise healthy elderly individual who vigorously denies cysts,17 aneurysms and other masses in the third ventricle loss of consciousness.” Such attacks have previously been or posterior fossa,18 congenital cardiac lesions,19 Parkin­ blamed for as many as 15% o f geriatric falls.2 Several son’s disease,20 Meniere’s disease,21-22 and hypothyroid­ pathophysiologic mechanisms have been implicated, ism.23 Some elderly patients who experience drop attacks may simply have weak quadriceps muscles that “ give out” most involving acute intermittent disturbances o f brain suddenly after extended use. stem function.3’4 Drop attacks have traditionally been Because o f the prevalence of cerebrovascular disease considered one o f the specific fall syndromes observed in and the reported association of drop attacks with neck elderly patients. More recently some geriatricians argue hyperextension and with abnormalities o f the brain stem, that drop attacks should be considered symptomatic of a vertebrobasilar insufficiency is generally considered to be a spectrum o f diseases rather than a distinct clinical entity, common cause o f true drop attacks in the elderly.24 Drop and that the 15% figure is an overestimate o f the true attacks have been reported to occur in up to 25% of prevalence of drop attacks.5 Some have suggested aban­ patients with symptomatic vertebrobasilar insufficiency.25 doning the term altogether.6 In such cases, the pathophysiologic mechanisms may in­ In children and younger adults, drop attacks have clude mechanical obstruction (kinking) of the vertebro­ been reported to be a manifestation of seizure disor­ basilar arteries,26 sudden systemic hypotension (caused by ders. 7~10 A specific syndrome, which has been described in arrhythmia, for example), embolization, or spasm. Other middle-aged women, seems to be hereditary to some de- than the avoidance of extreme neck movement and the empiric use o f aspirin or warfarin, no effective treatment Submitted, revised, March 2, 1995. has been identified for drop attacks that result from ver­ tebrobasilar insufficiency. Because o f the sudden, bilat­ From the Research Division, Department o f Family Medicine, University o f Okla­ homa Health Sciences Center, Oklahoma City. Requests fo r reprints should be ad ­ eral, reversible nature of drop attacks, vascular spasm in­ dressed to James W. Mold, MD, Associate Professor, Director, Research Division, volving an atherosclerotic vertebrobasilar system seems a Department o f Family Medicine, University o f Oklahoma Health Sciences Center, Family Medicine Center, Suite 2207, 900 N E 10th St, Oklahoma City, O K 73104. plausible mechanism, particularly when there has been no © 1995 Appleton & Lange ISSN 0094-3509 The Journal o f Family Practice, Vol. 41, No. l(Jul), 1995 91 Treatment of Drop Attacks with Nifedipine Mold history of neck extension or turning and no evidence for eye examination were normal. She had mildly impaired hypotension. It was on this basis that nifedipine was cho­ hearing bilaterally. She was edentulous with well-fitting sen as a pharmacologic agent to treat the patient in this dentures. She had decreased range of neck movement case. without pain, and hyperextension caused a “ funny feeling in my head” but no loss of postural control. There was a thyroidectomy scar, and the residual thyroid tissue felt Case Report slightly larger than a normal gland. Examinations o f her chest, heart, and abdomen re­ An 86-year-old widowed woman was referred by her fam­ vealed no abnormalities. Carotid, radial, and dorsalis pe­ ily physician to a geriatric evaluation clinic in January o f dis pulses were intact with no bruits, but her femoral 1986 because of recurrent falls. Over the previous 5 years, pulses were somewhat diminished with a bruit on the she had experienced 12 falls, at least 8 of which had right, and her posterior tibial pulses were absent. She had occurred during the most recent 2 years. In the past year, bilateral 1 + pitting ankle edema. she had injured her right side during one fall and her right On neurologic examination, her cranial nerves, shoulder during two others, and fractured her left hip as a strength, tone, deep tendon reflexes, and sensation to pin result o f a fourth fall. Each fall had occurred suddenly and and touch were normal. Vibratory sensation was dimin­ without warning, as if her legs had simply collapsed. By ished at the ankles. There was no tremor. Her Romberg her recollection, the episodes were not associated with test was positive and her gait asymmetric, as she favored looking up or to the side and had not occurred while she her left leg. Her Folstein Mini-Mental State score was was wearing tight neckwear. She reported having felt pos­ 2 9 /3 0 . terior neck pain, which lasted for an hour or so following Laboratory testing included a complete blood count, about half of the episodes. The pain was accompanied by chemistry panel, thyroid-stimulating hormone, vitamin a feeling that blood was rushing up and down the back of B 12, folate, rapid plasma reagin, and urinalysis. The results her neck. Although she acknowledged that she had been were all within normal limits with the exception of a unable to extend her neck very far without experiencing a nonfasting total cholesterol o f 300 m g/dL (7.76 mmol/L) “ funny feeling” in her head, she carefully avoided doing and triglycerides of240 m g/d L (2.71 mmol/L). so and, thus, did not relate this to her falls. She was returned to the care o f her primary physician The patient’s medical history was significant for a with the following recommendations regarding the drop stroke in 1974, resulting in left-sided hemiparesis that attacks: (1) switch from the thiazide diuretic to nifedipine eventually resolved with almost no residual. She also re­ and avoid decongestants; (2) avoid neck hyperextension ported a vague history of coronary artery disease with (which she was already doing); (3) conduct a home-safety angina, and even some “ heart attacks” in the past (no evaluation; (4) obtain a telephone connection to Lifeline, hospitalization) but no related problems within the most an emergency assistance service; (5) obtain cervical spine recent several years. She had a 10-year history o f hyper­ radiographs; (6) discontinue dipyridamole; and (7) ob­ tension. She also had been treated for glaucoma for 2 tain an informal vascular surgery consultation regarding years with timolol eye drops, and had used decongestants the potential value o f cerebral arteriography. off and on between 1971 and 1983 for frontal sinusitis The cervical spine radiographs revealed marked de­ but was no longer bothered by this problem. Previous generative joint disease but no other abnormalities. This surgical procedures included a thyroidectomy for a goiter, type o f imaging study is actually o f limited value in these a cholecystectomy, and a hysterectomy, all in the remote cases.27 The vascular surgeon did not think arteriograms past, and she had a left hip fixation in October 1985. would be helpful since no satisfactory surgical procedure At the time o f initial evaluation her medications was available to treat the vertebral stenosis. This advice were: aspirin 325 mg daily; dipyridamole 50 mg three was not entirely correct, as there are a number of studies times daily; hydrochlorthiazide 25 mg once a day; timolol to indicate otherwise.28-33 Her son helped her safety- eye drops twice daily; calcium carbonate 500 mg three proof her home, and a Lifeline hookup was obtained. She times daily; a multivitamin with iron daily; and occasional tolerated nifedipine 10 mg every 8 hours with no substan­ doses of acetaminophen with codeine for pain resulting tial change in blood pressure but with some increase in from her healing hip fracture. her dependent edema. She was 5’0” tall and weighed 104 pounds. Her Since the relocation o f her original primary care phy­ blood pressure supine was 148/78 mm Hg, sitting sician to another town, she has been followed by the 150/92 mm Hg, and standing 150/78 mm Hg, with author. During 9 years o f follow-up, she has experienced pulse rates of 78, 80, and 86 beats per minute, respec­ only two falls. The first, which occurred in 1987 while she tively. Her skin was generally dry, and the results o f her was visiting her sister in a nursing home in Denver, was a 92 The Journal of Family Practice, Vol. 41, No. l(Jul), 1995 Treatment of Drop Attacks with Nifedipine M old classic drop attack that resulted in fractures of her right by vascular relaxation accompanied by pain.