Slips, Trips, Falls

…..and syncope

Falls - the size of the problem

• Each year 30% of those aged over 65, 40% over 80yo living in the community and 60% of nursing home residents will fall (Shaw 1996)

• 400,000 older people attend A&E in England because of an accident (DTI 1997, O’Loughlin 1993)

• One third of those aged over 50 yrs age attending Newcastle’s A&E do so because of a fall: 10,000 people each year (Richardson 2001).

• Older people who have fallen are at risk of falling again.

• Many elderly fallers don’t seek help or don’t get further assessed.

Falls why bother

• Intervention reduces falls and fractures

• First indication of undetected illness that is easy to treat

It is a miracle we don’t fall more often!

Bipedality makes humans inherently unstable.

We’d be better as a tortoise!

Maintaining an upright positionVision

Central processingVestibular function

Muscle strength Joints

Sensation Proprioception

Changes with age

• Postural sway increases (Dheshi 2001)• Muscle strength decreases• Reaction times slower• Vision

– Acuity, contrast, depth perception

• Disease

What happened when you last fell?

Consequences that make older adults different from young

adults

• Risk of fracture increases– less force needed– muscle padding– bone density

Loss of confidence

Consequences of falling

• Hypothermia

• pressure related injury

• Reduced mobility leading to social isolation and depression

• Increased dependency and disability

Fear of falling

• 30% of older people fear falling (Arfken 1994)

• Fear level is greater than the fear of being robbed in the street (Howland 1993)

• Associated with older age, poor balance and reduced mobility (Arfken 1994) (Howland 1993)

• Psychological barrier to exercise (Bruce 2002)

Vicious circle

•15% falls result in serious injury•Leading cause of mortality due to injury in over 75yo in UK (HEA 1999)

•5% falls result in fracture 1% hip (Tinetti 1988, O’Loughlin JL

1993)

•1/3 hip fractures can no longer live independently and 25% are dead at 6 months•14,000 people die every year

from hip # in UK (Melton 1998)

Falls - the size of the problem

Aims of Falls assessment

• To prevent further falls

• To prevent serious injury - especially fracture

Causes of falling are multifactorial, rarely one cause non accidental fallers attending A&E, >50 yo.

• In 88% of an attributable cause can be identified • Median number of risk factors 4

– 90% gait– 85% balance– 55% cardiovascular– 45% medications– 30% medical cause– 30% vision– 30% footwear– 10% depression– 10% environment– 10% other Richardson 2001

Identifiable risk factors

400– Female– Age– Previous fall

Risk factors for falling• Intrinsic

– Muscle weakness– Impaired balance– Impaired gait– Transfer skills

• PD, CVA, Degenerative joint disease– Impaired cognition– Depression– Polypharmacy

• > 4 drugs, sedatives, hypotensive drugs– Postural hypotension – Visual impairment

Risk factors for falling

• Extrinsic

– poor lighting especially on stairs– steep stairs– loose carpets/rugs– slippery floors– footwear– lack of safety equipment– inaccesible lights or windows

Multiple intervention strategies

Proven success in diverse groups

– Community based prevention studies in those with 1 or more risk factors (Tinetti 94 Campbell A&A 1999 )

– In residential care after fall (Rubenstein 1990)

– A&E attendees (Close 99)– Cognitively impaired fallers attending A&E (Shaw)

– No studies reported yet on specifically altering the ‘fear load’

Single intervention studies

• Sedative withdrawl (Campbell 99)

• Enviromental modification (Cumming 99)

• Exercise programs (Province 95, Campbell 97,99 Robertson 01)

• Tai Chi - Fear ?? (Wolf 96)

Intervention strategies RISK FACTOR

• Muscle weakness• Impaired balance• Impaired gait• Transfer skills

INTERVENTION

• Resistance training• Training, assistive

devices• Training, environment• Training, grab rails

Intervention strategies RISK FACTOR

• >4 prescribed drugs

• Sedative use

INTERVENTION

• Review

• Educate, withdraw

Intervention strategies

RISK FACTOR

• Environmental hazards

• Footwear

INTERVENTION

• Give Advice• Handrails• Remove items• Secure rugs/carpets

• New shoes

Intervention strategies RISK FACTOR

• Visual impairment

• Cognitive impairment

• Depression

INTERVENTION

• Glasses, cataracts

• minimise

• treat

Intervention strategies RISK FACTOR

• Postural hypotension

• Carotid sinus syndrome

• Vasovagal syncope

INTERVENTION

Bone protection

• Calcium and Vitamin D (Chapuy 92, 94,)

– Other effects (Pfeifer 00)

• Oestrogens• Raloxifene• Etidronate• Alendronate• Risedronate• Calcitonin

– (RCPhys Lon & Bone and Teeth Soc of GB)

Hip protectors

• In danish nursing homes – 53% reduction in # risk. – Low risk of # if wore garment – compliance 24% - 61%,

• Lauritzen 1993, 1996, Kannus 2000.

• Recommend use in institutional care, consider in housebound and others with high risk for falls

Cardiovascular causes of falls

• Neurally mediated syndromes– Othostatic hypotension– Carotid sinus syndrome– Vasovagal syncope– Postprandial hypotension– Situational syncope

• Cardiac abnormalities– Arrhythmias– structual

• Miscellaneous– PE– TIA– Subclavian steal

Why do Syncope and falls overlap

• syncope amnesia

• cognitive impairment

• cerebral hypoperfusion results in gait and balance disturbance

Overlap between Syncope and falls

• Evidence: • Anecdotal • Case series

– 20% of cardiovascular syncope present with falls– Individuals with CSS had reduction in falls as well as

syncopal events after pacing• Safe Pace 1

– 2/3 reduction in falls in recurrent unexplained fallers with CICSH after pacing

• 3% all falls are syncope (Rubenstein 1996)

Overlap between Syncope and falls

• Consider in unexplained and recurrent fallers (18% of AE attendees) as 55% have a cardiovascular attributable cause– Especially with significant injury– or a prodrome of ‘dizziness’– or if lack of recollection how ended up on the

ground

What is Carotid sinus hypersensitivity?

• Defined as > 3secs asystole (cardioinhibitory) &/or

>50mmHg fall in SBP (vasodepressor)

At carotid sinus massage

• The cause of symptoms in 30% of elderly people with syncope

• If witnessed to syncope during Carotid sinus massage, and cardioinhibition documented 90% chance that pacing will abort events

How do you do carotid sinus massage?• Carotid sinus is located at junction of int and ext carotid

arteries, 2fb below jaw level of thyroid cartilage. ECG (and BP monitoring)

• Massage carotid sinus for 5secs on each side right and left supine and then erect. 30% CSH missed in supine alone

Onset of CSM

5.2 secs of asystole with brief LOC64mmHg vasodepressionno awareness to LOC

baseline133/49

Case History Two Carotid Sinus Massage, Right Supine

5.2s

69/24mmHg

Contraindications to CSM 1:2000 risk of TIA, 1/8000 risk of CVA Characteristics of patients with complications over 80 years, cardiovascular and cerebrovascular co-morbidity Davies and Kenny, Am J Card

1998, Munro and Kenny, JAGS 1994

• History of ventricular tachycardia

• Cerebrovascular event within 3 months

• Myocardial infarction within 3 months

• Carotid bruit present

• Lack of consent

Orthostatic (Postural) hypotension diagnosis

The Active Stand test• Morning• 10 minute rest• Anaeroid sphygmanometer is sufficient • May need two or even three people • Rapid stand• Repeated BPs over 2-3 minutes• Repeat measurements may be needed, orthostatic response

variable time of day and day to day• Beat to Beat BP monitoring facilitates detection

Orthostatic hypotension definition?

• 20mmHg fall in systolic blood pressure OR 10mmHg fall in diastolic blood pressure within 2 minutes of standing

Don’t forget rare causes of OH• Illness

– Fever, dehydration, acute blood loss and anaemia– Prolonged bed rest

• Inadequate fluid intake• Culprit medications 28%• Age related 20%• Autonomic failure: - if no clear explanation consider AFTs

– Primary 24% – MSA 13%– Diabetes 3%– PD 5%

• Cardiovascular disease 5%• Addisons - worth checking cortisol/ synachten test• Undiagnosed 2%

Orthostatic hypotension non drug management for all..

• Conservative advice – Fluids– Take time – Exercise pre stand– Heat– Alcohol No Crossed legs, squat– Large CHO meals Salt– Don’t strain at stool Sit to wee.

• Cognaisance of precipitating factors • Graduated compression stockings/tights• Abdominal binders

OH Management refractory cases

• Caffeine 2 cups in the morning• Raise head end of bed (RAS activation) Bannister 1969

• Abdominal binders

• Specific drugs– Fludrocortisone – Midodrine– NSAIDs – SSRIs – Others

Vasovagal syncope

Diagnosis

• History

• Head up tilt test

Feeling a bit overwhelmed?

The next faller….

Periodic case finding in

primary care ask all patients about falls in last year

No falls

Single fallRecurrent falls

Check for gait and balance

problem

Patient presents to medical facility

after a fall

No problem

gait and balance

problems

FallEvaluation

Guidelines for the prevention of Falls in Older persons consensus group JAGS 2001

FallEvaluation

Assessment

History

Medications

Vision

Gait and balance

Neurological

Cardiovascular

Mutifactorial interventionas appropriate

Gait, balance and exercise programs

Medication modification

Postural hypotension

modification

Environmental hazard modification

Cardiovascular disorder treatment

Crucial resources

NSF For older people DOH website/by post

Guidelines for the prevention of Falls in Older persons JAGS 2001;49: supplement No 5.