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 position
Vision
Central processing
Vestibular 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
Falls - the size of the problem
•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)
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
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–
–
–
–
–
–
–
–
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
INTERVENTION
RISK FACTOR
• Environmental hazards
•
•
•
•
• Footwear
• New shoes
Give Advice
Handrails
Remove items
Secure rugs/carpets
Intervention strategies
RISK FACTOR
INTERVENTION
• Visual impairment
• Glasses, cataracts
• Cognitive impairment
• minimise
• Depression
• 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
Case History Two Carotid Sinus Massage, Right Supine
baseline
133/49
69/24mmHg
5.2s
Onset of CSM
5.2 secs of asystole with brief LOC
64mmHg vasodepression
no awareness to LOC
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
•
•
•
•
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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
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•
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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
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Fluids
Take time
Exercise pre stand
Heat
Alcohol
Large CHO meals
Don’t strain at stool
No Crossed legs, squat
Salt
Sit to wee.
• Cognaisance of precipitating factors
• Graduated compression stockings/tights
• Abdominal binders
OH Management refractory cases
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•
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Caffeine 2 cups in the morning
Raise head end of bed (RAS activation) Bannister 1969
Abdominal binders
Specific drugs
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Fludrocortisone
Midodrine
NSAIDs
SSRIs
Others
Vasovagal syncope
Diagnosis
• History
• Head up tilt test
Feeling a bit overwhelmed?
The next faller….
Guidelines for the prevention of Falls in Older persons consensus group JAGS 2001
Periodic case
finding in
primary care ask
all patients about
falls in last year
No falls
No problem
Recurrent
falls
Patient presents
to medical facility
after a fall
Single fall
Fall
Evaluation
Check for gait
and balance
problem
gait
and balance
problems
Fall
Evaluation
Assessment
Mutifactorial intervention
as appropriate
History
Gait, balance and exercise programs
Medications
Medication modification
Vision
Postural hypotension
Gait and balance
modification
Neurological
Environmental hazard modification
Cardiovascular
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.