Slips, Trips, Falls ''and syncope

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Slips, Trips, Falls..and syncope
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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 AE in England
  because of an accident (DTI 1997, OLoughlin
  1993)
• One third of those aged over 50 yrs age attending
  Newcastles AE 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 dont seek help or dont get
  further assessed.

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Falls why bother

• Intervention reduces falls and fractures
• First indication of undetected illness that is
  easy to treat

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It is a miracle we dont fall more
often! Bipedality makes humans inherently
unstable. Wed be better as a tortoise!
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Maintaining an upright position
Vision Central processing Vestibular
function Muscle strength Joints
Sensation Proprioception
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Changes with age

• Postural sway increases (Dheshi 2001)
• Muscle strength decreases
• Reaction times slower
• Vision
• Acuity, contrast, depth perception
• Disease

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What happened when you last fell?
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Consequences that make older adults different
from young adults

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

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Consequences of falling

• Hypothermia
• pressure related injury
• Reduced mobility leading to social isolation and
  depression
• Increased dependency and disability

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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
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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,
  OLoughlin 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)

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Aims of Falls assessment

• To prevent further falls
• To prevent serious injury - especially fracture

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Causes of falling are multifactorial, rarely one
cause non accidental fallers attending AE, gt50
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

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Identifiable risk factors

• 400
• Female
• Age
• Previous fall

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Risk factors for falling

• Intrinsic
• Muscle weakness
• Impaired balance
• Impaired gait
• Transfer skills
• PD, CVA, Degenerative joint disease
• Impaired cognition
• Depression
• Polypharmacy
• gt 4 drugs, sedatives, hypotensive drugs
• Postural hypotension
• Visual impairment

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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

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Multiple intervention strategies

• Proven success in diverse groups
• Community based prevention studies in those with
  1 or more risk factors (Tinetti 94 Campbell AA
  1999 )
• In residential care after fall (Rubenstein 1990)
• AE attendees (Close 99)
• Cognitively impaired fallers attending AE (Shaw)
• No studies reported yet on specifically altering
  the fear load

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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)

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Intervention strategies

• INTERVENTION
• Resistance training
• Training, assistive devices
• Training, environment
• Training, grab rails

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

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Intervention strategies

• RISK FACTOR
• gt4 prescribed drugs
• Sedative use

• INTERVENTION
• Review
• Educate, withdraw

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Intervention strategies

• INTERVENTION
• Give Advice
• Handrails
• Remove items
• Secure rugs/carpets
• New shoes

• RISK FACTOR
• Environmental hazards
• Footwear

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Intervention strategies

• INTERVENTION
• Glasses, cataracts
• minimise
• treat

• RISK FACTOR
• Visual impairment
• Cognitive impairment
• Depression

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Intervention strategies

• INTERVENTION

• RISK FACTOR
• Postural hypotension
• Carotid sinus syndrome
• Vasovagal syncope

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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)

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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

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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

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Why do Syncope and falls overlap

• syncope amnesia
• cognitive impairment
• cerebral hypoperfusion results in gait and
  balance disturbance

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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)

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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

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What is Carotid sinus hypersensitivity?

• Defined as
• gt 3secs asystole (cardioinhibitory) /or
• gt50mmHg 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

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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

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Case History Two Carotid Sinus Massage, Right
Supine
baseline 133/49
69/24mmHg
5.2s
5.2 secs of asystole with brief LOC 64mmHg
vasodepression no awareness to LOC
Onset of CSM
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Contraindications to CSM

• 12000 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

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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

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Orthostatic hypotension definition?

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

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Dont 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

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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
• Dont strain at stool Sit to wee.
• Cognaisance of precipitating factors
• Graduated compression stockings/tights
• Abdominal binders

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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

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Vasovagal syncope

• Diagnosis
• History
• Head up tilt test

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Feeling a bit overwhelmed?The next faller.
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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
Check for gait and balance problem
Single fall
Fall Evaluation
Patient presents to medical facility after a
fall
gait and balance problems
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Fall Evaluation
Mutifactorial intervention as appropriate Gait,
balance and exercise programs Medication
modification Postural hypotension modification Env
ironmental hazard modification Cardiovascular
disorder treatment
Assessment History Medications Vision Gait and
balance Neurological Cardiovascular
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Crucial resourcesNSF For older people DOH
website/by postGuidelines for the prevention of
Falls in Older persons JAGS 200149 supplement
No 5.