1. Slips, Trips, Falls …..and syncope

2. 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.

3. Falls why bother Intervention reduces falls and fractures
First indication of undetected illness that is easy to treat

4. It is a miracle we don’t fall more often!
Bipedality makes humans inherently unstable.
We’d be better as a tortoise!

5. Maintaining an upright position
Vision
Central processing
Vestibular function
Muscle strength Joints
Sensation Proprioception

6. Changes with age Postural sway increases (Dheshi 2001)
Muscle strength decreases
Reaction times slower
Vision
Acuity, contrast, depth perception
Disease

7. What happened when you last fell?

8. Consequences that make older adults different from young adults
Risk of fracture increases
less force needed
muscle padding
bone density
Loss of confidence

9. Consequences of falling
Hypothermia
pressure related injury
Reduced mobility leading to social isolation and depression
Increased dependency and disability

10. 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

11. 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)

12. Aims of Falls assessment
To prevent further falls
To prevent serious injury - especially fracture

13. 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

14. Identifiable risk factors
400
Female
Age
Previous fall

15. 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

16. 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

17. 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’

18. 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)

19. Intervention strategies
Resistance training
Training, assistive devices
Training, environment
Training, grab rails
RISK FACTOR
Muscle weakness
Impaired balance
Impaired gait
Transfer skills

20. Intervention strategies
RISK FACTOR
>4 prescribed drugs
Sedative use
INTERVENTION
Review
Educate, withdraw

21. Intervention strategies
Give Advice
Handrails
Remove items
Secure rugs/carpets
New shoes
RISK FACTOR
Environmental hazards
Footwear

22. Intervention strategies
Glasses, cataracts
minimise
treat
RISK FACTOR
Visual impairment
Cognitive impairment
Depression

23. Intervention strategies
RISK FACTOR
Postural hypotension
Carotid sinus syndrome
Vasovagal syncope

24. Bone protection Calcium and Vitamin D (Chapuy 92, 94,) Oestrogens
Other effects (Pfeifer 00)
Oestrogens
Raloxifene
Etidronate
Alendronate
Risedronate
Calcitonin
(RCPhys Lon & Bone and Teeth Soc of GB)

25. 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

26. 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

27. Why do Syncope and falls overlap
syncope amnesia
cognitive impairment
cerebral hypoperfusion results in gait and balance disturbance

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. Orthostatic hypotension definition?
20mmHg fall in systolic blood pressure OR 10mmHg fall in diastolic blood pressure within 2 minutes of standing

36. 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 %

37. 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

38. 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

39. Vasovagal syncope
Diagnosis
History
Head up tilt test

40. Feeling a bit overwhelmed? The next faller….

41. 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

42. Mutifactorial intervention as appropriate
Fall
Evaluation
Mutifactorial intervention
as appropriate
Gait, balance and exercise programs
Medication modification
Postural hypotension
modification
Environmental hazard modification
Cardiovascular disorder treatment
Assessment
History
Medications
Vision
Gait and balance
Neurological
Cardiovascular

43. 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.