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
– 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
INTERVENTION
RISK FACTOR

• Muscle weakness • Resistance training

• Impaired balance • Training, assistive
devices
• Impaired gait
• Training, environment
• Transfer skills
• Training, grab rails
 Intervention strategies
RISK FACTOR INTERVENTION

• >4 prescribed • Review

drugs
• Educate, withdraw
• Sedative use
 Intervention strategies
RISK FACTOR INTERVENTION

• Environmental hazards • Give Advice

• Handrails
• Remove items
• Secure rugs/carpets

• Footwear • New shoes

 Intervention strategies
INTERVENTION
RISK FACTOR

• Visual impairment • Glasses, cataracts

• Cognitive impairment • minimise

• Depression • treat
 Intervention strategies
RISK FACTOR INTERVENTION

• Postural hypotension

• Carotid sinus syndrome

• Vasovagal syncope
 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 69/24mmHg
133/49

5.2s

5.2 secs of asystole with brief LOC

Onset of CSM 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

• 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….

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

Periodic case
finding in
No falls
primary care ask
all patients about
falls in last year
No problem

Recurrent Check for gait

Single fall
falls and balance
problem

Patient presents gait

Fall
to medical facility and balance
Evaluation
after a fall problems
 Fall
Evaluation

Mutifactorial intervention
Assessment
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.