Professional Documents
Culture Documents
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
Bipedality makes
humans inherently
unstable.
We’d be better as a
tortoise!
Maintaining an upright position
Vision
Central processing
Vestibular function
Sensation Proprioception
Changes with age
• 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
Vicious circle
Falls - the size of the problem
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
• Depression • treat
Intervention strategies
RISK FACTOR INTERVENTION
• Postural hypotension
• 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
• 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
baseline 69/24mmHg
133/49
5.2s
• 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.
• History
• Head up tilt test
Feeling a bit overwhelmed?
Periodic case
finding in
No falls
primary care ask
all patients about
falls in last year
No problem
Mutifactorial intervention
Assessment
as appropriate