![Page 1: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/1.jpg)
Slips, Trips, Falls
…..and syncope
![Page 2: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/2.jpg)
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.
![Page 3: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/3.jpg)
Falls why bother
• Intervention reduces falls and fractures
• First indication of undetected illness that is easy to treat
![Page 4: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/4.jpg)
It is a miracle we don’t fall more often!
Bipedality makes humans inherently unstable.
We’d be better as a tortoise!
![Page 5: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/5.jpg)
Maintaining an upright positionVision
Central processingVestibular function
Muscle strength Joints
Sensation Proprioception
![Page 6: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/6.jpg)
Changes with age
• Postural sway increases (Dheshi 2001)• Muscle strength decreases• Reaction times slower• Vision
– Acuity, contrast, depth perception
• Disease
![Page 7: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/7.jpg)
What happened when you last fell?
![Page 8: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/8.jpg)
Consequences that make older adults different from young
adults
• Risk of fracture increases– less force needed– muscle padding– bone density
Loss of confidence
![Page 9: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/9.jpg)
Consequences of falling
• Hypothermia
• pressure related injury
• Reduced mobility leading to social isolation and depression
• Increased dependency and disability
![Page 10: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/10.jpg)
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
![Page 11: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/11.jpg)
•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)
Falls - the size of the problem
![Page 12: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/12.jpg)
Aims of Falls assessment
• To prevent further falls
• To prevent serious injury - especially fracture
![Page 13: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/13.jpg)
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
![Page 14: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/14.jpg)
Identifiable risk factors
400– Female– Age– Previous fall
![Page 15: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/15.jpg)
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
![Page 16: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/16.jpg)
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
![Page 17: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/17.jpg)
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’
![Page 18: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/18.jpg)
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)
![Page 19: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/19.jpg)
Intervention strategies RISK FACTOR
• Muscle weakness• Impaired balance• Impaired gait• Transfer skills
INTERVENTION
• Resistance training• Training, assistive
devices• Training, environment• Training, grab rails
![Page 20: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/20.jpg)
Intervention strategies RISK FACTOR
• >4 prescribed drugs
• Sedative use
INTERVENTION
• Review
• Educate, withdraw
![Page 21: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/21.jpg)
Intervention strategies
RISK FACTOR
• Environmental hazards
• Footwear
INTERVENTION
• Give Advice• Handrails• Remove items• Secure rugs/carpets
• New shoes
![Page 22: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/22.jpg)
Intervention strategies RISK FACTOR
• Visual impairment
• Cognitive impairment
• Depression
INTERVENTION
• Glasses, cataracts
• minimise
• treat
![Page 23: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/23.jpg)
Intervention strategies RISK FACTOR
• Postural hypotension
• Carotid sinus syndrome
• Vasovagal syncope
INTERVENTION
![Page 24: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/24.jpg)
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)
![Page 25: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/25.jpg)
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
![Page 26: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/26.jpg)
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
![Page 27: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/27.jpg)
Why do Syncope and falls overlap
• syncope amnesia
• cognitive impairment
• cerebral hypoperfusion results in gait and balance disturbance
![Page 28: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/28.jpg)
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)
![Page 29: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/29.jpg)
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
![Page 30: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/30.jpg)
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
![Page 31: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/31.jpg)
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
![Page 32: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/32.jpg)
Onset of CSM
5.2 secs of asystole with brief LOC64mmHg vasodepressionno awareness to LOC
baseline133/49
Case History Two Carotid Sinus Massage, Right Supine
5.2s
69/24mmHg
![Page 33: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/33.jpg)
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
![Page 34: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/34.jpg)
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
![Page 35: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/35.jpg)
Orthostatic hypotension definition?
• 20mmHg fall in systolic blood pressure OR 10mmHg fall in diastolic blood pressure within 2 minutes of standing
![Page 36: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/36.jpg)
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%
![Page 37: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/37.jpg)
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
![Page 38: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/38.jpg)
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
![Page 39: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/39.jpg)
Vasovagal syncope
Diagnosis
• History
• Head up tilt test
![Page 40: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/40.jpg)
Feeling a bit overwhelmed?
The next faller….
![Page 41: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/41.jpg)
Periodic case finding in
primary care ask all patients about falls in last year
No falls
Single fallRecurrent falls
Check for gait and balance
problem
Patient presents to medical facility
after a fall
No problem
gait and balance
problems
FallEvaluation
Guidelines for the prevention of Falls in Older persons consensus group JAGS 2001
![Page 42: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/42.jpg)
FallEvaluation
Assessment
History
Medications
Vision
Gait and balance
Neurological
Cardiovascular
Mutifactorial interventionas appropriate
Gait, balance and exercise programs
Medication modification
Postural hypotension
modification
Environmental hazard modification
Cardiovascular disorder treatment
![Page 43: 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%](https://reader035.vdocuments.us/reader035/viewer/2022062511/5516129e550346d46f8b62e2/html5/thumbnails/43.jpg)
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.