Investigation & Management of Falls & Syncope

Dr Asso Fariadoon Ali Amin MRCP(UK)

GIM/ Care of Elderly physician

Falls are common presentation to a GP surgery, accident and emergency, orthopaedic and medical admission units.

Mechanical or accidental falls refer to a fall secondary to slipping or tripping over something. Mechanical falls among Elderly above the age of 65 admitted to hospital are uncommon and recurrent falls should never be considered accidental. Older people often fall as a result of medical condition , many of which can be treated.

Definition:- of fall is unintentionally coming to rest on the ground or some lower level and other than a consequences of sustaining a violent blow, loss of consciousness, or sudden onset of paralysis as in stroke or epilepsy.

Very common in elderly, 1/3 of elderly above the age of 65 living in their own homes fall each year. ½ of these falls occurs during doing normal daily activity with no environmental factors. The incidence of fall is higher among those living in institutions , around half of care home residents who are mobile falls each year.

Falls in the Elderly

Injury:- 40-60% of falls lead to injury, 40-50% are minor injuries, 5-6% are major (excluding fracture) and 5% fracture.

Hospital admission:- admission due to falls are six times higher in older people above the age of 65.

Psychological:- 1/3 of those age over 60 years develop a fear of falling loss of confidence Post fall anxiety self imposed functional limitation Social isolation Depression. Disability Long Lie:- defined as remaining on the floor for more than 1 hour. Which can result in:- Pressure sore Hypothermia Orthostatic pneumonia Rhabdomyolysis Dehydration Increase mortality , 50% of those remain on the floor for 1 or more hour are dead within 6

months- 1 year. Institutionalisation

Consequences of Falls

Falls due to acute illness:- Infection:- mainly bronchopneumonia or UTI Vascular:- Myocardial infarction or Cererbrovascular accident Metabolic:- hypoglycaemia, hyponatremia

Single fall which may be accidental Recurrent falls

Categories of fall

Social and demographic factors:- Advanced age Living alone Previous falls Limited activity of daily living Age related changes reduced ability to discriminate edges. ( e.g. Stairs) , reduced peripheral sensation, slower reaction time muscle weakness Poor gait and balance Medical problem:- e.g. Parkinson's disease, cognitive impairment, CVA,

Poor vision ( cataract and glaucoma) , foot problems, arthritis, peripheral neuropathy, incontinence

Medication:- antihypertensive, antipsychotic, sedative, opiates, diuretic, hypoglycaemic specially long acting oral drugs and insulin

Environmental :- Ill fitting footwear or wearing bifocal spectacles

Risk factors for falls

NSF – identifying those at risk

Intrinsic Risk Factors• Balance, gait or mobility

problems• Taking four or more

medications – especially sedating drugs, anti-hypertensives, anti-depressants, diuretics, anti-anginals, Digoxin

• Visual impairment• Impaired cognition or

depression• Postural hypotension, Carotid

Sinus Hypersensitivity, Vasovagal tendency

• Fear of falling

Extrinsic Risk Factors• Poor lighting –particularly

on the stairs• Steep Stairs• Loose carpets & rugs• Slippery floors• Badly fitting footwear or

clothing• Lack of grab rails or raised

seating • Inaccessible lights or

windows

History of the fall in details , review of system, and medication review. Examination of :- the injuries Vital signs including respiratory rate Conjunctivae for severe anaemia Chest, abdomen, CVS, neurological examination Blood pressure lying and standing Cognitive function Functional assessment – get up and go test. Test- investigation:- FBC, Urea and Electrolyte, CRP, glucose, CXR, ECG.

Assessment of Acute fall

Acute Fall

1•Fall presenting to acute medical service

2

•History•Medication • Examination•Lying and standing BP•Get-up-and go test• Investigation

3

• Acute Medical condition e.g. Serious injury or pneumonia ?

yes

Admit to treat and consider

MFA

Can mobilise

no YesOP

NSF – who should be referred to a specialist falls service?

Those who have had a previous or new fragility fracture

Those who attend A&E having fallen Those who have called out an ambulance

having fallen Those who have two or more intrinsic risk

factors in the context of a fall Those who have frequent unexplained falls Those who fall in a care home Those who live in unsafe housing Those who are very afraid of falling

History taking (splatt) Symptoms:- dizziness, vertigo, chest pain, palpitation, speech problem Previous fall:- is this the first fall secondary to acute illness or recurrent

secondary to mobility problem or cognitive function. Location:- outdoor or indoor ( outdoor has a better prognosis than the ones at

home) Activity:- walking, hanging out washing, standing on a chair, standing from

sitting Time:- after meal, early in the morning. Trauma:- sustained? Medication review Cognitive function assessment ( AMT) Functional assessment ( get up and go test) Vision assessment ( cataract-acuity, visual field) Hearing CVS examination Blood Pressure Lying and standing * Investigation:- FBC, Urea and electrolyte, LFT, TFT, CRP, Urine , ECG, Further test:- CXR, ECHO, 12 Hour ECG, Holter , Tilt Test, CT-scan brain.

Single and Recurrent fall assessment

Drugs associated with falls Works either directly or may lead to systemic hypotension

and cerebral hypo perfusion. Poly pharmacy is an independent risk factor.

Benzodiazepines Tricyclic antideprresant Skeletal muscle relaxant like baclofen Opiate Diuretic Antihypertensives specilly ACE I and alpha blockers Hypoglycaemic

Syncope:- sudden, transient loss of consciousness, due to reduced cerebral perfusion. The patient is unresponsive with loss of control.

Pre-syncope:- feeling of light-headiness tat would lead to syncope, if corrective measures were not taken ( usually sitting, lying or hanging)

It is a major cause of morbidity in elderly population occurs in ½ of institutionalized patients. Account for 5% of hospital admission.

Causes:- Vasovagal :- vagal stimulation for example in fears and bad news Postural hypotension:- main causes dehydration, septicaemia, medication,

autonomic in Diabetes and addison’s disease. Carotid sinus hypersensitivity Cardiovascular :- arrythmia and outlet obstruction e.g. Aortic stenosis. Neurology:- TIA and stroke.

Syncope and pre-syncope

ORTHOSTATIC HYPOTENSION Common condition Most marked after meal, high

temperature, exercise, and at night. Reduction in systolic BP of 20mmHg on

standing Reduction in systolic BP to less than

90mmHg on standing Reduction in diastolic BP of 10mmHg with symptoms

ORTHOSTATIC HYPOTENSIONCauses

Drugs Dehydration Septicemia Prolonged hypertension Autonomic failure (pure, diabetic,

parkinsons) Adrenal insufficiency

ORTHOSTATIC HYPOTENSION - THERAPY

Lifestyle measures Stop offending drugs Compression hosiery Sympathomimetic vasoconstrictors -

Midodrine, 2.5 mg tds (max 40mg daily) CI in IHD

Caffeine with meal or NSAID Head up-tilt to bed Erythropoietin or octreotide Volume expansion - Fludrocortisone, DDAVP

VASOVAGAL SYNCOPE -MECHANISM

Upright posture, downward displacement of blood & venous pooling leading to:

Decreased ventricular filling & cardiac mechanoreceptor activation leading to:

Increased brainstem input & reduced sympathetic outflow & increased vagal tone

Resulting in vasodilatation & bradycardia syncope

CAROTID SINUS HYPERSENSITIVITY

2% in healthy individual, and 35% of fallers above the age of 80 years.

Mechanism Typical triggers are:- neck turning( looking up or around),

tight collars, straining, meal, prolonged standing. How to perform CSM

CAROTID SINUS HYPERSENSITIVITY

Carotid sinus massage for 5 seconds:

Cardio inhibitory: 3 second or more period of asystole

Vasodepressor: a 50mmHg fall in systolic blood pressure

Mixed response

CSH - THERAPY

Cardio-inhibitory: permanent pacing

Vasodepressor: very difficult to treat, consider those therapies used for orthostatic hypotension

Dizziness

Full history ?dizziness, ?vertigo, Pre-syncope, mixed, unsteadiness, malaise or generalised weakness

Causes • Acute lybranthitis • Menieres disease• BPV• Causes of syncope and pre-syncope • Post Circulation infarction• Vertebrobasilar insufficiency • Anxiety and depression Multifactorial •

PATIENT ASSESSMENT FOR SYNCOPE

HISTORY Situation in which syncope occurred Posture at time Preceding symptoms Actual loss of consciousness Subsequent symptoms Eye witness account Co-morbidity Drug history

EXAMINATION

Heart rate / rhythm Postural BP Carotid bruits Carotid sinus massage Presence of murmurs Neurology: evidence of stroke, cerebellar

signs, Parkinson’s Disease

INVESTIGATIONS

Baseline bloods : anaemia, renal dysfunction, diabetes

12 lead ECG Holter monitoring Tilt testing : 80’ head up tilt for 45 minutes

+/- GTN provocation. CSM supine & 80’ head up tilt

Tilt Table Testing

Advise patient to avoid caffeine, large meals & alcohol prior to test

Omit cardiac drugs prior to test

Consent for the procedure

Lie flat on tilt table for 15 minutes

CSM Supine

Tilt for 30 minutes

If no events – carry out CSM when tilted

If no events – administer 2 puffs GTN sublingually & monitor for a further 15-20 minutes depending on response

Life Example

66 lady from India, diabetic on metformin, presented with history of recurrent falls in the last 6 months. She also complained of generally feeling weak, tired, lost 7kg in the last 3 months with nausea and vomiting in the morning . O/E Bp Lying 130/80 Standing 100/60

76 years old , history of recurrent fall, with historyOf hypertension on amlodipine, and osteoarthritis ofBoth knees. Last fall happened while searching for a book in his library . O/E BP L/S normal , bilateralKnee swelling, X-ray neck severe OA (previous film)

Life Examples

74 man , hypertensive on amlodipine ,and amiloride, and lisinopril also has history of bilateral knee OA with left sided TKR. Recently visited a surgeon for symptoms of BPH , started on Doxazocin 4mg . Presented with feeling light headed , dizzy, and followed by blackout and then fall.

77 old man , history of parkinson disease , presented with recurrent falls associated with feeling dizzy on standing up ,BP (L) 140/90 (S) 110/70

The End