Falls in the elderly - gimsi.it
Transcript of Falls in the elderly - gimsi.it
Falls in the elderly
DoloMeeting ArrhythmiasInternational Workshop
Bolzano, February 20th-21st, 2020
Giulia Rivasi, MD Hypertension Clinic, Syncope Unit
Department of GeriatricsAOU Careggi, University of Florence
In the community …▪ 28–35% incidence/year in subjects ≥65 year ▪ 40%/year in subjects ≥80 ▪ 15% of older people falls at least twice
In the hospital …▪ 2% of hospitalized patients ▪ 25% injurious falls
In long-term care settings …▪ 30–50%/year, with 40% falling recurrently▪ 10% severely injurious falls
Patients with dementia 60% annual incidence
Way, NEJM 1997; Masud , Age Ageing 2001; WHO Global report 2007; Lelaurin, Clin Geriatr Med 2019
Falls in the elderly… a common concern
Falls in the elderly
Prognosis
Tinetti ME, NEJM 2003; Khow K, Clin Geriatr Med 2017
Mortality
Early admission to long term
care facilities
Emergency department visits
Fear of fallingActivity restriction
DeconditioningHealth care costs
Functional decline and dependencyMobility
Impairment
Hip fractureDisability
InstitutionalizationMortality
Social isolationDepression
AnxietyLow quality of life
Major Injuries Fractures Hospitalization
Accidental falls(Accidental causes like slipping or tripping)
Falls associated with medical conditions(gait and balance disorders, neurological diseases,
cardiovascular diseases, …)
Falls in people with dementia(occurring in patients with moderate to severe dementia)
Unexplained falls (15-40%)
(non-accidental falls, where no apparent cause has been found)
Masud T, Age Ageing, 2001
Mussi C ,Curr Gerontol Geriatr Res, 2013
Falls in the elderly
Classification
“… I found myself suddenly on
the ground …”
FallsVision deficits
BalanceImpairment
Gaitdisorders
Sarcopenia
Advancedage
Dementia
Malnutrion
Hypotension
Poli-pharmacy
DisabilityHospitalization MortalityInstitutionalization
Mossello E, in Manuale di Geriatria, 2019
A multifactorial phenomenon
1. Multifactorial
diagnostic
assessment
2. Individual’s
risk profile
3. Individualized
multifactorial
interventions
… to define …
… to provide …
Falls in the elderly
A multifactorial syndrome
Neurocardiovascular instability
Multifactorial diagnostic assessment
Neurocardiovascular Instability
NeuroCardioVascular Instability (NCVI)
Abnormal neural control of the CV system characterized by age-related changes in blood pressure and heart-rate behaviour,
predominantly resulting in hypotension and bradyarrhythmias. Clinically, NCVI manifests as fatigue, falls, presyncope and syncope.
Balance instability due to cerebral hypoperfusion
Syncope with retrograde amnesia
FALLS
SYNDROME DIAGNOSIS
Orthostatic Hypotension Fall in systolic BP ≥ 20 mmHg or to a level <90 mm Hg,
or a fall in diastolic BP ≥10 mmHg within 3 minutes of
standing
Post-prandial Hypotension Fall in supine systolic BP ≥20 mmHg or more during or
within 2 hours after meals
Carotid sinus Syndrome Syncope during carotid sinus massage associated with
asystole >3 s and/or a fall in systolic BP >50mmHg
Vasovagal syncope Syncope associated with typical predisposing
situations and prodrome
NeuroCardioVascular Instability syndromes
Multifactorial diagnostic assessment
Neurocardiovascular Instability
Prevalence of postprandialhypotension in geriatric falls clinic
N=95 participants (mean age 77.5) undergoing a standardized meal test during
beat-to-beat BP monitoringPostprandial hypotension prevalence assessed with
different time windows length
42.1% prevalence with BP measurements at 10 min intervals
Postprandial hypotension
prevalence ranging from 81% to 11%according to the frequency of BP measurements
Madden KM, Clin Invest Med 2019
N=298 subjects with unexplained falls N=989 subjects with unexplained syncope
Diagnosis achieved after the neuroautonomic evaluation
✓ 64% of patients with unexplained syncope
✓ 61 % of patients with unexplained falls
Brignole M, Eur Heart J 2018
Jansen S, Age &Ageing 2015
cross-sectional studyN= 8173 individuals aged 50+, mean age
14
Low risk, arrhythmia likely & recurrent
episodes
Not indicated
If negative
Syncope T-LOCnon-syncopal
Unconfirmedepilepsy
Unexplained falls
Low risk &rare episodes
High risk, arrhythmia likely
In-hospitalmonitoring
(Class I)
ILR(Class I)
Low risk, reflex likely & need for specific
therapy
ELR(Class IIa)
Holter(Class IIa)
ILR(Class I)
ILR(Class IIa)
ILR(Class IIb)
Certain diagnosis/mechanism
Treat appropriately
T-LOC suspected syncope
Uncertain diagnosis/mechanism
1. Multifactorial
diagnostic
assessment
2. Individual’s
risk profile
3. Individualized
multifactorial
interventions
… to define …
… to provide …
Medications
Falls in the elderly
A multifactorial syndrome
Falls
Vestibularsuppressants
Laxatives
Multifactorial diagnostic assessment
Medications
Beta-blockers
Hypoglycemic
agents
BDZs
Opioids
Nitrates
Calcium
Antagonists
Levo Dopa
Anti
psychotics
Alpha-blockers
Antidepressants
Diuretics
Huang AR and Hill K, Drugs Aging 2012
Falls
Diuretics
Vestibularsuppressants
Laxatives
Multifactorial diagnostic assessment
Medications
Beta-blockers
Hypoglycemic
agents
BDZs
Opioids
Nitrates
Calcium
Antagonists
Levo Dopa
Anti
psychotics
Alpha-blockers
Antidepressants
Huang AR and Hill K, Drugs Aging 2012
Falls
Diuretics
Vestibularsuppressants
Multifactorial diagnostic assessment
Medications
Beta-blockers
Hypoglycemic
drugs
BDZs
Opioids
Nitrates
Calcium
Antagonists
Levo Dopa
Anti
psychotics
Alpha-blockers
Antidepressants
Laxatives
Huang AR, Drugs Aging 2012; Machado Duque, Int Psychogeriatrics 2017
Multifactorial diagnostic assessment
Medications
Multifactorial Interventions
Medication Review
Decision tree formanagement
Of fall-risk-increasingdrugs
(FRIDs)
1. Multifactorial
diagnostic
assessment
2. Individual’s
risk profile
3. Individualized
multifactorial
interventions
… to define …
… to provide …
Vestibular disorders
Falls in the elderly
A multifactorial syndrome
Schlick C, J of Vestibular Research 2015
Multifactorial diagnostic assessment
Vestibular Disorders
Frequency of falls in vertigo and balance disordersData from a German centre
Single fallers
Frequent fallers (> 5 falls in the past year)
Recurrent fallers (>1 falls in the past year)
Multifactorial diagnostic assessment
Vestibular Disorders
Severity of falls in vertigo and balance disordersData from a German centre
Fallers requiring hospital admission
Near-fallers
Fallers requiring no medical attention
Fallers requiring medical attention
Schlick C, J of Vestibular Research 2015
Epley repositioning procedure
Balance exercise and vestibular rehabilitation
Dix-Halpike diagnostic maneuvre
Benign paroxysmal positional vertigo
Multifactorial diagnostic assessment
Vestibular Disorders
Gait disorders
Postural instability
Poor coordination
Reduced attention
Psychomotor slowing
Prolonged reaction times
Sensory impairment
Neurological and cerebrovascular diseases
Behavioral symptoms
“… more than enough for accidental falling …”
… or AGEISM?
Falls in Patients with Dementia
Ungar A, Aging Clin Exp Res 2015
Ungar A, Aging Clin Exp Res 2015
Freidenberg DL, Cogn Behav Neurol 2013
Signs and symptoms of
Orthostatic Hypotension
in Dementia
N=188 patients with dementia51% prevalence of orthostatic hypotension
Pa
tie
nts
with
De
me
ntia
Syncope
Unexplained falls
Syncopal Falls
Clinical features
suggesting a …
syncopal fall
• Neurovegetative
prodrome
• Alpha-blockers
• Trigger situations
… NON syncopal fall
• Insulin
• Benzodiazepines
• Severe dementiaMossello E , Eur J Intern Med 2018
Non syncopalfalls
Mossello E , Eur J Intern Med 2018
Syncopal Fall Score in Dementia
Score 4+ predicted of syncopal falls
sensitivity 82%, specificity 56%
✓Falls are common in older people and have a negative prognostic impact
✓A multifactorial approach is essential for diagnosis, treatment and prevention
✓Neurocardiovascular Instability✓Medications
✓Vestibular disorders
✓Orthostatic hypotension is a common cause of falling in dementia
✓A diagnostic assessment of falls is feasible
Falls in the elderly
Take Home Messages
Do notforget
Falls in dementia
Thank you for your attention