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


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


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 …


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


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

Vestibularsuppressants

Laxatives


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


Laxatives


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



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


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



Schlick C, J of Vestibular Research 2015


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)



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



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

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


Take Home Messages

Do notforget

Falls in dementia

Thank you for your attention

Falls in the elderly - gimsi.it

Documents

Transcript of Falls in the elderly - gimsi.it