Falls in the elderly.

Diagnostic and therapeutic approach

Stylianos Tzeis MD, PhD, FESC
Henry Dunant Hospital, Athens, Greece

FALLS IN THE ELDERLY

Each year, more than one third of persons over

the age of 65 fall.

In half of such cases falls are recurrent
One in 10 falls results in serious injury.
Falls are responsible for two-thirds of the deaths
resulting from unintentional injuries.

Major health
and socioeconomic problem

ESC Guidelines for the diagnosis

and management of syncope 2009

Falls

Syncope

Syncope Definition
Transient loss of consciousness
due to transient global cerebral hypoperfusion
characterized by rapid onset, short duration,
and spontaneous complete recovery.

Differentiating syncopal from non-syncopal causes of fall

Yes

Loss of consciousness ?

Syncopal
Not clear

No

Non-syncopal

Limiting factors
Difficulties in history-taking (cognitive impairment )
Amnesia for loss of consciousness
Syncopal episodes or falls are unwitnessed in 40%-60% of older people.
Gait and balance instability
Modest haemodynamic changes Insufficient to cause loss of

consciousness BUT sufficient to cause loss of balance

1st level
All elderly patients

General fall
evaluation

2nd level
Loss of consciousness
No plausible explanation
for the mechanism of fall

Detailed
cardiovascular
assessment

1st level
All elderly patients

General fall
evaluation

Evaluation of gait (Get up and Go test)

Evaluation of balance (One-legged stand test)

Assessment of cognitive status (mini-mental state score)

Assessment of vision (Snellen chart)

History and physical examination

2nd level
Loss of consciousness
No plausible explanation

for the mechanism of fall

Detailed
cardiovascular
assessment

Detailed history
Physical examination
12-lead electrocardiography
Lying and standing blood pressure

Detailed history
1. Fall associated with loss of consciousness ?
2. Symptoms prior to fall
Nausea, blurred vision, and sweating are or Dyspnea
3. Fall immediately after change of posture ?
4. Fall related to specific activities (micturition, coughing, defecation)?
5. History of heart disease
6. Past medical history (diabetes, features of Parkinsonism)
7. Drugs (antihypertensives, antidepressants, antiarrhythmics,
vasodilators, eye drops, anticholinergic, hypoglycemics, neuroleptics..)

Physical examination
Signs of underlying structural heart disease

Supine and standing blood pressure measurement

12-lead electrocardiography
Abnormal ECG findings suggest arrhythmic (cardiac) syncope

ESC Guidelines for management of syncope 2009

Diagnosis
ECG
Supine and
standing BP
measurement

Physical
examination

Detailed
history

Cardiovascular syncope
if syncopal fall presents in
patients with severe AS

Vasovagal syncope if syncopal fall

is precipitated by emotional distress
or orthostatic stress and is
associated with typical prodromal
symptoms
Situational syncope if syncopal fall
occurs during or immediately after
specific triggers

Orthostatic syncope
if fall/syncope is
occuring after standing
up and there is
documentation of OH

Arrhythmia related syncope if

Sinus bradycardia < 40 bpm
Repetitive sinoatrial block
Sinus pauses > 3 sec
Mobitz II 2nd or 3rd degree AVB
Alternating RBBB and LBBB
VT or rapid paroxysmal SVT
Long or short QT interval and
non-sustained polymorphic VT
Pacemaker or ICD malfunction
with cardiac pauses
Evidence of acute ischemia

Carotid sinus massage

Lege artis test performance
5-10 sec pressure over maximal carotid pulsation

Right and then left-sided CSM in the supine position

Right and then left-sided CSM in the upright position
Continuous blood pressure and heart rate
monitoring preferably with the use of non-invasive
beat-to-beat blood pressure monitoring
Definition of CS hypersensitivity:
Asystole of 3 sec or more (cardioinhibitory)
Drop of 50 mmHg or more in SBP
(vasodepressor)
Or both (mixed)
With or without symptom reproduction

Aim: To determine the prevalence of

carotid sinus hypersensitivity using
standardized diagnostic criteria
In an unselected community sample of older people (> 65 ys), n=272

In a subsample with no history of syncope, dizziness, or falls, n=80

Kerr et al. Arch Intern Med 2006;166:515

Distribution of response (RR interval prolongation and SBP drop)

during CSM in the asymptomatic subgroup
95th percentile
RR interval: 7.277 sec
Systolic BP drop: 77 mmHg

Importance of symptom
reproduction
Redefinition of the traditional
cutoff level of 3 sec for
diagnosis of cardioinhibitory
CSH

Kerr et al. Arch Intern Med 2006;166:515

Is there a relationship between abnormal response to

CSM and syncope or falls ?

Comparison of the recurrence rate of

syncope before and after pacing

Analysis of the occurrence of

asystolic episodes among patients
with cardioinhibitory response to
CSM using an implanted device

Fewer recurrences during

follow-up among paced patients

Long pauses were very

common

The finding of cardioinhibitory response to CSM is predictive of

the occurrence of spontaneous asystolic episodes

Am J Cardiol. 1992 Apr 15;69(12):1039

Europace 2007;9:932936

Europace 2007;9:563567
Am J Cardiol 1993;72:11521155.

Main indication: demonstrate

susceptibility to reflex syncope

European Heart J (2009) 30, 26312671

Davison et al. Age and Ageing 2005; 34: 382386

Age and Ageing 2003; 32: 185

WHEN?

in older patients with non-accidental falls to establish the

syncopal nature of the event.

Where in the

workup?

Early

after initial
evaluation

In older people with little or no functional impairment, EPS is indicated for

unexplained falls and syncope when a cardiac arrhythmia is suspected.

Non
syncopal
fall

Prevention
of recurrences

Multifactorial

Syncopal
fall

Mortality Reduction
Prevention
of recurrences

Treatment tailored

intervention

to specific cause

NEJM 2003;348(1):43

Aim of the study: Evaluate withdrawal (discontinuation or dose reduction) of FRID was associated
with a decrease in fall risk in older fallers
Fall Risk Increasing Drugs
Anxiolytics/hypnotics

Total population = 139

Neuroleptics

Antidepressants

NO FRID withdrawal

Antihypertensives
Antiarrhythmics
Nitrates and other vasodilators
Digoxin
B-blocker eye drops
Analgesics (mainly opioid)
Anticholinergic
Antihistamines
Antivertigo drugs
Hypoglycemics
Br J Clin Pharmacol 2006; 63 :2 233

FRID withdrawal (n=75, 54%)

Orthostatic

hypotension

Cardiac pacing

Cardiac
arrhythmias

Catheter ablation

Antiarrhythmic drug therapy

Implantable cardioverter defibrillator
Europace 2009;11:671

Reflex

syncopal fall

JACC 2001;38:1491

175 older patients (> 50 ys) with a non-accidental fall with no evident cause apart from CICSH.

Randomization to rate drop response pacemaker or no pacing intervention

Primary outcome measure: number of falls during the year after randomization
Total number of falls was reduced over two thirds in pacemaker recipients
HOWEVER: NO placebo-controlled study

Heart 2009;95:405

34 patients (> 55 ys) with 3 falls in the last 6 months with CSH as the sole attributable cause.
DC pacemaker with rate drop response and crossover double blind randomization to pacing
ON (DDD) or off (ODO) for 6 months and then to alternate mode
Primary outcome measure: number of falls
Permanent pacing had NO effect on number of falls.
HOWEVER: Small number of patients completing the study

Heart 2010;96:347

141 patients with two unexplained falls and/or one syncopal event in the previous
12 months with no evident cause apart from CICSH.
Randomization to rate responsive pacemaker or ILR
Primary outcome measure: number of falls after implantation
No significant reduction in falls between paced and loop recorder groups
HOWEVER: Underpowered study - Patients older, less severe CSH, more frail

The role of pacing for reduction of FALLS among elderly

fallers with only cardioinhibitory carotid sinus

hypersensitivity has NOT yet been established.

 Falls are a common multifactorial problem in elderly people.

Clarification of transient loss of consciousness is pivotal

during history taking.

It is prudent to manage unclear episodes as syncopal falls.

Diagnostic approach should aim to clarify specific cause.

Front-line therapy mainly includes non-pharmacologic,

multifactorial interventions.
Treatment options are limited.

Cardiovascular causes of falls in elderly people

Limitations

Inaccurate classification in cases of patients with amnesia

Over one-third of older people have more than one attributable cause

Kurbaan AS, et al. J Am Coll Cardiol, 2003:41:1004