Falls and Syncope in the Elderly

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Falls and Syncope in the Elderly

• Lewis A. Lipsitz, MD
• Hebrew Rehabilitation Center for Aged,
• Beth Israel Deaconess Hospital,
• Harvard Medical School,
• Boston, MA

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Falls Epidemiology

• Common 30 of community-dwelling elderly, 50 of
  NH residents fall each year.
• High morbidity, mortality, service use
• Multiple causes risk factors
• Potentially preventable

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Common Risk Factors for FallsResults of 16
Studies
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Common Risk Factors for Falls-2Results of 16
Studies
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Disease Related Risk Factors

• Perceptual deficits
• Cataracts
• Hearing loss
• Peripheral neuropathy
• Vestibular disease

• Orthopedic
• Arthritis
• Orthopedic injury
• Spinal stenosis

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Disease Related Risk Factors (Contd)

• Cardiovascular
• Arrhythmia
• Valvular disease
• Postural hypotension
• Postprandial hypotn.
• Carotid Sinus Syndrome

• Neuromuscular
• Stroke
• Myopathy
• Parkinsons Ds.
• Hydrocephalus
• Peripheral Neuropathy

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Disease Related Risk Factors (Contd)

• Drugs and alcohol
• Diuretics
• Antihypertensives
• Sedatives
• Anticholinergic medications
• Remember to ask about alcohol!

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Environmental Hazards

• Poor lighting
• Slippery floors
• Loose rugs, electrical cords
• Moveable furniture
• Stairs
• Poor fitting shoes

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Syncope Another Cause of Falls

• Transient loss of consciousness, characterized by
  sudden loss of postural tone and spontaneous
  recovery.
• Due primarily to a transient global reduction in
  cerebral blood flow.

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Epidemiology of Syncope

• Prevalence up to 47 in healthy young
• 23 10-year prevalence in frail elders.
• 6-33 1-year mortality in pts. over 60.
• Up to 40 of cases remain unex-plained, despite
  extensive evaluations.

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Etiology of Syncope in the NH

• Diseases No. of Patients
• Myocardial Infarction 6
• Aortic Stenosis 5
• Dehydration 4
• Seizure Disorder 3
• Cerebrovascular Event 3
• Cardiac Ischemia 3
• Tachy-Brady Syndrome 3

Lipsitz, LA, J Chronic Ds, 1986 39619
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Etiology of Syncope - 2

• Diseases No. of Patients
• Acute respiratory failure 2
• Cervical Spondylosis 1
• Sinus arrest 1
• Paroxysmal atrial tachycardia 1
• Carotid sinus syndrome 1
• Heart block 1

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Etiology of Syncope - 3

• Situational Stresses No. of Patients
• Drug-induced hypotension 11
• Postprandial hypotension 8
• Defecation/colostomy irrigation 7
• Orthostatic hypotension 6
• Fecal impaction 3
• Vomiting 1
• Micturition 1
• Bending over 1

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Etiology of Syncope - 4

• Unknown No. of Patients
• No identifiable precipitants 17
• Unexplained hypotension 8

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Abnormalities in BP Regulation

• Reduced baroreflex sensitivity
• Decreased cerebral blood flow
• Greater renal excretion of salt and water
• Decreased diastolic filling

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190
SUP
STD
BREAK
STD/AMB
STG
STD
AMB
MED
LUNCH
STD
170
150
SBP (mm Hg)
old
130
young
110
90
9
7
8
10
11
12
1
Time (hours)
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Elderly patients are at risk of hypotension
during common daily activities.
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Evaluation of the Faller History DDROPP

• Diseases
• Drugs
• Recovery
• Onset
• Prodrome
• Precipitants

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Evaluation of the Faller Physical Exam

• Postural vital signs
• Carotid bruits and upstroke
• Murmurs of AS, MR, or HCM
• Stool hemoccult
• Neurologic exam sensation, motor, reflexes,
  cerebellar
• Observe activities associated with the fall

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Get Up and Go Test

• 1. Chair stand get up from chair without
  using hands
• 2. Romberg eyes open and closed, then sternal
  push
• 3. 20 foot walk
• 4. 360 degree turn

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Gait Observations

• Shuffle Parkinsons
• Petit-pas frontal/CVD
• Hemiparetic stroke
• Ataxic cerebellar

• Antalgic arthritic
• Spastic Cerv. Spond.
• Foot Drop Peroneal
• Sensory Neuropathy

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Laboratory Studies

• CBC, electrolytes, BUN/creatinine, glucose
• Drug levels where appropriate
• Syncope or cardiac sx EKG
• Suspected arrhythmia event monitor, CSM, EPS
• Focal neuro. abnormalities EEG, MRI or CT
• Suspicious systolic murmur cardiac echo
• Selected patients audiogram, neck films, ENT
  referral

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Interventions to Prevent Falls
Risk Ratio
Significant Factor from 40 RCTs

• Muscle Strengthening Balance Training 0.80
• Tai Chi Chuan 0.51
• Home Hazard Assessment Modification 0.64
• Withdrawal of Psychotropic Medications 0.34
• Multidisciplinary, Multifactorial 0.75
• Home/Environment Risk Screening/Intervention

Cochran Database of Systematic Reviews, 2002,
Issue 3