Clinical Ageing and Health: Falls and Syncope

Background: Why Falls Matter?

  • Falls are the most common cause of accidents and associated morbidity in older adults.

  • 45\% of A&E attendances in those >65 years are associated with a fall.

  • 35\% of community-dwelling older adults >65 years will fall in any given year.

  • 24\% result in serious injury.

  • 10\% result in a fracture.

  • 5-10\% result in hospital admission.

  • Falls are estimated to cost the NHS more than £2.3 billion per year.

  • Even without injury, falls can cause: loss of confidence to perform ADLs, changes in health status, social isolation, increased hospitalisation and increased likelihood of nursing home admission.

Falls - Definition

  • Falls are defined as “An event, reported either by the faller or a witness, resulting in a person inadvertently coming to rest on the ground or another lower level, with or without loss of consciousness or injury” (Rubenstein 1990).

Syncope - Definition

  • Syncope is defined as “A transient loss of consciousness, characterised by unresponsiveness and loss of postural tone, with spontaneous recovery, not requiring specific resuscitation intervention” (Lipsitz 1983).

Overlap Between Falls and Syncope

  • Traditionally considered as separate syndromes with separate aetiology.

  • Rationale for overlap between falls and syncope:

    • Unreliability of history: 32\% of older adults with documented falls were unable to recall the event 3 months later (Cummings 1988).

    • Lack of witness account: Only 40-60\% of syncopal events are witnessed (McIntosh 1993).

    • Amnesia for loss of consciousness.

Falls Risk Factors

  • Intrinsic:

    • Lower limb muscle weakness

    • Gait and balance abnormalities

    • Visual impairment

    • Cognitive impairment

    • Neuro-cardiovascular abnormalities

  • Extrinsic:

    • Polypharmacy

    • Environmental hazards

    • Walking aids

  • Synergism of risk factors (consider modifiable vs. non-modifiable factors).

NICE Clinical Guidelines

  • NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales.

  • This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available.

  • Health care professionals are expected to take it fully into account when exercising their clinical judgement.

  • Expected publication 21 August 2024.

NICE Guidelines (2013)

  • Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and / or balance should be offered a multi-factorial falls risk assessment.

  • This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service.

  • This assessment should be part of an individualised multi-factorial intervention.

  • Multi-factorial assessment may include:

    • Identification of falls history

    • Assessment of gait, balance and mobility and muscle weakness

    • Assessment of osteoporosis risk

    • Assessment of older person’s perceived functional ability and fear of falling

    • Assessment of visual impairment

    • Assessment of cognitive impairment and neurological examination

    • Assessment of continence

    • Assessment of home hazards

    • Cardiovascular examination and medication review

Newcastle Integrated Falls Service

  • The Newcastle Integrated Falls Service (NIFS) integrates various services including:

    • Osteoporosis Services (Bone Clinic & Fracture Clinic)

    • Community Care Alarm Service

    • Social Services Team Leaders/Care Managers

    • Falls and Syncope Unit

    • CPNs

    • General Practitioners

    • Consultants/Medical Staff

    • Nurses in secondary care- including mental health

    • Physiotherapists

    • Occupational Therapists

    • North East Ambulance Service

    • District Nurses/ Health Visitors

    • Care Homes/Care Home Liaison Nurses

    • Practice Nurses

    • Nurse Practitioners

    • A&E/Minor Injuries Units/ Walk-in Centres

    • Rapid Response

    • Community Rehabilitation Service

    • District Nurse Liaison Service

    • Podiatry

    • Community Resource Teams (North, West and East)

    • Day Hospitals (Melville Day Unit & Belsay Day Unit)

Newcastle Falls Exercise ‘Continuum’

  • Falls Rehabilitation Group (Day Hospitals)

  • Preventative Exercise Group (Community)
    * Community-Based Activities
    * 1:1 Physiotherapy
    * 1:1 – Individualized
    * Group – Place of Safety/Social element
    * Community – non- medicalizing

Falls and Syncope Service

  • Regional MDT out-patient unit

  • Largest in Europe

  • See over 4,000 patients each year

  • Mainly (but not exclusively) older adults

  • MDT – medical (geriatricians), nursing, physiotherapy, occupational therapy staff and admin support

Case Study 1

  • 84-year-old lady

  • Referred via GP

  • Longstanding history of falls

  • Previously seen by day hospital

  • 3 recent falls in 2 months

  • ? drop attacks (difficult to diagnose) – sudden fall not associated with perceptible loss of consciousness

History

  • Seen by medical staff:

    • 1 x fall with probable LOC – walking along pavement, woke up on floor, no prodrome (warning signs), no particular symptoms afterwards, no witness account, sustained laceration to forehead

    • 2 x falls in home associated with looking upwards, turning in bed and bending down to floor, denies LOC / vertigo / dizziness

    • Falls can present differently.

Management Plan

  • 24 hour ECG / BP

  • Echo ?structural abnormalities

  • R –Test (ECG event recorder – infrequent events)

  • Tilt table testing

    • Reproducing symptoms under controlled and safe conditions

    • HR (increases) and BP (falls) monitored - ?any symptoms

    • Tilted to standing position

  • FASS physiotherapist – gait and balance. See: STARS (starstloc.org)

Medical Intervention

  • Echo – normal LV systolic function with no significant valve problems

  • HUT – syncope with brief prodrome

    • Vasovagal syncope (most common cause) – conservative advice

  • Await results of 24 hour ECG / BP

  • ? Reduce Amlodipine (calcium channel blocker)

Physiotherapy

  • Right benign paroxysmal positional vertigo (BPPV ) (?secondary to minor HI) – treated successfully with Epley manoeuvre

  • Reasonable balance

  • Cautious gait and reduced outdoor mobility due to fear of falling

  • Stick vs. delta

  • Referral to Staying Steady community exercise programme

Case Study 2

  • 80-year-old lady

  • Referred by Consultant Physician/Geriatrician at Hexham General Hospital

  • 2 syncopal episodes

  • Past medical history includes COPD, previous bowel cancer with hemi -colectomy and right upper lobe resection for lung cancer

History

  • Seen by medical staff:

    • First episode – Coming out of kitchen into living room, felt dizzy and lightheaded as if she was going to faint. Reached out for settee, but ended up on floor. Did not lose consciousness completely. Shouted for husband who said she was semi-conscious and it took a couple of minutes before she was back to her usual self

    • Second episode – Putting dishes away in kitchen. Husband heard noise of dishes breaking and arrived to find her on the floor. No warning, woken by voice of husband. Ambulance called – sent to Cramlington Hospital

Management Plan

  • Head Up Tilt +/- carotid sinus massage (CSM)

  • DEXA scan ?osteoporosis

  • Echocardiogram

  • Referral to FASS Physiotherapist (underlying multi-factorial gait and balance disorder)

Medical Intervention

  • CSM – negative

  • HUT – different type of dizziness in association with hypotension. As BP remained low despite lack of symptom reproduction, discontinued test (“is this like the symptoms you usually get?” False positive?)

  • Echocardiogram – normal left ventricular function, mild mitral regurgitation

  • Plan for 3 week R-test (external loop recorder)

    • Progress to REVEAL (implantable loop recorder) See Syncope toolkit: Investigations (rcgp.org.uk)

  • DEXA – evidence of osteoporosis with T-score of -3.2 at left neck of femur (NOF). Commenced on alendronic acid once weekly plus calcium and vit D via GP

Physiotherapy

  • Mobilises with stick

  • Impaired balance – bilateral proximal lower limb muscle weakness and evidence of right ankle weakness / instability

  • Issued home exercise programme – lower limb strengthening exercises

Summary

  • Causes of falls and syncope in older adults are many

  • Prevalence is high

  • Falls and syncope overlap

  • Falls and syncope are associated with high morbidity and mortality

  • A good history and targeted investigation yield good results

  • Multi-disciplinary assessment and intervention is essential to successful patient management