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Gallagher E, Mehmood M, Lavan A, Kenny RA, Briggs R. Psychotropic medication use and future unexplained and injurious falls and fracture amongst community-dwelling older people: data from TILDA. Eur Geriatr Med 2023:10.1007/s41999-023-00786-x. [PMID: 37157012 DOI: 10.1007/s41999-023-00786-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/13/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE Psychotropic medications (antidepressants, anticholinergics, benzodiazepines, 'Z'-drugs and antipsychotics) are frequently identified as Falls Risk Increasing Drugs. The aim of this study is to clarify the association of psychotropic medication use with future falls/fracture amongst community-dwelling older people. METHODS Participants ≥ 65 years from TILDA were included and followed from Waves 1 to 5 (8-year follow-up). Incidence of falls (total falls/unexplained/injurious) and fracture was by self-report; unexplained falls were falls not caused by a slip/trip, with no apparent cause. Poisson regression models reporting incidence rate ratios (IRR) assessed the association between medications and future falls/fracture, adjusted for relevant covariates. RESULTS Of 2809 participants (mean age 73 years), 15% were taking ≥ 1 psychotropic medication. During follow-up, over half of participants fell, with 1/3 reporting injurious falls, over 1/5 reporting unexplained falls and almost 1/5 reporting fracture. Psychotropic medications were independently associated with falls [IRR 1.15 (95% CI 1.00-1.31)] and unexplained falls [IRR 1.46 (95% CI 1.20-1.78)]. Taking ≥ 2 psychotropic medications was further associated with future fracture (IRR 1.47 (95% CI 1.06-2.05)]. Antidepressants were independently associated with falls [IRR 1.20 (1.00-1.42)] and unexplained falls [IRR 2.12 (95% CI 1.69-2.65)]. Anticholinergics were associated with unexplained falls [IRR 1.53 (95% CI 1.14-2.05)]. 'Z'-drug and benzodiazepine use were not associated with falls or fractures. CONCLUSION Psychotropic medications, particularly antidepressants and anticholinergic medications, are independently associated with falls and fractures. Regular review of ongoing need for these medications should therefore be central to the comprehensive geriatric assessment.
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Affiliation(s)
- Eleanor Gallagher
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Mustafa Mehmood
- Department of Emergency Medicine, St James's Hospital, Dublin, Ireland
| | - Amanda Lavan
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Rose Anne Kenny
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Robert Briggs
- Mercer's Institute of Successful Ageing, St James's Hospital, Dublin, Ireland.
- Discipline of Medical Gerontology, Trinity College Dublin, Dublin, Ireland.
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland.
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Savelieva I, Fumagalli S, Kenny RA, Anker S, Benetos A, Boriani G, Bunch J, Dagres N, Dubner S, Fauchier L, Ferrucci L, Israel C, Kamel H, Lane DA, Lip GYH, Marchionni N, Obel I, Okumura K, Olshansky B, Potpara T, Stiles MK, Tamargo J, Ungar A. EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2023; 25:1249-1276. [PMID: 37061780 PMCID: PMC10105859 DOI: 10.1093/europace/euac123] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 04/17/2023] Open
Abstract
There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.
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Affiliation(s)
- Irina Savelieva
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
| | - Rose Anne Kenny
- Mercer’s Institute for Successful Ageing, Department of Medical Gerontology, St James’s Hospital, Dublin, Ireland
| | - Stefan Anker
- Department of Cardiology (CVK), Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Germany
- German Centre for Cardiovascular Research (DZHK) partner site Berlin, Germany
- Charité Universitätsmedizin Berlin, Germany
| | - Athanase Benetos
- Department of Geriatric Medicine CHRU de Nancy and INSERM U1116, Université de Lorraine, Nancy, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jared Bunch
- (HRS representative): Intermountain Medical Center, Cardiology Department, Salt Lake City,Utah, USA
- Stanford University, Department of Internal Medicine, Palo Alto, CA, USA
| | - Nikolaos Dagres
- Heart Center Leipzig, Department of Electrophysiology, Leipzig, Germany
| | - Sergio Dubner
- (LAHRS representative): Clinica Suizo Argentina, Cardiology Department, Buenos Aires Capital Federal, Argentina
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, General Cardiology Division, University of Florence and AOU Careggi, Florence, Italy
| | - Israel Obel
- (CASSA representative): Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Ken Okumura
- (APHRS representative): Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa CityIowa, USA
- Covenant Hospital, Waterloo, Iowa, USA
- Mercy Hospital Mason City, Iowa, USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Serbia
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Martin K Stiles
- (APHRS representative): Waikato Clinical School, University of Auckland and Waikato Hospital, Hamilton, New Zealand
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, CIBERCV, Universidad Complutense, Madrid, Spain
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
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3
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Magnavita N, Di Prinzio RR, Arnesano G, Cerrina A, Gabriele M, Garbarino S, Gasbarri M, Iuliano A, Labella M, Matera C, Mauro I, Barbic F. Association of Occupational Distress and Low Sleep Quality with Syncope, Presyncope, and Falls in Workers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312283. [PMID: 34886008 PMCID: PMC8657064 DOI: 10.3390/ijerph182312283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/18/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022]
Abstract
Syncope and presyncope episodes that occur during work could affect one's safety and impair occupational performance. Few data are available regarding the prevalence of these events among workers. The possible role of sleep quality, mental stress, and metabolic disorders in promoting syncope, presyncope, and falls in workers is unknown. In the present study, 741 workers (male 35.4%; mean age 47 ± 11 years), employed at different companies, underwent clinical evaluation and blood tests, and completed questionnaires to assess sleep quality, occupational distress, and mental disorders. The occurrence of syncope, presyncope, and unexplained falls during working life was assessed via an ad hoc interview. The prevalence of syncope, presyncope, and falls of unknown origin was 13.9%, 27.0%, and 10.3%, respectively. The occurrence of syncope was associated with an increased risk of occupational distress (adjusted odds ratio aOR: 1.62, confidence intervals at 95%: 1.05-2.52), low sleep quality (aOR: 1.79 CI 95%: 1.16-2.77), and poor mental health (aOR: 2.43 CI 95%: 1.52-3.87). Presyncope was strongly associated with occupational distress (aOR: 1.77 CI 95%: 1.25-2.49), low sleep quality (aOR: 2.95 CI 95%: 2.08-4.18), and poor mental health (aOR: 2.61 CI 95%: 1.78-3.84), while no significant relationship was found between syncope or presyncope and metabolic syndrome. These results suggest that occupational health promotion interventions aimed at improving sleep quality, reducing stressors, and increasing worker resilience might reduce syncope and presyncope events in the working population.
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Affiliation(s)
- Nicola Magnavita
- Postgraduate School of Occupational Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.R.D.P.); (G.A.); (S.G.); (A.I.); (I.M.); (F.B.)
- Department of Woman, Child & Public Health Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Local Sanitary Unit Roma4, 00053 Civitavecchia, Italy; (A.C.); (M.G.); (M.G.); (M.L.); (C.M.)
- Correspondence: ; Tel.: +39-3473300367
| | - Reparata Rosa Di Prinzio
- Postgraduate School of Occupational Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.R.D.P.); (G.A.); (S.G.); (A.I.); (I.M.); (F.B.)
| | - Gabriele Arnesano
- Postgraduate School of Occupational Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.R.D.P.); (G.A.); (S.G.); (A.I.); (I.M.); (F.B.)
| | - Anna Cerrina
- Local Sanitary Unit Roma4, 00053 Civitavecchia, Italy; (A.C.); (M.G.); (M.G.); (M.L.); (C.M.)
| | - Maddalena Gabriele
- Local Sanitary Unit Roma4, 00053 Civitavecchia, Italy; (A.C.); (M.G.); (M.G.); (M.L.); (C.M.)
| | - Sergio Garbarino
- Postgraduate School of Occupational Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.R.D.P.); (G.A.); (S.G.); (A.I.); (I.M.); (F.B.)
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal-Infantile Sciences (DINOGMI), 16132 Genoa, Italy
| | - Martina Gasbarri
- Local Sanitary Unit Roma4, 00053 Civitavecchia, Italy; (A.C.); (M.G.); (M.G.); (M.L.); (C.M.)
| | - Angela Iuliano
- Postgraduate School of Occupational Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.R.D.P.); (G.A.); (S.G.); (A.I.); (I.M.); (F.B.)
| | - Marcella Labella
- Local Sanitary Unit Roma4, 00053 Civitavecchia, Italy; (A.C.); (M.G.); (M.G.); (M.L.); (C.M.)
| | - Carmela Matera
- Local Sanitary Unit Roma4, 00053 Civitavecchia, Italy; (A.C.); (M.G.); (M.G.); (M.L.); (C.M.)
| | - Igor Mauro
- Postgraduate School of Occupational Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.R.D.P.); (G.A.); (S.G.); (A.I.); (I.M.); (F.B.)
| | - Franca Barbic
- Postgraduate School of Occupational Health, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.R.D.P.); (G.A.); (S.G.); (A.I.); (I.M.); (F.B.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
- Internal Medicine, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
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Kim SH, Higuchi M, Ishigami Y, Makishi G, Tada M, Hibino S, Gottlieb M, Lee S. Five Key Papers About Emergency Department Fall Evaluation: A Curated Collection for Emergency Physicians. Cureus 2021; 13:e17717. [PMID: 34650891 PMCID: PMC8489554 DOI: 10.7759/cureus.17717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2021] [Indexed: 11/24/2022] Open
Abstract
The evaluation of patients who have experienced a fall has been an integral part of geriatric emergency care. All physicians who engage in the care of the geriatric population in acute settings need to familiarize themselves with the current literature on this topic. However, it can be challenging to navigate the large body of literature on this topic. The purpose of this article is to identify and summarize the key studies that can be helpful for faculty interested in an evidence-based fall evaluation. The authors compiled a list of key papers on emergency department (ED) based upon a structured literature search supplemented with suggestions by key informants and an open call on social media; 32 studies on ED evaluation were identified. Our authorship group then engaged in a modified Delphi technique to develop consensus on the most important studies about fall evaluation for emergency physicians. This process eventually resulted in the selection of the top five articles on fall evaluation. Additionally, we summarize these studies with regard to their relevance to emergency medicine (EM) trainees and junior faculty. Evaluation of older patients with a history of falls is a challenging but crucial component of EM training. We believe our review will be educational for junior and senior EM faculty to better understand these patients' care and to design an evidence-based practice.
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Affiliation(s)
- Sung-Ho Kim
- Emergency Medicine, Rinku General Hospital, Osaka, JPN.,Trauma and Critical Care, Senshu Trauma and Critical Care Center, Osaka, JPN
| | - Masaya Higuchi
- Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, USA
| | | | - Go Makishi
- Emergency Medicine, Seirei Mikatahara General Hospital, Shizuoka, JPN
| | - Masafumi Tada
- Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, JPN.,Neurology-Emergency Medicine, Nagoya City University East Medical Center, Nagoya, JPN
| | - Seikei Hibino
- Emergency Medicine, University of Minnesota, Minneapolis, USA
| | - Michael Gottlieb
- Emergency Medicine, Rush University Medical Center, Chicago, USA
| | - Sangil Lee
- Emergency Medicine, University of Iowa Carver College of Medicine, Iowa, USA
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5
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Johansson M, Rogmark C, Sutton R, Fedorowski A, Hamrefors V. Risk of incident fractures in individuals hospitalised due to unexplained syncope and orthostatic hypotension. BMC Med 2021; 19:188. [PMID: 34446019 PMCID: PMC8394111 DOI: 10.1186/s12916-021-02065-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 07/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Impaired orthostatic blood pressure response and syncope confer a high risk of falls and trauma. The relationship between a history of unexplained syncope and orthostatic hypotension (OH) with subsequent fractures, however, has not been thoroughly examined. In this study, we aimed to investigate the relationship between previous hospital admissions due to unexplained syncope and OH and incident fractures in a middle-aged population. METHODS We analysed a large population-based prospective cohort of 30,399 middle-aged individuals (age, 57.5 ± 7.6; women, 60.2%). We included individuals hospitalised due to unexplained syncope or OH as the main diagnosis. Multivariable-adjusted Cox regression analysis was applied to assess the impact of unexplained syncope and OH hospitalisations on subsequent incident fractures. RESULTS During a follow-up period of 17.8 + 6.5 years, 8201 (27%) subjects suffered incident fractures. The mean time from baseline and first admission for syncope (n = 493) or OH (n = 406) was 12.6 ± 4.2 years, and the mean age of the first hospitalisation was 74.6 ± 7.4 years. Individuals with incident fractures were older, more likely to be women, and had lower BMI, higher prevalence of prevalent fractures, and family history of fractures. Multivariable-adjusted Cox regression showed an increased risk of incident fractures following hospitalisations due to unexplained syncope (HR 1.20; 95% CI 1.02-1.40; p = 0.025) and OH (HR 1.42; 95% CI 1.21-1.66; p < 0.001) compared with unaffected individuals. CONCLUSIONS Individuals hospitalised due to unexplained syncope and orthostatic hypotension have an increased risk of subsequent fractures. Our findings suggest that such individuals should be clinically assessed for their syncope aetiology, with preventative measures aimed at fall and fracture risk assessment and management.
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Affiliation(s)
- Madeleine Johansson
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden. .,Department of Cardiology, Skåne University Hospital, Malmö, Sweden.
| | - Cecilia Rogmark
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden.,Department of Orthopaedics, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Richard Sutton
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,National Heart and Lung Institute, Imperial College, Hammersmith Hospital Campus, London, UK
| | - Artur Fedorowski
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences, Clinical Research Center, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
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The Dilemma of Falls in Older Persons: Never Forget to Investigate the Syncope. ACTA ACUST UNITED AC 2021; 57:medicina57060623. [PMID: 34203693 PMCID: PMC8232203 DOI: 10.3390/medicina57060623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/07/2021] [Accepted: 06/11/2021] [Indexed: 11/16/2022]
Abstract
Background and objectives: Falls represent a major cause of morbidity, hospitalizations, and mortality in older persons. The identification of risk conditions for falling is crucial. This study investigated the presence of syncope as a possible cause of falls in older persons admitted to a Sub-Acute Care Unit (SACU) with a diagnosis of accidental fall after initial management in an emergency department and acute hospitalization. Materials and methods: A retrospective monocentric study of patients aged ≥65 years, consecutively admitted to a SACU with a diagnosis of fall-related trauma. All patients underwent a complete assessment of the index event and clinical status. Patients were categorized into three groups according to the identified cause of falls: (1) transient loss of consciousness (T-LOC), (2) unexplained fall (UF), and (3) definite accidental fall (AF). Results: A total of 100 patients were evaluated. T-LOC was present in 36 patients, UF in 37, and AF in 27. Of the 36 patients with T-LOC, a probable origin was identified in most cases (n = 33, 91%), 19 subjects (53%) had orthostatic hypotension, 9 (25%) a cardiac relevant disturbance, 2 (6%) a reproduced vaso-vagal syncope, 2 (6%) severe anemia, and 1 (3%) severe hypothyroidism. The T-LOC group was older and more clinically complex than the other groups. Conclusion: In older patients who recently experienced a fall event, the prevalence of syncope is relevant. In frail and clinically complex patients with falls, the identification of the underlying cause is pivotal and can be achieved through prolonged monitoring and a comprehensive assessment of the person.
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Fitzgibbon-Collins LK, Heckman GA, Bains I, Noguchi M, McIlroy WE, Hughson RL. Older Adults' Drop in Cerebral Oxygenation on Standing Correlates With Postural Instability and May Improve With Sitting Prior to Standing. J Gerontol A Biol Sci Med Sci 2021; 76:1124-1133. [PMID: 32766776 DOI: 10.1093/gerona/glaa194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Impaired blood pressure (BP) recovery with orthostatic hypotension on standing occurs in 20% of older adults. Low BP is associated with low cerebral blood flow but mechanistic links to postural instability and falls are not established. We investigated whether posture-related reductions in cerebral tissue oxygenation (tSO2) in older adults impaired stability upon standing, if a brief sit before standing improved tSO2 and stability, and if Low-tSO2 predicted future falls. METHOD Seventy-seven older adults (87 ± 7 years) completed (i) supine-stand, (ii) supine-sit-stand, and (iii) sit-stand transitions with continuous measurements of tSO2 (near-infrared spectroscopy). Total path length (TPL) of the center of pressure sway quantified stability. K-cluster analysis grouped participants into High-tSO2 (n = 62) and Low-tSO2 (n = 15). Fall history was followed up for 6 months. RESULTS Change in tSO2 during supine-stand was associated with increased TPL (R = -.356, p = .001). When separated into groups and across all transitions, the Low-tSO2 group had significantly lower tSO2 (all p < .01) and poorer postural stability (p < .04) through 3 minutes of standing compared to the High-tSO2 group. There were no effects of transition type on tSO2 or TPL for the High-tSO2 group, but a 10-second sitting pause improved tSO2 and enhanced postural stability in the Low-tSO2 group (all p < .05). During 6-month follow-up, the Low-tSO2 group had a trend (p < .1) for increased fall risk. CONCLUSIONS This is the first study to show an association between posture-related cerebral hypoperfusion and quantitatively assessed instability. Importantly, we found differences among older adults suggesting those with lower tSO2 and greater instability might be at increased risk of a future fall.
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Affiliation(s)
- Laura K Fitzgibbon-Collins
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
- Department of Kinesiology, University of Waterloo, Ontario, Canada
| | - George A Heckman
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
| | - Ikdip Bains
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
| | - Mamiko Noguchi
- Department of Kinesiology, University of Waterloo, Ontario, Canada
| | | | - Richard L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, Ontario, Canada
- Department of Kinesiology, University of Waterloo, Ontario, Canada
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8
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Blomaard LC, Mooijaart SP, van Meer LJ, Leander J, Lucke JA, de Gelder J, Anten S, Gussekloo J, de Groot B. Geriatric screening, fall characteristics and 3- and 12 months adverse outcomes in older patients visiting the emergency department with a fall. Scand J Trauma Resusc Emerg Med 2021; 29:43. [PMID: 33663559 PMCID: PMC7934471 DOI: 10.1186/s13049-021-00859-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls in older Emergency Department (ED) patients may indicate underlying frailty. Geriatric follow-up might help improve outcomes in addition to managing the direct cause and consequence of the fall. We aimed to study whether fall characteristics and the result of geriatric screening in the ED are independently related to adverse outcomes in older patients with fall-related ED visits. METHODS This was a secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study, of which a subset of patients aged ≥70 years with fall-related ED visits were prospectively included in EDs of two Dutch hospitals. Fall characteristics (cause and location) were retrospectively collected. The APOP-screener was used as a geriatric screening tool. The outcome was 3- and 12-months functional decline and mortality. We assessed to what extent fall characteristics and the geriatric screening result were independent predictors of the outcome, using multivariable logistic regression analysis. RESULTS We included 393 patients (median age 80 (IQR 76-86) years) of whom 23.0% were high risk according to screening. The cause of the fall was extrinsic (49.6%), intrinsic (29.3%), unexplained (6.4%) or missing (14.8%). A high risk geriatric screening result was related to increased risk of adverse outcomes (3-months adjusted odds ratio (AOR) 2.27 (1.29-3.98), 12-months AOR 2.20 (1.25-3.89)). Independent of geriatric screening result, an intrinsic cause of the fall increased the risk of 3-months adverse outcomes (AOR 1.92 (1.13-3.26)) and a fall indoors increased the risk of 3-months (AOR 2.14 (1.22-3.74)) and 12-months adverse outcomes (AOR 1.78 (1.03-3.10)). CONCLUSIONS A high risk geriatric screening result and fall characteristics were both independently associated with adverse outcomes in older ED patients, suggesting that information on both should be evaluated to guide follow-up geriatric assessment and interventions in clinical care.
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Affiliation(s)
- Laura C Blomaard
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Simon P Mooijaart
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Institute of Evidence-Based Medicine in Old Age | IEMO, Leiden, The Netherlands
| | - Leonie J van Meer
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Julia Leander
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Jacinta A Lucke
- Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Jelle de Gelder
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Sander Anten
- Department of Internal Medicine, section Acute Care, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, section Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Jusmanova K, Rice C, Bourke R, Lavan A, McMahon CG, Cunningham C, Kenny RA, Briggs R. Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness. QJM 2021; 114:32-38. [PMID: 32866245 DOI: 10.1093/qjmed/hcaa261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/22/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission. AIM To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness. DESIGN Pre- and post-cohort study. METHODS Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS). RESULTS There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P < 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4-24.0] days compared to 18.2 (95% CI 14.6-21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030). CONCLUSION This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.
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Affiliation(s)
- K Jusmanova
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - C Rice
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - R Bourke
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - A Lavan
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
| | - C G McMahon
- Department of Emergency Medicine, St James's Hospital, Dublin 8, Ireland
| | - C Cunningham
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - R A Kenny
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
| | - R Briggs
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin 8, Ireland
- Department of Medical Gerontology, Trinity College Dublin, Dublin 1, Ireland
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10
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Doundoulakis I, Gatzoulis KA, Arsenos P, Dilaveris P, Skiadas I, Tsiachris D, Antoniou C, Soulaidopoulos S, Karystinos G, Pylarinou V, Drakopoulou M, Sideris S, Vlachopoulos C, Tousoulis D. Permanent pacemaker implantation in unexplained syncope patients with borderline sinus bradycardia and electrophysiology study-proven sinus node disease. J Arrhythm 2021; 37:189-195. [PMID: 33664902 PMCID: PMC7896452 DOI: 10.1002/joa3.12460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/22/2020] [Accepted: 10/25/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Significant sinus bradycardia (SB) in the context of sinus node dysfunction (SND) has been associated with neurological symptoms. The objective was to evaluate the effect of permanent pacing on the incidence of syncope in patients with rather mild degrees of SB, unexplained syncope, and "positive" invasive electrophysiologic testing. METHODS This was an observational study based on a prospective registry of 122 consecutive mild SB patients (61.90 ± 18.28 years, 61.5% male, 57.88 ± 7.73 bpm) presenting with recurrent unexplained pre and syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. Eighty patients received the ABP, while 42 denied. RESULTS The mean of reported syncope episodes was 2.23 ± 1.29 (or presyncope 2.36 ± 1.20) in the last 12 months before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (50.39 ± 32.40 months), the primary outcome event (syncope) occurred in 18 of 122 patients (14.8%), 6 of 80 (7.5%) in the ABP group as compared to 12 of 42 (28.6%) in the no pacemaker group (P = .002). CONCLUSIONS Among patients with mild degree of SB and a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined SND after differentiating reflex syncope, identifies a subset of patients who will benefit from permanent pacing.
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Affiliation(s)
- Ioannis Doundoulakis
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Konstantinos A. Gatzoulis
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Petros Arsenos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Polychronis Dilaveris
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Ioannis Skiadas
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | | | | | - Stergios Soulaidopoulos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - George Karystinos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Voula Pylarinou
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Maria Drakopoulou
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Skevos Sideris
- State Department of Cardiology“Hippokration” HospitalAthensGreece
| | - Charalambos Vlachopoulos
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
| | - Dimitrios Tousoulis
- First Department of CardiologyNational and Kapodistrian University“Hippokration” HospitalAthensGreece
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11
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Zuj KA, Hedge ET, Milligan JD, Peterson SD, Hughson RL. Intermittent compression of the calf muscle as a countermeasure to protect blood pressure and brain blood flow in upright posture in older adults. Eur J Appl Physiol 2021; 121:839-848. [PMID: 33386985 DOI: 10.1007/s00421-020-04547-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE Orthostatic hypotension, leading to cerebral hypoperfusion, can result in postural instability and falls in older adults. We determined the efficacy of a novel, intermittent pneumatic compression system, applying pressure around the lower legs, as a countermeasure against orthostatic stress in older adults. METHODS Data were collected from 13 adults (4 male) over 65 years of age. Non-invasive ultrasound measured middle cerebral artery blood velocity (MCAv) and finger photoplethysmography measured mean arterial blood pressure (MAP). Intermittent lower leg compression was applied in a peristaltic manner in the local diastolic phase of each cardiac cycle to optimize venous return during 1-min of seated rest and during a sit-to-stand transition to 1-min of quiet standing with compression initiated 15 s before transition. RESULTS During seated rest, compression resulted in a 4.5 ± 6.5 mmHg increase in MAP, and 2.3 ± 2.1 cm/s increase in MCAv (p < 0.05). MAP and MCAv increased during the 15 s of applied compression before the posture transition (2.3 ± 7.2 mmHg and 2.1 ± 4.0 cm/s, respectively, p < 0.05) with main effects for both variables confirming continued benefit during the transition and quiet stand periods. CONCLUSIONS Application of carefully timed, intermittent compression to the lower legs of older adults increased MAP and MCAv during seated rest and maintained an elevated MAP and MCAv during a transition to standing posture. Future research could assess the benefits of this technology for persons at risk for orthostatic hypotension on standing and while walking in an effort to reduce injurious, unexplained falls in older adults.
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Affiliation(s)
- K A Zuj
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.,Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada
| | - E T Hedge
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.,Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada
| | - J D Milligan
- Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada.,Centre for Family Medicine, Kitchener, ON, Canada
| | - S D Peterson
- Department of Mechanical Engineering, University of Waterloo, Waterloo, ON, Canada
| | - R L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, 250 Laurelwood Dr., Waterloo, ON, N2J 0E2, Canada.
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12
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Wood KN, Greaves DK, Hughson RL. Interrelationships between pulse arrival time and arterial blood pressure during postural transitions before and after spaceflight. J Appl Physiol (1985) 2019; 127:1050-1057. [PMID: 31414954 DOI: 10.1152/japplphysiol.00317.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We tested the hypothesis that acute changes in arterial blood pressure (BP) when astronauts moved between supine and standing posture before and after spaceflight can be tracked by beat-to-beat changes in pulse arrival time (PAT). Nine male crewmembers (45 ± 7 yr of age; mean mission length: 165 ± 13 days) participated in a standardized supine-to-sit-to-stand test (5 min-30 s-3 min) before flight and 1 day following return to Earth with continuous monitoring of ECG and finger arterial BP. PAT was determined from the R-wave of the ECG to the foot of the BP waveform. On average, modest cardiovascular deconditioning was detected by ~10 beats/min increase in heart rate in supine and standing posture after spaceflight (P < 0.05). When looking across the full data collection period, the r2 values between inverse of PAT (1/PAT) and systolic (SBP) and diastolic BP (DBP) varied considerably between individuals (SBP preflight 0.142 ± 0.186, postflight 0.262 ± 0.243). Individual variability was consistent during periods of transition (SBP preflight 0.284 ± 0.324, postflight 0.297 ± 0.269); however, when SBP dropped >20 mmHg, r2 was significant in 5 of 5 preflight tests and 5 of 7 postflight tests. The standard error of the estimate based on a simple linear model during both pre- and postflight testing was 9-11 mmHg for SBP and 6-7 mmHg for DBP. Overall, the results support the hypothesis that PAT tracked dynamic changes in BP. PAT as a noninvasive, nonintrusive surrogate for changes in BP could be developed as an indicator of risk for syncope on return from spaceflight or other Earth-based applications.NEW & NOTEWORTHY Astronauts returning to Earth's gravity are at increased risk of low blood pressure on standing. Arterial pulse arrival time tracked the decrease in arterial blood pressure on moving from supine to upright posture. Nonintrusive technology providing indicators sensitive to acute changes in blood pressure could act as an early warning system to identify risk for hypotension that place astronauts, or people on Earth, at risk of impaired cognitive performance, fainting, and falls.
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Affiliation(s)
- Katelyn N Wood
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
| | - Danielle K Greaves
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
| | - Richard L Hughson
- Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
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13
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Sakhi R, Theuns DAMJ, Szili-Torok T, Yap SC. Insertable cardiac monitors: current indications and devices. Expert Rev Med Devices 2018; 16:45-55. [PMID: 30522350 DOI: 10.1080/17434440.2018.1557046] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Recurrent unexplained syncope is a well-established indication for an insertable cardiac monitor (ICM). Recently, the indications for an ICM have been expanded. AREAS COVERED This review article discusses the current indications for ICMs and gives an overview of the latest generation of commercially available ICMs. EXPERT COMMENTARY The 2018 ESC Syncope guidelines have expanded the indications for an ICM to patients with inherited cardiomyopathy, inherited channelopathy, suspected unproven epilepsy, and unexplained falls. ICMs are also increasingly used for the detection of subclinical atrial fibrillation (AF) in patients with cryptogenic stroke. Whether treatment of subclinical AF (SCAF) with oral anticoagulation prevents recurrent stroke is yet unknown. The current generation of ICMs are smaller, easier to implant, have better diagnostics, and are capable of remote monitoring. The Reveal LINQ (Medtronic) is the smallest ICM and has the most extensive performance and clinical data. The BioMonitor 2 (Biotronik) is the largest ICM but has excellent R-wave amplitudes, longest longevity, and reliable remote monitoring. The Confirm Rx (Abbott) is capable to provide mobile data transmission enabled by a smartphone app. Future generation of ICMs will incorporate heart failures indices to facilitate remote monitoring of heart failure patients.
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Affiliation(s)
- Rafi Sakhi
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Dominic A M J Theuns
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Tamas Szili-Torok
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Sing-Chien Yap
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
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14
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Characteristics and outcomes of older adults presented to Spanish emergency departments after a fall. Eur Geriatr Med 2018; 9:631-640. [PMID: 34654232 DOI: 10.1007/s41999-018-0103-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To study patient profile, fall-related characteristics and immediate outcomes according to age and to determine the effect of age in the outcomes among older patients presenting to ED after a fall. METHODS Cross-sectional analysis of the FALL-ER registry that included patients aged ≥ 65 years old that presented to five Spanish EDs after a fall. Patients were classified into three age categories, and demographic, comorbidity, chronic medication, fall-related characteristics, health care resources and immediate outcomes data were analysed. RESULTS We included 1610 patients, 541 (28%) aged 65-74, 647 (40.2%) aged 74-84 and 512 (31.8%) aged ≥ 85 years old. Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. Medications related to risk of falling and antithrombotic therapy significantly increased with age category. Physical, functional and psychological consequences and healthcare resource use increased significantly with age group. Age was independently associated with severe injury (adjusted OR 1.02; IC 95% 1.01-1.04), fear of falling (adjusted OR 1.02; IC 95% 1.01-1.04) and acute functional impairment (adjusted OR 1.02; IC 95% 1.00-1.04). CONCLUSIONS Indoor falls, with no witnesses, at night and due to non-identified causes were significantly more likely among the oldest old. The probability of presenting with severe injury, fear of falling and acute functional impairment increases with age.
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