Drop attacks in older adults: systematic assessment has a high diagnostic yield

The impact of cardiovascular diagnostics and treatments on fall risk in older adults: a scoping review and evidence map

BACKGROUND

We aimed to summarize the published evidence on the fall risk reducing potential of cardiovascular diagnostics and treatments in older adults.

METHODS

Design: scoping review and evidence map.

DATA SOURCES

Medline and Embase.

ELIGIBILITY CRITERIA

all available published evidence; Key search concepts: "older adults," "cardiovascular evaluation," "cardiovascular intervention," and "falls." Studies reporting on fall risk reducing effect of the diagnostic/treatment were included in the evidence map. Studies that investigated cardiovascular diagnostics or treatments within the context of falls, but without reporting a fall-related outcome, were included in the scoping review for qualitative synthesis.

RESULTS

Two articles on cardiovascular diagnostics and eight articles on cardiovascular treatments were included in the evidence map. Six out of ten studies concerned pacemaker intervention of which one meta-analyses that included randomized controlled trials with contradictory results. A combined cardiovascular assessment/evaluation (one study) and pharmacotherapy in orthostatic hypotension (one study) showed fall reducing potential. The scoping review contained 40 articles on cardiovascular diagnostics and one on cardiovascular treatments. It provides an extensive overview of several diagnostics (e.g., orthostatic blood pressure measurements, heart rhythm assessment) useful in fall prevention. Also, diagnostics were identified, that could potentially provide added value in fall prevention (e.g., blood pressure variability and head turning).

CONCLUSION

Although the majority of studies showed a reduction in falls after the intervention, the total amount of evidence regarding the effect of cardiovascular diagnostics/treatments on falls is small. Our findings can be used to optimize fall prevention strategies and develop an evidence-based fall prevention care pathway. Adhering to the World guidelines on fall prevention recommendations, it is crucial to undertake a standardized assessment of cardiovascular risk factors, followed by supplementary testing and corresponding interventions, as effective components of fall prevention strategies. In addition, accompanying diagnostics such as blood pressure variability and head turning can be of added value.

Clinical predictors of cardiac syncope in patients with unexplained syncope after the implantation of an insertable cardiac monitor

Syncope prognosis is related to both its etiology and comorbidities, with cardiac syncope (CS) having higher risks for mortality and cardiovascular events than syncope of non-cardiac causes. Although a novel insertable cardiac monitor (ICM) is an effective diagnostic tool for unexplained syncope, decision regarding ICM implantation with a high pre-test likelihood of CS should contribute to economic cost reduction and avoidance of unnecessary complications. This study aimed to investigate clinical factors associated with CS after ICM implantation in patients with unexplained syncope. This retrospective observational study included 31 consecutive patients with ICM implantation for syncope between September 2016 and August 2021. The initial examinations for syncope included a detailed history, physical examination, blood tests, 12-lead electrocardiograms, and transthoracic echocardiography. Of the 31 patients, 13 (41.9%) experienced recurrent CS during follow-up (676 ± 469 days). Among several clinical factors, syncope-related minor injuries (p = 0.017) and higher brain natriuretic peptide (BNP; p = 0.043) levels were significantly associated with CS. Moreover, multivariable analysis showed that both syncope-related minor injuries (odds ratio, 11.2; 95% confidence interval, 1.4-88.4; p = 0.022) and BNP higher than 64.0 pg/mL (odds ratio, 7.0; 95% confidence interval, 1.1-44.2; p = 0.038) were independent predictors of CS after ICM implantation. In conclusion, a history of minor injury secondary to syncope and higher BNP levels were independent CS predictors in patients receiving ICM for syncope. These results emphasized the utility of ICM implantation early in the diagnostic journey of patients presenting with CS predictors requiring specific treatments.

World guidelines for falls prevention and management for older adults: a global initiative

BACKGROUND

falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.

OBJECTIVES

to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.

METHODS

a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.

RECOMMENDATIONS

all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

CONCLUSIONS

the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

A Novel Approach to Proactive Primary Care-Based Case Finding and Multidisciplinary Management of Falls, Syncope, and Dizziness in a One-Stop Service: Preliminary Results

National and international evidence and guidelines on falls prevention and management in community-dwelling elderly adults recommend that falls services should be multifactorial and their interventions multicomponent. The way that individuals are identified as having had or being at risk of falls in order to take advantage of such services is far less clear. A novel multidisciplinary, multifactorial falls, syncope, and dizziness service model was designed with enhanced case ascertainment through proactive, primary care-based screening (of individual case notes of individuals aged ≥60) for individual fall risk factors. The service model identified 4,039 individuals, of whom 2,232 had significant gait and balance abnormalities according to senior physiotherapist assessment. Significant numbers of individuals with new diagnoses ranging from cognitive impairment to Parkinson's disease to urgent indications for a pacemaker were discovered. More than 600 individuals were found who were at high risk of osteoporosis according to World Health Association Fracture Risk Assessment Tool score, 179 with benign positional paroxysmal vertigo and 50 with atrial fibrillation. Through such screening and this approach, Comprehensive Geriatric Assessment Plus (Plus falls, syncope and dizziness expertise), unmet need was targeted on a scale far outside the numbers seen in clinical trials. Further work is needed to determine whether this approach translates into fewer falls and decreases in syncope and dizziness.

The Role of the Syncope Management Unit

Syncope is a common symptom, experienced by 15% of persons less than 18 years old and up to 23% of elderly nursing home residents, so it is important to consider optimizing strategies for the management of these patients. The strategy selected will inevitably differ from place to place. However, an organized structure offers more cost-effective care. This article discusses possible health care delivery models for syncope management and reviews the current status of the organization of syncope care, to show the value of a multidisciplinary approach to the organized management of patients with syncope.

Cardiac Iodine-123-Meta-Iodo-Benzylguanidine Uptake in Carotid Sinus Hypersensitivity

Background

Carotid sinus syndrome is the association of carotid sinus hypersensitivity with syncope, unexplained falls and drop attacks in generally older people. We evaluated cardiac sympathetic innervation in this disorder in individuals with carotid sinus syndrome, asymptomatic carotid sinus hypersensitivity and controls without carotid sinus hypersensitivity.

Methods

Consecutive patients diagnosed with carotid sinus syndrome at a specialist falls and syncope unit were recruited. Asymptomatic carotid sinus hypersensitivity and non-carotid sinus hypersensitivity control participants recruited from a community-dwelling cohort. Cardiac sympathetic innervation was determined using Iodine-123-metaiodobenzylguanidine (123-I-MIBG) scanning. Heart to mediastinal uptake ratio (H:M) were determined for early and late uptake on planar scintigraphy at 20 minutes and 3 hours following intravenous injection of 123-I-MIBG.

Results

Forty-two subjects: carotid sinus syndrome (n = 21), asymptomatic carotid sinus hypersensitivity (n = 12) and no carotid sinus hypersensitivity (n = 9) were included. Compared to the non- carotid sinus hypersensitivity control group, the carotid sinus syndrome group had significantly higher early H:M (estimated mean difference, B = 0.40; 95% confidence interval, CI = 0.13 to 0.67, p = 0.005) and late H:M (B = 0.32; 95%CI = 0.03 to 0.62, p = 0.032). There was, however, no significant difference in early H:M (p = 0.326) or late H:M (p = 0.351) between the asymptomatic carotid sinus hypersensitivity group and non- carotid sinus hypersensitivity controls.

Conclusions

Cardiac sympathetic neuronal activity is increased relative to age-matched controls in individuals with carotid sinus syndrome but not those with asymptomatic carotid sinus hypersensitivity. Blood pressure and heart rate measurements alone may therefore represent an over simplification in the assessment for carotid sinus syndrome and the relative increase in cardiac sympathetic innervation provides additional clues to understanding the mechanisms behind the symptomatic presentation of carotid sinus hypersensitivity.

Symptomatic presentation of carotid sinus hypersensitivity is associated with impaired cerebral autoregulation

Background

Carotid sinus hypersensitivity (CSH) is associated with syncope, unexplained falls, and drop attacks in older people but occurs asymptomatically in 35% of community‐dwelling elders. We hypothesized that impaired cerebral autoregulation is associated with the conversion of asymptomatic CSH to symptomatic CSH. We therefore conducted a case–control study evaluating individuals with CSH with and without the symptoms of syncope or unexplained falls, as well as non‐CSH controls, to determine whether the blood pressure and heart rate changes associated with CSH are associated with symptoms only when cerebral autoregulation is altered.

Methods and Results

Bilateral middle cerebral artery blood flow velocities (BFV) were measured in consecutive patients with symptomatic CSH (n=22) and asymptomatic controls with (n=18) and without CSH (n=14) using transcranial Doppler ultrasonography during lower body negative pressure‐induced systemic hypotension. Within‐group comparisons revealed significantly lower cerebrovascular resistance index (CVR_i) at nadir for the asymptomatic CSH group (right, mean [95% CI]: 2.2 [1.8, 2.8] versus 2.6 [2.2, 3.0]; P=0.005; left: 2.8 [2.4, 3.3] versus 3.1 [2.7, 3.8]; P=0.016). Between‐group comparisons showed higher mean BFV (right: estimated mean difference, B=5.49 [1.98, 8.80], P=0.003; left: 4.82 [1.52, 8.11], P=0.005) and lower CVR_i (right: B=0.08 [0.03, 0.12], P=0.003, left: B=0.07 [0.02, 0.12], P=0.006) in asymptomatic CSH versus symptomatic CSH groups. There were no significant differences in bilateral mean BFV or right CVR_i between the non‐CSH and symptomatic CSH groups but differences were present for left CVR_i (B=0.07 [0.02, 0.013], P=0.015).

Conclusion

Cerebral autoregulation is altered in symptomatic CSH and therefore appears to be associated with the development of hypotension‐related symptoms in individuals with CSH.

Syncope in the Elderly

A rapid change in ageing demographic is taking place worldwide such that healthcare professionals are increasingly treating old and very old patients. Syncope in the elderly is a challenging presentation that is under-recognised, particularly in the acute care setting. The reason for this is that presentation in the older person may be atypical: patients are less likely to have a prodrome, may have amnesia for loss of consciousness and events are frequently unwitnessed. The older patient thus may present with a fall rather than transient loss of consciousness. There is an increased susceptibility to syncope with advancing age attributed to age-related physiological impairments in heart rate and blood pressure, and alterations in cerebral blood flow. Multi-morbidity and polypharmacy in these complex patients increases susceptibility to syncope. Cardiac causes and more than one possible cause are also common. Syncope is a major cause of morbidity and mortality and is associated with enormous personal and wider health economic costs. In view of this, prompt assessment and early targeted intervention are recommended. The purpose of this article is to update the reader regarding the presentation and management of syncope in this rapidly changing demographic.

Symptoms and signs of neuro-otologic disorders

PURPOSE OF REVIEW

Symptoms and signs of neuro-otologic disorders are critical components in the diagnostic assessment of patients with vestibular symptoms such as vertigo, dizziness, unsteadiness, and oscillopsia. Most diagnoses can be accomplished at the bedside. An understanding of key diagnostic principles is essential for all practicing neurologists, who are often faced with determining whether such patients warrant urgent diagnostic testing or hospital admission. This article introduces readers to core concepts and recent advances in the understanding of directed history taking and physical examination in patients with vestibular symptoms or suspected neuro-otologic disorders.

RECENT FINDINGS

International consensus definitions for vestibular symptoms have recently been published. During the past 5 years, a growing body of scientific evidence has demonstrated that the traditional approach to bedside diagnosis of patients with vertigo and dizziness is inadequate. Former teaching that history taking should first rely on categorizing symptoms by type (eg, vertigo, presyncope, disequilibrium, nonspecific dizziness) has been replaced by an emphasis on categorizing timing and triggers for vestibular symptoms, which focuses the clinician's attention on four key syndromic patterns: (1) acute, spontaneous, prolonged vestibular symptoms; (2) episodic, positional vestibular symptoms; (3) episodic, spontaneous vestibular symptoms; and (4) chronic unsteadiness (with or without oscillopsia). Each of these categories delineates a relatively narrow differential diagnosis within which a focused examination distinguishes between benign common causes and dangerous uncommon ones.

SUMMARY

A focused approach to bedside assessment of patients with vestibular symptoms is essential for accurate and efficient diagnosis. All neurologists should be aware of major recent advances.

Carotid sinus syndrome is common in very elderly patients undergoing tilt table testing and carotid sinus massage because of syncope or unexplained falls

BACKGROUND AND AIMS

Although the incidence of falls and syncope increase with age, the underlying mechanisms are not fully understood, particularly in very old patients. We report diagnostic outcomes of tilt table and carotid sinus massage (TT/CSM) testing in a population of older old subjects (82% over 80 years of age) referred for TT/CSM from a falls clinic for assessment of syncope or unexplained falls.

METHODS

Prospective observational study between January 1, 2001 and January 1, 2005 involving 290 consecutive subjects undergoing TT/CSM testing according to European Society of Cardiology guidelines for the diagnosis and management of syncope.

RESULTS

Combination of TT/CSM provided a positive result in 62% of subjects, and was significantly more likely to be positive in subjects over the age of 80 (68% vs 50%, p=0.001). Carotid sinus syndrome (CSS) was the most common diagnosis, and was significantly more common in subjects over 80 (48% vs 34%, p=0.022) particularly due to a higher incidence of mixed CSS (16% vs 7%, p=0.023). There was no significant difference in the diagnosis of subjects referred due to falls and those reporting syncope (p=0.93). No cardiovascular or neurological adverse events occurred.

CONCLUSIONS

In our cohort of very elderly patients, the diagnostic accuracy of tilt testing and carotid sinus massage was high and adverse incidents absent when testing was indicated by a geriatrician experienced in the assessment of falls and syncope. We advocate the use of TT/CSM testing as part of a comprehensive falls/syncope assessment for the diagnostic evaluation of older patients presenting with unexplained falls and/or syncope in whom structured assessment has not identified a cause for their symptoms.

Vasovagal syncope in the older person: differences in presentation between older and younger patients

BACKGROUND

vasovagal syncope (VVS) has been diagnosed with increasing frequency in older people since the description of the head-up tilt table test (HUTT). There is, however, a paucity of research describing the clinical features of VVS in this group. To address this issue, we investigated the age distribution and differences in clinical characteristics associated with age in patients diagnosed with VVS by HUTT at our tertiary referral centre.

METHODS

1,060 consecutive patients with tilt-positive VVS were identified from a prospective database containing the demographic and clinical information of individuals assessed in our unit over a 10-year period. VVS was diagnosed with appropriate haemodynamic changes during HUTT and accompanying symptom reproduction.

RESULTS

we found a bimodal age distribution with a small peak at 20-29 years and a larger peak at 70-79 years. Patients aged > or =60 years were less likely to report total loss of consciousness [odds ratio (OR) 0.50, 95% confidence interval (CI) = 0.38-0.64], near loss of consciousness (OR 0.53, 95% CI = 0.40-0.70) or palpitations (OR 0.45, 95% CI = 0.28-0.72) and more likely to present with unexplained falls (OR 2.33, 95% CI = 1.36-4.32). The typical provoking factors of prolonged standing (OR 0.55, 95% CI = 0.40-0.72), posture change (OR 0.61, 95% CI = 0.46-0.82) and hot environments (OR 0.57, 95% CI = 0.42-0.78) were also less common in older patients.

CONCLUSION

in our large study population, VVS was more common in older patients. The clinical presentation differed significantly between the two groups. Older patients were less likely to give a typical history and therefore clinicians need to have a high index of suspicion when evaluating the older patient presenting with collapse or unexplained falls.

Carotid sinus hypersensitivity is common in patients presenting with hip fracture and unexplained falls

BACKGROUND

We tried to determine the prevalence of carotid sinus hypersensitivity (CSH) in patients with hip fractures with and without a clear history of an accidental fall.

METHODS

We studied 51 patients hospitalized for a hip fracture and 51 matched controls from our outpatients department. All patients were subjected to a carotid sinus massage in the supine and upright position. Patients were categorized in accidental (Group A) and unexplained (Group B) fallers.

RESULTS

Six of 33 (18.2%) patients in Group A and 12 of 18 (66.7%) patients in Group B (P < 0.001) had a positive response to the carotid sinus massage. Nine controls (17.6%) also demonstrated CSH. Patients in Group B were older (A: 75.5 +/- 8.5 years vs B: 80.1 +/- 5.9 years, P =0.029) and were more likely to have a history of unexplained falls or syncope in the past (A: 0% vs B: 66.7%, P < 0.0001) than individuals in group A. Vasodepressor/mixed forms accounted for the majority of CSH responses in Group B (75%). When compared with the control group, CSH was still more common in Group B (B: 66.7% vs control: 17.6%, P < 0.0001) but not in Group A (A: 18.2% vs control: 17.6%, P =1.000).

CONCLUSIONS

The prevalence of CSH is increased in elderly patients with hip fractures, only in those who present with an unexplained fall and report a history of syncope or unexplained falls in the past. The vasodepressor/mixed forms account for the majority of CSH responses in the group of unexplained fallers.

Results of carotid sinus massage in a tertiary referral unit--is carotid sinus syndrome still relevant?

BACKGROUND

carotid sinus hypersensitivity (CSH) is associated with syncope, drop attacks and unexplained falls in older people. However, a recent study has also reported a prevalence of 35% in asymptomatic community-dwelling older people.

OBJECTIVE

we conducted a retrospective observational study to investigate the haemodynamic and symptom responses of a large cohort of patients undergoing carotid sinus massage (CSM).

METHODS

the electronically stored haemodynamic data of 302 consecutive patients, aged 71 +/- 11 years, investigated with CSM for unexplained falls and syncope was analysed. Bilateral sequential CSM was performed in the supine and upright positions with continuous electrocardiogram (ECG) and non-invasive beat-to-beat blood pressure monitoring (Taskforce, CN Systems, Austria). CSH (CSH) was defined by maximal R-R interval > or =3 s (cardioinhibitory) and/or a systolic blood pressure drop of > or =50 mmHg (vasodepressor).

RESULTS

a total of 74/302 (25%) subjects had CSH, 37 (50%) of which were cardioinhibitory (CI) and 37 (50%) were vasodepressor (VD) subtypes. Subjects with positive CSM were significantly older (75.2 vs 70.2 years, P < 0.001), and more likely to be male (32% vs 19%, P < 0.01). CSH was diagnosed with right-sided CSM alone in 45 (61%) subjects and erect CSM only in 36 (49%) subjects. Symptom reproduction was more likely with the CI than the VD subtypes (82% vs 28%; P < 0.001).

CONCLUSION

CSH was diagnosed in 25% of patients investigated with CSM at our specialist unit, lower than the prevalence of 39% reported for community-dwelling older individuals. This discrepancy may be explained by selection bias and demographic differences, but raises the possibility of CSH being an age-related epiphenomenon rather than a causal mechanism for syncope, drop attacks and unexplained falls. Our observations have important implications for clinical practice and the development of future research strategies.

Gait disorders are associated with non-cardiovascular falls in elderly people: a preliminary study

Background

The association between unexplained falls and cardiovascular causes is increasingly recognized. Neurally mediated cardiovascular disorders and hypotensive syndromes are found in almost 20 percent of the patients with unexplained falls. However, the approach to these patients remains unclear. Gait assessment might be an interesting approach to these patients as clinical observations suggests that those with cardiovascular or hypotensive causes may not manifest obvious gait alterations. Our primary objective is to analyze the association between gait disorders and a non-cardiovascular cause of falls in patients with unexplained falls. A second objective is to test the sensitivity and specificity of a gait assessment approach for detecting non-cardiovascular causes when compared with intrinsic-extrinsic classification.

Methods

Cross-sectional study performed in a falls clinic at a university hospital in 41 ambulatory elderly participants with unexplained falls. Neurally mediated cardiovascular conditions, neurological diseases, gait and balance problems were assessed. Gait disorder was defined as a gait velocity < 0.8 m/s or Tinetti Gait Score <9. An attributable etiology of the fall was determined in each participant. Comparisons between the gait assessment approach and the attributable etiology regarding a neurally mediated cardiovascular cause were performed. Fisher exact test was used to test the association hypothesis. Sensitivity and specificity of gait assessment approach and intrinsic-extrinsic classification to detect a non-cardiovascular mediated fall was calculated with 95% confidence intervals (CI95%).

Results

A cardiovascular etiology (orthostatic and postprandial hypotension, vasovagal syndrome and carotid sinus hypersensitivity) was identified in 14% of participants (6/41). Of 35 patients with a gait disorder, 34 had a non-cardiovascular etiology of fall; whereas in 5 out of 6 patients without a gait disorder, a cardiovascular diagnosis was identified (p < 0.001). Sensitivity and specificity of the presence of gait disorder for identifying a non-cardiovascular mediated cause was 97.1% (CI95% = 85–99) and 83% (CI95% = 36–99), respectively.

Conclusion

In community dwelling older persons with unexplained falls, gait disorders were associated with non-cardiovascular diagnosis of falls. Gait assessment was a useful approach for the detection of a non-cardiovascular mediated cause of falls, providing additional value to this assessment.