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.

Cardiovascular disease and the risk of incident falls and mortality among adults aged ≥ 65 years presenting to the emergency department: a cohort study from national registry data in Denmark

BACKGROUND

Falls cause 58% of injury-related Emergency Department (ED) attendances. Previous research has highlighted the potential role of cardiovascular risk factors for falls. This study investigated the impact of cardiovascular disease (CVD) risk on three-year incident falls, with presentation to the ED, and mortality.

METHODS

A matched cohort study design was employed using national registry data from 82,292 adults (33% male) aged ≥ 65 years living in Denmark who attended the ED in 2013. We compared age and gender matched ED attendees presenting with a fall versus another reason. The cohort was followed for three-year incident falls, with presentation to the ED, and mortality. The impact of falls-related CVDs was also examined.

RESULTS

Three-year incident falls was twofold higher among age and gender matched ED attendees aged ≥ 65 years presenting with a fall versus another reason at baseline. A presentation of falls with hip fracture had the highest percentage of incident falls in the 65-74 age group (22%) and the highest percentage mortality in all age groups (27-62%). CVD was not a significant factor in presenting with a fall at the ED, nor did it contribute significantly to the prediction of three-year incident falls. CVD was strongly associated with mortality risk among the ED fall group (RR = 1.81, 95% CI: 1.67-1.97) and showed interactions with both age and fall history.

CONCLUSION

In this large study of adults aged ≥ 65 years attending the ED utilising data from national administrative registers in Denmark, we confirm that older adults attending the ED with a fall, including those with hip fracture, were at greatest risk for future falls. While CVD did not predict incident falls, it increased the risk of mortality in the three-year follow up with advancing age. This may be informative for the provision of care pathways for older adults attending the ED due to a fall.

Effectiveness of Cardiovascular Evaluations and Interventions on Fall Risk: A Scoping Review

OBJECTIVE

Cardiovascular abnormalities are consistently associated with fall risk in older people. However, little research has been done to assess the effect of cardiovascular interventions on fall risk. The aim of this scoping review is to explore the current literature on the effectiveness of cardiovascular evaluations and interventions in reducing fall risk in older people.

DESIGN

Scoping review.

DATA SOURCES

Medline, Cochrane Library, and WHO ICTRP Search Portal were systematically searched.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and intervention studies of community-dwelling adults aged ≥50 years or with a mean age of >60 years that assessed the effect of a cardiovascular assessment and interventions in reducing fall risk. Key search concepts were "falls" and "aged", and terms for different cardiovascular evaluations and interventions were included. The Cochrane Checklist for risk of bias and the ROBINS-I tool were used to assess the quality of the studies.

RESULTS

Seven studies were included. The majority showed a reduction in falls after cardiovascular evaluation and intervention. Two out of four studies that focused on carotid sinus hypersensitivity (CSH) as a modifiable cardiovascular risk factor for falls, showed a significant reduction in falls after pacemaker implantation. Two studies that looked at sinus node dysfunction (SND) both showed a significant reduction in falls after pacemaker implantation. One study showed that 33% of the patients experienced a fall after cardiovascular evaluation and intervention, whereas all patients fell before assessment.

CONCLUSIONS

The majority of the included studies showed a reduction in falls after the intervention. However, the number of published papers regarding the effect of cardiovascular assessment and interventions on falls is small. A standardized assessment of cardiovascular risk factors may be essential in preventing falls in older adults and could consequently reduce injuries, loss of quality of life, deaths, and fall-related expenditures.

AF is associated with self-reported syncope and falls in a general population cohort

BACKGROUND

syncope is an important, but underestimated clinical problem in older persons. It is often overlooked in clinical practice or mistaken for falls. Atrial fibrillation (AF) is the most common cardiac arrhythmia, but little evidence exists regarding the association between AF, falls and syncope in the general population.

METHODS

cross-sectional analyses within a population sample of people aged 50+, taken from The Irish Longitudinal Study on Ageing. Ten-minute electrocardiogram recordings (n = 4,885) were analysed to detect AF. Syncope (self-reported faints or blackouts) and falls in the past year, co-morbidities, health measures and medications were gathered through computer-aided personal interviews. Multivariable logistic regression was performed to study associations between AF, falls and syncope.

RESULTS

mean age was 62 years (range: 50-91), 54% were female. Prevalence of AF was 3%, increasing to 8% in participants aged 75+. Of participants, 5% (n = 223) reported syncope and 20% (n = 972) reported falls. After adjustment for confounders, AF was significantly associated with faints and blackouts (odds ratio (OR) 2.0 [95% confidence interval (CI) 1.0-3.9]). After stratification by age category, we found that this association was strongest and only significant in participants aged 50-64 years (OR 4.4 [1.5-12.6]). Stratified for age group, AF was significantly associated with falls in participants aged 65-74 years (OR 2.0 [1.0-4.1]).

CONCLUSIONS

adults aged 50+ with self-reported syncope and adults aged 65-74 years with falls are twice as likely to have AF at physical examination. These associations are independent of stroke, cardiovascular and psychotropic drugs and other confounders. Further longitudinal studies are needed to explore this association and potential causality further.

Self-reported cardiovascular conditions are associated with falls and syncope in community-dwelling older adults

BACKGROUND

with increasing age, causes of syncope are more often of cardiac origin. Syncope in older persons is often mistaken for falls. Data regarding the association between specific cardiovascular conditions, falls and syncope are limited.

METHODS

cross-sectional analyses within a population sample aged 50+ (n = 8,173). Syncope and falls in the past year, cardiovascular conditions and co-variates were gathered through personal interviews. Associations between cardiovascular conditions and (recurrent) falls and syncope were studied through multivariable logistic regression.

RESULTS

mean age was 64 years (range: 51-105); 54% was female. Four per cent reported syncope, 19% falls and 23% cardiovascular morbidity. Abnormal heart rhythm was associated with falls (odds ratio (OR) 1.3 [95% confidence interval (CI) 1.0-1.5]), syncope (OR 1.6 [1.2-2.3]) and recurrent syncope (OR 2.2 [1.3-3.6]). Heart murmur was associated with falls (OR 1.4 [1.1-1.8]), recurrent falls (OR 1.5 [1.0-2.0]) and syncope (OR 1.9 [1.3-2.7]). Angina was associated with recurrent falls (OR 1.4 [1.0-1.9]), syncope (OR 1.8 [1.2-2.6]) and recurrent syncope (OR 2.7 [1.6-4.6]). Heart failure was associated with recurrent falls (OR 1.9 [1.0-3.4]) and myocardial infarction with syncope (OR 1.5 [1.0-2.3]).

CONCLUSION

self-reported cardiovascular conditions are associated with falls and syncope in a general population cohort. This warrants additional cardiovascular evaluation in older patients with unexplained falls and syncope.

Decreased left ventricular (LV) function is associated with hip-fractures

BACKGROUND

Several risk factors for falls and hip-fractures have been recognized, but controversy still exists toward the importance of structural cardiac abnormalities as a potentially modifiable risk factor for recurrent falls. Aim of this study was to determine the association between echocardiographic abnormalities and hip-fractures.

METHODS

Design case-control study within consecutive patients undergoing hip-surgery in an academic hospital.

CASES

patients with traumatic hip-fractures.

CONTROLS

patients undergoing planned hip surgery (non-traumatic).

INCLUSION CRITERIA

age≥50 years, presence of pre-operative echocardiogram.

EXCLUSION CRITERIA

high energy trauma, pathological and/or previous hip-fracture.

OUTCOME

echocardiographic abnormalities (ventricular function, atrial enlargement, valve stenosis and/or regurgitation, pulmonary hypertension (pulmonary artery pressure (PAP) ≥35mmHg)). Multivariate logistic regression was performed to calculate odds ratios (OR) and to correct for confounders.

RESULTS

We included 197 patients (141 cases). Mean age was 77 years (SD), 65% female. After adjustment for potential confounders, decreased LV systolic function was associated with hip-fractures (OR 3.2 [95%CI 1.1-9.1]). Increasing severity of LV dysfunction was also associated with hip-fractures (p for trend=0.012).

DISCUSSION

In conclusion, patients with traumatic hip-fracture had greater risk of decreased LV function than patients who underwent planned hip-surgery. Possibly, decreased LV function is an underestimated risk factor for injurious falls.