What is the evidence for cardiovascular disorders as a risk factor for non-syncopal falls? Scope for future research

Impact of cardiovascular evaluations and interventions on fall risk in older adults: a protocol for a scoping review and evidence map

INTRODUCTION

Cardiovascular disorders are increasingly recognised as important fall risk factors in older adults. Falls are a major public health problem in older adults, and therefore, effective interventions for reducing falls are essential for this population. Cardiovascular disease is a clinically relevant (but often overlooked) and potentially modifiable risk factor for falls. Literature describing the effects of cardiovascular assessments and treatments on fall prevention has generally focused on only one specific test or treatment. A comprehensive, comparative overview surrounding the effectiveness of available assessments and treatments on cardiovascular related fall risk is currently lacking.

METHODS AND ANALYSIS

A scoping review and evidence map will be conducted to summarise the available evidence regarding the (comparative) effectiveness of cardiovascular assessments and therapeutic interventions on reducing fall risk in older individuals. A systematic and comprehensive literature search will be performed in MEDLINE and Embase using the key components 'older adults', 'cardiovascular evaluation', 'cardiovascular intervention' and 'falls'. Furthermore, we will create an evidence map to summarise the quantity and quality of currently available evidence identified in the scoping review. The evidence map will consider, but will not be limited to, observational studies, randomised controlled trials and reviews evaluating cardiovascular tests and treatments (vs controls) on fall risk in older adults.

ETHICS AND DISSEMINATION

The scoping review and evidence map will only include data that are publicly available and, therefore, ethical approval is not required. The results will be submitted for publication in a peer-reviewed journal and presented at scientific conferences.

The effect of a stability and coordination training programme on balance in older adults with cardiovascular disease: a randomised exploratory study

BACKGROUND

Cardiovascular diseases are considered a leading factor in mortality and morbidity. The older adult population with cardiovascular diseases has a higher risk of falls as compared to a matched age healthy population.

OBJECTIVE

To investigate the effect of stability and coordination training within a cardiac rehabilitation programme on fall risk in older adults with cardiovascular diseases enrolled in cardiac rehabilitation.

METHODS

Twenty-six people with cardiovascular diseases (age 74±8) were divided randomly into intervention and control groups. The intervention group received 20 min of stability and coordination exercises as part of their 80 min cardiac rehabilitation programme, while the control group performed the traditional cardiac rehabilitation programme, twice a week, for 12 weeks. Balance assessment was based on three tests: the Timed Up and Go, Functional Reach and Balance Error Scoring System, which were measured twice before the intervention, once following the intervention and once four weeks after the termination of the intervention. A two-way analysis of variance (group × time) with repeated measures was performed to examine differences between groups and between assessments.

RESULTS

Seventy per cent of participants in the intervention group adhered to the programme, with significant improvement post-intervention in the Timed Up and Go (p < .01) and the Balance Error Scoring System (p < .05) with no changes among the control group.

DISCUSSION

Stability and coordination training alongside a traditional cardiac rehabilitation programme may improve static and dynamic balance, and muscle strength, skills that are considered major components in postural control. Clinicians who work in cardiac rehabilitation centres should consider including this training alongside the routine cardiac rehabilitation programme.

A prospective study of the association between orthostatic hypotension and falls: definition matters

Background

falls are a common cause of morbidity and mortality in older people. Orthostatic hypotension (OH) is considered an important risk factor for falls, but longitudinal studies have failed to show a clear association. This disparity may be because conventional methods of measuring blood pressure (BP) changes are too imprecise and/or the diagnostic criteria for OH are inappropriate. Over recent years, beat-to-beat BP monitoring techniques, which enabled accurate measurement of vasodepression, have become widely used and in 2011 the American Academy of Neurology produced revised diagnostic criteria for OH.

Objective

to use beat-to-beat monitoring to compare the prevalence of OH using the standard and revised diagnostic criteria and to establish which criteria are most valuable in predicting future falls.

Design

two hundred and ninety-seven community-dwelling older people aged ≥65 years underwent assessment. Active stand using digital photoplethysmography was used to record postural change in BP. One hundred participants were asked to complete prospective weekly falls diaries for 12 months.

Results

OH, defined according to the revised American Academy of Neurology diagnostic criteria, affected 25% of participants and was an independent predictor of falls (odds ratio 10.299, 95% confidence interval [95% CI]: 1.703-61.43, P = 0.011) and time to first fall (hazard ratio 3.017, 95% CI: 1.291-7.050, P = 0.011). OH, defined according to standard criteria, affected 80% of the population and was not associated with falls.

Conclusion

OH, defined according to 2011 criteria, is associated with falls and time to first fall. These findings indicate that beat-to-beat monitoring and the 2011 criteria for OH are valuable in the clinical assessment of older fallers.

The Association of Cardiovascular Disorders and Falls: A Systematic Review

OBJECTIVE

Cardiovascular disorders are recognized as risk factors for falls in older adults. The aim of this systematic review was to identify cardiovascular disorders that are associated with falls, thus providing angles for optimization of fall-preventive care.

DESIGN

Systematic review.

DATA SOURCES

Medline and Embase.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

studies addressing persons aged 50 years and older that described cardiovascular risk factors for falls. Key search terms for cardiovascular abnormalities included all synonyms for the following groups: structural cardiac abnormalities, cardiac arrhythmia, blood pressure abnormalities, carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), vasovagal syncope (VVS), postprandial hypotension (PPH), arterial stiffness, heart failure, and cardiovascular disease. Quality of studies was assed using the Newcastle-Ottawa Scale.

RESULTS

Eighty-six studies were included. Of studies that used a control group, most consistent associations with falls were observed for low blood pressure (BP) (4/5 studies showing a positive association), heart failure (4/5), and cardiac arrhythmia (4/6). Higher prevalences of CSH (4/6), VVS (2/2), and PPH (3/4) were reported in fallers compared with controls in most studies, but most of these studies failed to show clear association measures. Coronary artery disease (6/10), orthostatic hypotension (9/25), general cardiovascular disease (4/9), and hypertension (7/25) all showed inconsistent associations with falls. Arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardiographic abnormalities.

CONCLUSION

Several cardiovascular associations with falls were identified, including low BP, heart failure, and arrhythmia. These results provide several angles for optimizing fall-preventive care, but further work on standard definitions, as well as the exact contribution of individual risk factors on fall incidence is now important to find potential areas for preventive interventions.

Prospective study of falls and risk factors for falls in adults with advanced cancer

PURPOSE

Retrospective studies of inpatients with cancer suggest that a cancer diagnosis confers a high risk of falls. In adults with advanced cancer, we aimed to prospectively document the incidence of falls, identify the risk factors, and determine if falls in this population occur predominantly in older patients.

PATIENTS AND METHODS

Patients admitted consecutively to community and inpatient palliative care services with metastatic or locoregionally advanced cancer who were mobile without assistance were recruited. Risk-factor assessment was conducted on initial encounter. Patients underwent follow-up via weekly telephone contact for 6 months or until time of fall or death. Relationship between covariates and time to fall was examined using hazard ratios (HRs) derived from univariate and multivariate Cox proportional hazards models.

RESULTS

Of 185 participants (52.4% men; mean age 68 ± standard deviation of 12.6 years), 50.3% fell; 35 (53%) of 66 participants age < 65 years and 58 (48.7%) of 119 age ≥ 65 years fell; 61.3% of falls occurred in the community; 42% resulted in injury. Median time to fall was 96 days (95% CI, 64.66 to 127.34). Primary brain tumor or brain metastasis (HR 2.5; P = .002), number of falls in the preceding 3 months (HR, 1.27; P = .005), severity of depression (HR, 1.12; P = .012), benzodiazepine dose (HR, 1.05; P = .004), and cancer-related pain (HR, 1.96; P = .024) were independently associated with time to fall in multivariate analysis.

CONCLUSION

Fifty percent of adults with advanced cancer, regardless of age, will experience a fall associated with high risk of physical injury. There is a compelling need to assess the efficacy of assessment and management of modifiable fall risk factors in patients with advanced cancer.