Falls and Syncope in the Elderly

Question 1

How common are falls in over 65s?

Answer 1

30% >65yo fall each year

50%>85yo fall each year

Question 2

How many falls result in fractures?

Answer 2

Approx 7-10% of all falls

5-10% falls result in significant soft tissue injury

Other consequences = fear of falling –> limited activity, risk of institutionalisation

Question 3

Outcome after hip fracture:

Answer 3

Approx:
1/3 return home
1/3 institutionalised (newly)
1/3 dead by 6 months

Question 4

Risk factors for falls - 3 categories?

Answer 4

1. Patient factors - eg:
   - chronic illness
   - ageing
   - medications
2. Environment
3. Predisposing and Precipitating Factors

• visual, vestibular, proprioceptive changes
• increased reaction time, decreased muscle mass / strength / endurance, ligamentous change, altered bone biomechanics and strength

Question 5

Drug classes that increase risks of falls: the “antis”:

Answer 5

Antihypertensives
Anti-arrhythmics (Class I) - likely due to anticholinergic effects
Antidepressants (SSRI and TCA equal but bad)
Antipsychotics
Anti-Parkinson agents
Anti-convulsants

+ Benzos (and other sedatives)
+ Oral hypoglycaemics

Question 6

Causes of Syncope:

Answer 6

• structural eg. AS
• functional - arrhythmias, carotid sinus hypersens., postural hypotension
• situational - vasovagal, micturition, cough, valsalva

Question 7

Causes of Orthostatic Hypotension

Answer 7

Neurodegenerative conditions - MSA, Parkinson’s Plus Sydnromes, oligopontine ceerbellar atrophy

Medical conditions

Drugs

Hypovolaemia

Question 8

Carotid hypersensitivity syndrome - what is this?

how does it happen?

who is at risk?

Answer 8

Carotid sinus hypersensitivity (CSH) is an exaggerated response to carotid sinus baroreceptor stimulation. It results in dizziness or syncope from transient diminished cerebral perfusion.

diagnosed if 3 sec or greater asystole OR 50mmHg fall in systolic BP after carotid sinus massage for 5 seconds.

CSH is observed in up to 14% of elderly nursing home patients and 30% of elderly patients with unexplained syncope and drop attacks.

CSH is more common in males than in females, and is virtually unheard of in people <50 years of age.

Question 9

Progressive supranuclear palsy

Answer 9

a Parkinson Plus condition.

Question 10

A patient who tends to fall backward and has a tremor - are they more likely to have Parkinson’s Disease or Progressive Supranuclear Palsy?

Answer 10

PSP - patients usually stand with knees and trunk extended and fall backwards.

PD - flexed position. Tend to fall forwards.