Effectiveness of a Cardiovascular Evaluation and Intervention in Older Fallers: A Pilot Study

Cardiovascular abnormalities are increasingly being recognized as important fall-risk factors in older persons because syncope in older persons is often mistaken for falls because they have retrograde amnesia.1, 2 Despite recommendations of falls guidelines,3 cardiovascular examinations are still not routinely performed in the evaluation of older fallers.4 Furthermore, the effectiveness of treating these abnormalities on fall incidence is uncertain. The efficacy and feasibility of a comprehensive cardiovascular evaluation and intervention were therefore studied in a prospective pilot study of individuals aged 65 and older with one or more falls in the past year referred to a falls clinic. In addition to the routine multidisciplinary falls assessment, in which "traditional" modifiable fall-risk factors were identified,3 a comprehensive cardiovascular assessment was performed, including structured history taking, echocardiography, electrocardiography, and tilt-table testing with continuous blood pressure (BP) recording. A multidisciplinary evaluation followed this, and treatment advice (cardiologist and geriatrician) was provided. Main cardiovascular fall-risk factors under consideration were orthostatic hypotension (OH), carotid sinus syndrome (CSS), vasovagal syncope, structural cardiac abnormalities (ventricular dysfunction, heart valve abnormalities), and cardiac arrhythmia, diagnosed according to syncope guidelines.5 The intervention was aimed at optimizing cardiovascular function (drug interventions, specific advice, invasive diagnostics and treatment) to improve the effectiveness of the multifactorial intervention. The primary outcome measure was diagnosis of one or more additional cardiovascular conditions that contributed to the fall incident, followed by subsequent treatment. Secondary outcome measures included feasibility of the multidisciplinary intervention, fall incidents, and related injuries during 6 months of follow-up. Fifteen participants were included (mean age 75±7, 67% female). In 10 participants, a diagnosis was made upon comprehensive cardiovascular examination. These abnormalities were considered a cause or contributing factor to the fall incident in seven participants (47%): initial OH in four, delayed OH in one, CSS in one, and drug-induced hypotension in one (Table 1). Five participants (33%) fell during follow-up; one fall was injurious. The evaluation and intervention appeared to be feasible in current clinical practice. Cardiovascular conditions can lead to near-syncope, and thus falls, in those who already have other fall-risk factors, such as unstable gait, poor vision, or use of sedative medications, whereas this is not necessarily the case for younger and healthier individuals. The results of the pilot study show that, even in participants in whom falls were considered explained after multifactorial falls assessment, cardiovascular abnormalities that contributed to their fall incidents were found. For diagnosis of initial OH and CSS, continuous noninvasive BP measurement is required, which is not yet routinely performed in most fall clinics. Therefore, two important modifiable risk factors (CSS and initial OH) may be overlooked in current fall-prevention care, because important BP drops may be missed using intermittent measurements.6 Echocardiographic and electrocardiographic abnormalities were found in half of participants, none of which were considered a contribution to the fall in this sample, but recent studies have linked atrial fibrillation, poor left ventricular function, and valve abnormalities to falls.7-9 This suggests that greater awareness of atrial fibrillation and structural cardiac abnormalities may be necessary in older fallers, but this requires further study. These results confirm the multifactorial nature of fall incidents and emphasized the need for a broad assessment of fallers, including cardiovascular risk factors. This contrasts with current syncope guidelines, in which detailed history taking is considered the cornerstone of syncope assessment. In six participants in whom a cardiovascular cause of or contribution to their fall was found, the detailed history was suggestive of this finding, although in one participant with a cardiovascular explanation for the fall, the history did not provide any clues for an associated cardiovascular condition. Amnesia from loss of consciousness occurs frequently in syncope, and fall events are often not witnessed.1, 2 Furthermore, cognitive problems can complicate history taking, making history taking for falls due to syncope in older adults more challenging than in younger adults. Therefore, the role of structured "syncope" history taking in this population deserves further study. After a cardiovascular evaluation with structured additional history taking and subsequent intervention, a new or contributing cardiac cause of a fall was identified in nearly half of individuals who attended a falls clinic. This shows that a comprehensive cardiovascular analysis could be of additional value to the current assessment of older fallers, in which standard continuous BP measurement during routine falls examination is an important first step. Effectiveness of treatment of these cardiovascular abnormalities on fall reduction needs to be further studied in randomized clinical trials. We thank Mrs. Kammenga, Mrs. Scheffer, Mrs. de Bruin, and Mrs. Samson for their help in data acquisition. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study concept and design: Jansen, van der Velde. Acquisition of subjects and data: Jansen, de Lange, van der Velde. Analysis and interpretation of data: Jansen, van der Velde. Preparation of manuscript: Jansen, de Lange, de Rooij, van der Velde. Sponsor's Role: None.