Fiona Shaw

Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses

Objectives To evaluate the evidence for strategies to prevent falls or fractures in residents in care homes and hospital inpatients and to investigate the effect of dementia and cognitive impairment. Design Systematic review and meta-analyses of studies grouped by intervention and setting (hospital or care home). Meta-regression to investigate the effects of dementia and of study quality and design. Data sources Medline, CINAHL, Embase, PsychInfo, Cochrane Database, Clinical Trials Register, and hand searching of references from reviews and guidelines to January 2005. Results 1207 references were identified, including 115 systematic reviews, expert reviews, or guidelines. Of the 92 full papers inspected, 43 were included. Meta-analysis for multifaceted interventions in hospital (13 studies) showed a rate ratio of 0.82 (95% confidence interval 0.68 to 0.997) for falls but no significant effect on the number of fallers or fractures. For hip protectors in care homes (11 studies) the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and not enough studies on fallers. For all other interventions (multifaceted interventions in care homes; removal of physical restraints in either setting; fall alarm devices in either setting; exercise in care homes; calcium/vitamin D in care homes; changes in the physical environment in either setting; medication review in hospital) meta-analysis was either unsuitable because of insufficient studies or showed no significant effect on falls, fallers, or fractures, despite strongly positive results in some individual studies. Meta-regression showed no significant association between effect size and prevalence of dementia or cognitive impairment. Conclusion There is some evidence that multifaceted interventions in hospital reduce the number of falls and that use of hip protectors in care homes prevents hip fractures. There is insufficient evidence, however, for the effectiveness of other single interventions in hospitals or care homes or multifaceted interventions in care homes.

Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial

Abstract Objective: To determine the effectiveness of multifactorial intervention after a fall in older patients with cognitive impairment and dementia attending the accident and emergency department. Design: Randomised controlled trial. Participants: 274 cognitively impaired older people (aged 65 or over) presenting to the accident and emergency department after a fall: 130 were randomised to assessment and intervention and 144 were randomised to assessment followed by conventional care (control group). Setting: Two accident and emergency departments, Newcastle upon Tyne. Main outcome measures: Primary outcome was number of participants who fell in year after intervention. Secondary outcomes were number of falls (corrected for diary returns), time to first fall, injury rates, fall related attendances at accident and emergency department, fall related hospital admissions, and mortality. Results: Intention to treat analysis showed no significant difference between intervention and control groups in proportion of patients who fell during 1 years follow up (74% (96/130) and 80% (115/144), relative risk ratio 0.92, 95% confidence interval 0.81 to 1.05). No significant differences were found between groups for secondary outcome measures. Conclusions: Multifactorial intervention was not effective in preventing falls in older people with cognitive impairment and dementia presenting to the accident and emergency department after a fall. What is already known on this topic Multifactorial intervention prevents falls in cognitively normal older people living in the community and in those who present to the accident and emergency department after a fall Fall prevention strategies have not been tested by controlled trials in patients with cognitive impairment and dementia who fall What this study adds No benefit was shown from multifactorial assessment and intervention after a fall in patients with cognitive impairment and dementia presenting to the accident and emergency department The intervention was less effective in these patients than in cognitively normal older people

Carotid Sinus Syndrome: A Modifiable Risk Factor for Nonaccidental Falls in Older Adults (SAFE PACE)

OBJECTIVES The aim of the study was to determine whether cardiac pacing reduces falls in older adults with cardioinhibitory carotid sinus hypersensitivity (CSH). BACKGROUND Cardioinhibitory carotid sinus syndrome causes syncope, and symptoms respond to cardiac pacing. There is circumstantial evidence for an association between falls and the syndrome. METHODS A randomized controlled trial was done of consecutive older patients (>50 years) attending an accident and emergency facility because of a non-accidental fall. Patients were randomized to dual-chamber pacemaker implant (paced patients) or standard treatment (controls). The primary outcome was the number of falls during one year of follow-up. RESULTS One hundred seventy-five eligible patients (mean age 73 +/- 10 years; 60% women) were randomized to the trial: pacemaker 87; controls 88. Falls (without loss of consciousness) were reduced by two-thirds: controls reported 669 falls (mean 9.3; range 0 to 89), and paced patients 216 falls (mean 4.1; range 0 to 29). Thus, paced patients were significantly less likely to fall (odds ratio 0.42; 95% confidence interval: 0.23, 0.75) than were controls. Syncopal events were also reduced during the follow-up period, but there were much fewer syncopal events than falls-28 episodes in paced patients and 47 in controls. Injurious events were reduced by 70% (202 in controls compared to 61 in paced patients). CONCLUSIONS There is a strong association between non-accidental falls and cardioinhibitory CSH. These patients would not usually be referred for cardiovascular assessment. Carotid sinus hypersensitivity should be considered in all older adults who have non-accidental falls.

The Prevalence, Assessment and Associations of Falls in Dementia with Lewy Bodies and Alzheimer’s Disease

Falls were assessed for 3 months using a daily fall diary in 65 (30 dementia with Lewy bodies, DLB; 35 Alzheimer’s disease, AD) dementia patients from a case register, diagnosed using operationalised clinical criteria, with established accuracy against post-mortem. Multiple falls (>5) occurred in 37% of DLB patients and 6% of those with AD, often resulting in injury. None of the standard risk assessment tools identified fallers, but they did identify multiple fallers. More detailed evaluation methods examining gait patterns, sway and neurovascular instability were not helpful. Multiple falls were associated with DLB, parkinsonism, previous falls, greater impairment of activities of daily living and older age. Falls are particularly common in DLB sufferers and may aid diagnosis. Treatment studies evaluating fall reduction strategies are a priority.

Prevention of falls in older people with dementia

SummaryFalls are a major cause of morbidity and mortality in older people with dementia. However, although we know that people with dementia can comply with interventions known to reduce falls in cognitively normal populations, and that these interventions can modify certain risk factors for falls in patients with dementia, direct evidence that falls can be prevented in older people with dementia is lacking. Further research is required specifically targeting fall prevention in older people with dementia.

Prevalence of Cardioinhibitory Carotid Sinus Hypersensitivity in Patients 50 Years or over Presenting to the Accident and Emergency Department with “Unexplained” or “Recurrent” Falls

To study the prevalence of Cardioinhibitory Carotid Sinus Hypersensitivity (CICSH) in patients 50 years or over presenting to casualty with “unexplained” or “recurrent” falls. The prospective study was from October 1, 1995 to April 30, 1996 in the Inner City Accident and Emergency Departments, Newcastle Upon Tyne, U.K. Ten thousand four hundred forty‐three patients 50 years and over presented, of which 4,051 (39%) were fallers. Fallers were excluded if they lived over 15 miles from the hospital (81), were registered blind (17), were unable to speak English (22), were unable to previously walk (27), if there was a history of only one accidental fall (1,659) or were cognitively impaired (776: Mini Mental State Examination < 24 [30]) or if there was a clear attributable medical diagnosis for the fall (871). Five hundred ninety‐eight “unexplained” or “recurrent” fallers (defined as three or more falls in the previous 12 months) were assessed for carotid sinus massage (CSM). One hundred forty‐five patients declined CSM (24%), 70 (12%) had relative contraindications to CSM and 13 already had pacemakers in situ (2%). Two hundred seventy‐nine underwent CSM, of whom 65 had CICSH (23%), which might be amenable to treatment with pacemakers. The prevalence of CICSH (a potentially treatable condition) in “unexplained” or “recurrent” fallers who present to the accident and emergency department is 23%. A randomized control study to assess benefit from pacemaker intervention in these patients is underway.

The Newcastle protocols 2008: an update on head-up tilt table testing and the management of vasovagal syncope and related disorders

Since their publication in 2000, the Newcastle protocols1 on head-up tilt testing in the diagnosis of vasovagal syncope and related disorders have provided a succinct and practical guide for those setting up and managing syncope services incorporating the investigation and management of neurally mediated disorders. In the intervening seven years our protocols have changed in line with published evidence on new methodologies and management strategies and our own clinical experience (with more than 1000 new and 3000 review patients seen each year at our specialist syncope facility), so the time is ripe for a fresh approach. Much of this information is available in a number of important papers on syncope management2–4 and pacing indications5 6; while comprehensive, these guidelines are also lengthy and inclusive of competing methodologies. They are therefore less accessible for those needing a more prescriptive and pragmatic view. The Newcastle protocols 2008 presented below provide such a view. Since these protocols reflect current clinical practice, an exhaustive review of the evidence base for the various methodologies presented will not be attempted—the reader should consult the more detailed papers referenced if this is required.2–6 Similarly some prior knowledge of the subject matter is assumed, in particular the differentiation between syncope and non-syncopal loss of consciousness as well as the diagnostic process leading to head-up tilt table testing.2 3 The protocols are designed for adults with syncope (defined as transient loss of consciousness with loss of postural tone and spontaneous and complete recovery), with no upper limit on age. The Newcastle protocols 2008 are intended to complement rather than reproduce the originals, so only new information will be presented, occasionally with a summarised version of the old to aid clarity. Still-valid detailed prior information will be referenced to the …

Neurocardiovascular Instability, Hypotensive Episodes, and MRI Lesions in Neurodegenerative Dementia.

Abstract: We investigated whether carotid sinus hypersensitivity (CSH) and orthostatic hypotension (OH) were associated with a greater severity of hyperintensities on MRI scan in 30 patients with neurodegenerative dementia (17 dementia with Lewy bodies, 13 Alzheimers disease), who had a detailed evaluation of OH and CSH during active standing and head‐up tilt. Patients also underwent a 1.0 Tesla MRI scan, from which hyperintensities were rated on a standardized scale. A blood pressure (BP) drop >30 mm Hg during carotid sinus massage or active standing was significantly associated with the severity of MRI hyperintensities in the deep white matter (OR 10.0, 95%; CI 1.8–55.7) and in the basal ganglia (OR 11.0, 95%; CI 1.2–99.5) but not in periventricular areas (OR 1.4, 95%; CI 0.3–1.8). Patients with the cardio‐inhibitory form of CSH with the largest BP drops were the most at risk. Further longitudinal studies need to investigate the direction of causality to determine whether CSH or OH predispose to MRI hyperintensities and accelerate cognitive decline.

High prevalence of neurovascular instability in neurodegenerative dementias

Orthostatic hypotension and carotid sinus hypersensitivity were assessed in patients meeting clinical criteria for dementia with Lewy bodies (DLB; n = 30) and AD (n = 35). Cardioinhibitory carotid sinus hypersensitivity (CI) was the most common sign (AD patients, 28%; DLB patients, 41%). Preliminary data from a secondary analysis excluding patients with hypertension or EKG evidence of ischemia suggested that CI may be significantly more common in DLB. Larger studies are needed to evaluate the implications for treatment and to explore the underlying mechanisms.

Carotid sinus syndrome is common in dementia with Lewy bodies and correlates with deep white matter lesions

Background: Carotid sinus syndrome (CSS) is a common cause of syncope in older persons. There appears to be a high prevalence of carotid sinus hypersensitivity (CSH) in patients with dementia with Lewy bodies (DLB) but not in Alzheimer’s disease. Objective: To compare the prevalence of CSH in DLB and Alzheimer’s disease, and to determine whether there is an association between CSH induced hypotension and brain white matter hyperintensities on magnetic resonance imaging (MRI). Methods: Prevalence of CSH was compared in 38 patients with DLB (mean (SD) age, 76 (7) years), 52 with Alzheimer’s disease (80 (6) years), and 31 case controls (73 (5) years) during right sided supine carotid sinus massage (CSM). CSH was defined as cardioinhibitory (CICSH; >3 s asystole) or vasodepressor (VDCSH; >30 mm Hg fall in systolic blood pressure (SBP)). T2 weighted brain MRI was done in 45 patients (23 DLB, 22 Alzheimer). Hyperintensities were rated by the Scheltens scale. Results: Overall heart rate response to CSM was slower (RR interval = 3370 ms (640 to 9400)) and the proportion of patients with CICSH greater (32%) in DLB than in Alzheimer’s disease (1570 (720 to 7800); 11.1%) or controls (1600 (720 to 3300); 3.2%) (p<0.01)). The strongest predictor of heart rate slowing and CSH was a diagnosis of DLB (Wald 8.0, p<0.005). The fall in SBP during carotid sinus massage was greater with DLB (40 (22) mm Hg) than with Alzheimer’s disease (30 (19) mm Hg) or controls (24 (19) mm Hg) (both p<0.02). Deep white matter hyperintensities were present in 29 patients (64%). In DLB, there was a correlation between magnitude of fall in SBP during CSM and severity of deep white matter changes (R = 0.58, p = 0.005). Conclusions: Heart rate responses to CSM are prolonged in patients with DLB, causing hypotension. Deep white matter changes from microvascular disease correlated with the fall in SBP. Microvascular pathology is a key substrate of cognitive impairment and could be reversible in DLB where there are exaggerated heart rate responses to carotid sinus stimulation.