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      Cardiovascular Assessment of Falls in Older People

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          Abstract

          Falls in older people can be caused by underlying cardiovascular disorders, either because of balance instability in persons with background gait and balance disorders, or because of amnesia for loss of consciousness during unwitnessed syncope. Pertinent investigations include a detailed history, 12-lead electrocardiography, lying and standing blood pressure, carotid sinus massage (CSM), head-up tilt, cardiac electrophysiological tests, and ambulatory blood pressure and heart rate monitoring, which includes external and internal cardiac monitoring. The presence of structural heart disease predicts an underlying cardiac cause. Conversely, the absence of either indicates that neurally mediated etiology is likely. CSM and tilt-table testing should be considered in patients with unexplained and recurrent falls. Holter monitoring over 24 hours has a low diagnostic yield. Early use of an implantable loop recorder may be more cost-effective. A dedicated investigation unit increases the likelihood of achieving positive diagnoses and significantly reduces hospital stay and health expenditure.

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          Most cited references 89

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          Incidence and prognosis of syncope.

          Little is known about the epidemiology and prognosis of syncope in the general population. We evaluated the incidence, specific causes, and prognosis of syncope among women and men participating in the Framingham Heart Study from 1971 to 1998. Of 7814 study participants followed for an average of 17 years, 822 reported syncope. The incidence of a first report of syncope was 6.2 per 1000 person-years. The most frequently identified causes were vasovagal (21.2 percent), cardiac (9.5 percent), and orthostatic (9.4 percent); for 36.6 percent the cause was unknown. The multivariable-adjusted hazard ratios among participants with syncope from any cause, as compared with those who did not have syncope, were 1.31 (95 percent confidence interval, 1.14 to 1.51) for death from any cause, 1.27 (95 percent confidence interval, 0.99 to 1.64) for myocardial infarction or death from coronary heart disease, and 1.06 (95 percent confidence interval, 0.77 to 1.45) for fatal or nonfatal stroke. The corresponding hazard ratios among participants with cardiac syncope were 2.01 (95 percent confidence interval, 1.48 to 2.73), 2.66 (95 percent confidence interval, 1.69 to 4.19), and 2.01 (95 percent confidence interval, 1.06 to 3.80). Participants with syncope of unknown cause and those with neurologic syncope had increased risks of death from any cause, with multivariable-adjusted hazard ratios of 1.32 (95 percent confidence interval, 1.09 to 1.60) and 1.54 (95 percent confidence interval, 1.12 to 2.12), respectively. There was no increased risk of cardiovascular morbidity or mortality associated with vasovagal (including orthostatic and medication-related) syncope. Persons with cardiac syncope are at increased risk for death from any cause and cardiovascular events, and persons with syncope of unknown cause are at increased risk for death from any cause. Vasovagal syncope appears to have a benign prognosis. Copyright 2002 Massachusetts Medical Society
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            Fear of falling and fall-related efficacy in relationship to functioning among community-living elders.

            The relationships of fear of falling and fall-related efficacy with measures of basic and instrumental activities of daily living (ADL-IADL) and physical and social functioning were evaluated in a cohort of community-living elderly persons. Sociodemographic, medical, psychological, and physical performance (e.g., gait speed, timed hand function) measures were administered, during an in-home assessment, to a probability sample of 1,103 residents of New Haven, Connecticut, who were > or = 72 years of age. Falls and injuries in the past year, fear of falling, and responses to the Falls Efficacy Scale were also ascertained. The three dependent variables included a 10-item ADL-IADL scale, an 8-item social activity scale, and a scale of relative physical activity level. Among cohort members, 57% denied fear of falling whereas 24% acknowledged fear but denied effect on activity; 19% acknowledged avoiding activities because of fear of falling. Twenty-four percent of recent fallers vs 15% of nonfallers acknowledged this activity restriction (chi 2 = 13.1; p < .001). Mean fall-related efficacy score among the cohort was 84.9 (SD 20.5), 79.8 (SD 23.4), and 88.1 (SD 17.9) among fallers and nonfallers, respectively (p < or = .0001). Fall-related efficacy proved a potent independent correlate of ADL-IADL (partial correlation = .265, p < .001); physical (partial correlation = .234, p < .001); and social (partial correlation = .088, p < .01), functioning in multiple regression models after adjusting for sociodemographic, medical, psychological, and physical performance covariates as well as history of recent falls and injuries. Fear of falling was only marginally related (p = .05) with ADL-IADL functioning and was not associated with higher level physical or social functioning. The strong independent association between self-efficacy and function found in this study suggests that clinical programs in areas such as prevention, geriatric evaluation and management, and rehabilitation should attempt simultaneously to improve physical skills and confidence. Available knowledge of the factors influencing efficacy should guide the development of these efficacy-building programs.
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              Prevention of falls in the elderly trial (PROFET): a randomised controlled trial.

              Falls in elderly people are a common presenting complaint to accident and emergency departments. Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences, and possibilities for future prevention. We undertook a randomised controlled study to assess the benefit of a structured inderdisciplinary assessment of people who have fallen in terms of further falls. Eligible patients were aged 65 years and older, lived in the community, and presented to an accident and emergency department with a fall. Patients assigned to the intervention group (n=184) underwent a detailed medical and occupational-therapy assessment with referral to relevant services if indicated; those assigned to the control group (n=213) received usual care only. The analyses were by intention to treat. Follow-up data were collected every 4 months for 1 year. At 12-month follow-up, 77% of both groups remained in the study. The total reported number of falls during this period was 183 in the intervention group compared with 510 in the control group (p=0.0002). The risk of falling was significantly reduced in the intervention group (odds ratio 0.39 [95% CI 0.23-0.66]) as was the risk of recurrent falls (0.33 [0.16-0.68]). In addition, the odds of admission to hospital were lower in the intervention group (0.61 [0.35-1.05]) whereas the decline in Barthel score with time was greater in the control group (p<0.00001). The study shows that an interdisciplinary approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment.
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                Author and article information

                Journal
                Clin Interv Aging
                Clinical Interventions in Aging
                Clinical Interventions in Aging
                Dove Medical Press
                1176-9092
                1178-1998
                March 2006
                March 2006
                : 1
                : 1
                : 57-66
                Affiliations
                [1 ]Falls and Syncope Service, Royal Victoria Infirmary Newcastle upon Tyne, UK
                [2 ]Institute for Ageing and Health, Wolfson Research Centre, Newcastle General Hospital Newcastle upon Tyne, UK
                Author notes
                Correspondence: Maw Pin Tan Falls and Syncope Service, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK Tel +44 191 223 6161 Fax +44 191 222 5638 Email mptan@ 123456doctors.org.uk
                Article
                2682455
                18047258
                © 2006 Dove Medical Press Limited. All rights reserved
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