Monitoring devices for falls and syncope

Monitoring devices are an important adjunct to the clinical assessment of patients who experience falls. The use of these devices should be guided by the clinical history, a physical assessment, and routine investigations. Quantitative measures of postural sway should be used in conjunction with clinical measures to provide a more accurate assessment of gait and balance. Assessment of blood pressure changes during the investigation of neurocardiovascular causes of syncope and falls in older adults should be performed with noninvasive digital photoplethysmographic devices, so long as their appropriate use and limitations are applied and understood. Only minimal information can be gained from short-term heart rate and rhythm monitoring in patients with infrequent symptoms. The usefulness of long-term ECG monitoring (with both external and implantable recorders) is well established for the diagnosis of unexplained syncope but requires further assessment in older individuals who experience falls. Twenty-four-hour measurements of ambulatory blood pressure generally are not diagnostically helpful in patients who experience falls or syncope but do have a role in the monitoring of therapeutic interventions.     

Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION: Update of the 1996 U.S. Preventive Services Task Force (USPSTF) recommendation statement on counseling to prevent household and recreational injuries, including falls. METHODS: The USPSTF reviewed new evidence on the effectiveness and harms of primary care-relevant interventions to prevent falls in community-dwelling older adults. The interventions were grouped into 5 main categories: multifactorial clinical assessment (with or without direct intervention), clinical management (with or without screening), clinical education or behavioral counseling, home hazard modification, and exercise or physical therapy. RECOMMENDATIONS: The USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (Grade B recommendation)The USPSTF does not recommend automatically performing an in-depth multifactorial risk assessment in conjunction with comprehensive management of identified risks to prevent falls in community-dwelling adults aged 65 years or older because the likelihood of benefit is small. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values. (Grade C recommendation).     

Orthostatic hypotension

A common problem among elderly people, orthostatic hypotension is associated with significant morbidity and mortality, which may be caused by medications, the cumulative effects of age- and hypertension-related alterations in blood pressure regulation, or age-associated diseases that impair autonomic function. Evaluation requires multiple blood pressure measurements taken at different times of the day and after meals or medications. Central and peripheral nervous system disorders should be sought, and the laboratory evaluation should concentrate on ruling out diabetes mellitus, amyloidosis, occult malignancy, and vitamin deficiencies. If orthostatic hypotension is detected, it should be considered a risk factor for adverse outcomes and treated first with nonpharmacologic interventions, including the withdrawal of potentially hypotensive medications. In patients with hypertension and orthostatic hypotension, the judicious treatment of hypertension may be helpful. For persistent, symptomatic orthostatic hypotension caused by autonomic failure, pharmacologic interventions include fludrocortisone, midodrine, and a variety of other agents. The careful evaluation and management of orthostatic hypotension will hopefully result in a significant reduction in falls, syncope, and fractures, and an attenuation of functional decline in elderly patients.     

Orthostatic hypotension in the elderly: diagnosis and treatment

Orthostatic hypotension is a common problem among elderly patients, associated with significant morbidity and mortality. While acute orthostatic hypotension is usually secondary to medication, fluid or blood loss, or adrenal insufficiency, chronic orthostatic hypotension is frequently due to altered blood pressure regulatory mechanisms and autonomic dysfunction. The diagnostic evaluation requires a comprehensive history including symptoms of autonomic nervous system dysfunction, careful blood pressure measurement at various times of the day and after meals or medications, and laboratory studies. Laboratory investigation and imaging studies should be based upon the initial findings with emphasis on excluding diagnoses of neurodegenerative diseases, amyloidosis, diabetes, anemia, and vitamin deficiency as the cause. Whereas asymptomatic patients usually need no treatment, those with symptoms often benefit from a stepped approach with initial nonpharmacological interventions, including avoidance of potentially hypotensive medications and use of physical counter maneuvers. If these measures prove inadequate and the patient remains persistently symptomatic, various pharmacotherapeutic agents can be added, including fludrocortisone, midodrine, and nonsteroidal anti-inflammatory drugs. The goals of treatment are to improve symptoms and to make the patient as ambulatory as possible rather then trying to achieve arbitrary blood pressure goals. With proper evaluation and management, the occurrence of adverse events, including falls, fracture, functional decline, and myocardial ischemia, can be significantly reduced.     

Falls in older people: epidemiology, risk factors and strategies for prevention

Falls are a common and often devastating problem among older people, causing a tremendous amount of morbidity, mortality and use of health care services including premature nursing home admissions. Most of these falls are associated with one or more identifiable risk factors (e.g. weakness, unsteady gait, confusion and certain medications), and research has shown that attention to these risk factors can significantly reduce rates of falling. Considerable evidence now documents that the most effective (and cost-effective) fall reduction programmes have involved systematic fall risk assessment and targeted interventions, exercise programmes and environmental-inspection and hazard-reduction programmes. These findings have been substantiated by careful meta-analysis of large numbers of controlled clinical trials and by consensus panels of experts who have developed evidence-based practice guidelines for fall prevention and management. Medical assessment of fall risks and provision of appropriate interventions are challenging because of the complex nature of falls. Optimal approaches involve interdisciplinary collaboration in assessment and interventions, particularly exercise, attention to co-existing medical conditions and environmental inspection and hazard abatement.     

Accidental Falls and Risk of Mortality among Older Adults on Chronic Peritoneal Dialysis

Background and objectives

More than 40% of elderly hemodialysis patients experience one or more accidental falls within a 1-year period. Such falls are associated with higher mortality. The objectives of this study were to assess whether falls are also common in elderly patients established on peritoneal dialysis and evaluate if patients with falls have a higher risk of mortality than patients who do not experience a fall.

Design, setting, participants, & measurements

Using a prospective cohort study design, patients ages≥65 years on chronic peritoneal dialysis from April 2002 to April 2003 at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first 15 months were recorded. Outcome data were collected until death, study end (July 31, 2012), transplantation, or transfer to another dialysis center.

Results

Seventy-four of seventy-six potential patients were recruited, assessed at baseline, and followed biweekly for falls; 40 of 74 (54%) peritoneal dialysis patients experienced 89 falls (adjusted mean fall rate, 1.7 falls per patient-year; 95% confidence interval, 1.0 to 2.7). Patients with falls were more likely to have had previous falls, be more recently initiated onto dialysis, be men, be older, and have higher comorbidity. Twenty-eight patients died during the follow-up period. After adjustment for known risk factors, each successive fall was associated with a 1.62-fold higher mortality (hazard ratio, 1.62; 95% confidence interval, 1.29 to 2.02; P<0.001).

Conclusions

Accidental falls are common in the peritoneal dialysis population and often go unrecognized. Falls were associated with higher mortality risk. Because fall interventions are effective in other populations, screening peritoneal dialysis patients for falls may be a simple measure of clinical importance.     

A novel emergency medical services-based program to identify and assist older adults in a rural community

Rural-dwelling older adults experience unique challenges related to accessing medical and social services. This article describes the development, implementation, and experience of a novel, community-based program to identify rural-dwelling older adults with unmet medical and social needs that leveraged the existing emergency medical services (EMS) system. The program specifically included geriatrics training for EMS providers; screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; communication of EMS findings to community-based case managers; in-home evaluation by case managers; and referral to community resources for medical and social interventions. Measures used to evaluate the program included patient needs identified by EMS or the in-home assessment, referrals provided to patients, and patient satisfaction. EMS screened 1,231 of 1,444 visits to older patients (85%). Of those receiving specific screens, 45% had fall-related, 69% medication management-related, and 20% depression-related needs identified. One hundred and seventy-one eligible EMS patients who could be contacted accepted the in-home assessment. Of the 153 individuals completing the assessment, 91% had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in this rural community, although many will refuse the services. Further patient evaluations by case managers, with subsequent interventions by existing service providers as required, can facilitate the needed linkages between vulnerable rural-dwelling older adults and needed community-based social and medical services.     

Male impotence

Erectile dysfunction can be devastating for men and for their partners. A good sexual history and focused physical examination can provide clues as to whether the underlying cause is psychogenic or organic. Diagnostic investigation should be tailored to the clinical picture. Oral medications now represent first-line therapy. Penile injection therapy and vacuum constrictive devices are reasonable choices for men in whom oral therapy falls or is contraindicated. The penile prosthesis provides a reliable long-term solution with high satisfaction rates. Psychotherapy may be indicated. Physicians can have a positive impact on the quality of life of patients by providing a non-judgmental and supportive environment for discussion and management of impotence.     

Surgical management of crohn’s disease in children

Opinion statement One of the most common beliefs in the management of Crohn’s disease is that surgery should be considered only as a last resort. Surgery is often considered by patients and gastroenterologists to represent a "failure." However, the role of surgery in the care of patients with Crohn’s disease has increasingly become a collaborative effort, with surgeons involved in many aspects of the management of these patients. This is particularly true in pediatric patients, as issues of growth and development may involve surgical intervention at earlier stages than might be required in older patients. In fact, surgical interventions may be indicated at any stage of the disease process. For example, early examination under anesthesia with abscess drainage and delineation of fistula tracts has proven very useful in patients with complex perineal disease. Surgery may contribute to the medical management of the disease by way of providing chronic enteral or parenteral access for nutritional interventions such as elemental feedings and total parenteral nutrition. Finally, surgical treatment of intraabdominal complications including fistulas, phlegmon, and bowel strictures may have a dramatic impact on patient symptoms and side effects. Although bowel resection carries the long-term risk of short bowel syndrome should future resections be required, the improvements in medical therapy continue to reduce the risk of recurrent disease, making surgical resection more palatable. Surgical treatment of complicated disease offers significant potential to limit toxic medical therapy and improve quality of life. In addition, application of minimally invasive techniques can minimize the impact of insults to body image in this vulnerable patient population as well as speed recovery. Future interventions may be facilitated by reducing adhesion formation through the use of minimally invasive techniques. The dynamic nature of growth and development in the pediatric population presents unique complications from medical therapies that are different from those seen in adults. Criteria for surgical intervention must be interpreted in light of the specific challenges facing the pediatric population as frequently pointed out in the oft-quoted maxim, "children are not small adults!"     

New approaches to the treatment and prevention of neurally mediated reflex (neurocardiogenic) syncope

Neurally mediated reflex syncope (sometimes referred to as neurocardiogenic syncope), encompasses a group of disorders of which the best known and most frequently occurring forms are the vasovagal (or common) faint, and carotid sinus syndrome. Postmicturition syncope, defecation syncope, cough syncope, and other situational reflex faints are also included among these conditions. With the exception of carotid sinus syndrome in which cardiac pacing is effective, treatment of most neurally mediated reflex faints is shifting from reliance on various drugs to greater emphasis on education and nonpharmacologic therapy. Initial management should include counseling of patients regarding recognition of early warning symptoms, and avoidance of precipitating factors. Volume expansion with salt tablets or electrolyte-containing beverages and patient education on how to perform isometric arm contractions and/or leg crossing in order to abort impending syncope are also important. Thereafter, tilt-training has demonstrated benefit in several clinical studies. When symptoms remain despite the above-noted interventions, pharmacologic therapy with midodrine or a nonselective à-blocker can be considered. the case of most neurally mediated reflex faints, permanent cardiac pacing should be reserved only for those older patients with significant bradycardia or asystole at time of syncope when all other interventions have failed.     

Preventing falls and fall-related injuries in hospitals

Falls are a widespread concern in hospitals settings, with whole hospital rates of between 3 and 5 falls per 1000 bed-days representing around a million inpatient falls occurring in the United States each year. Between 1% and 3% of falls in hospitals result in fracture, but even minor injuries can cause distress and delay rehabilitation. Risk factors most consistently found in the inpatient population include a history of falling, muscle weakness, agitation and confusion, urinary incontinence or frequency, sedative medication, and postural hypotension. Based on systematic reviews, recent research, and clinical and ethical considerations, the most appropriate approach to fall prevention in the hospital environment includes multifactorial interventions with multiprofessional input. There is also some evidence that delirium avoidance programs, reducing sedative and hypnotic medication, in-depth patient education, and sustained exercise programs may reduce falls as single interventions. There is no convincing evidence that hip protectors, movement alarms, or low-low beds reduce falls or injury in the hospital setting. International approaches to developing and maintaining a fall prevention program suggest that commitment of management and a range of clinical and support staff is crucial to success.     

Monitoring falls in cohort studies of community-dwelling older people: effect of the recall interval

OBJECTIVES: To determine whether the interval over which patients are asked to remember their falls affects fall reporting. DESIGN: Systematic literature review. SETTING: Community. PARTICIPANTS: Individuals being monitored for falls in prospective studies that asked participants to recall falls over varying intervals. MEASUREMENTS: Sensitivity and specificity of retrospective recall compared with a criterion-standard prospective assessment using some form of ongoing fall monitoring. RESULTS: Six studies met the inclusion criteria. Recall of falls in the previous year was specific (specificity 91-95%) but less sensitive (sensitivity 80-89%) than the criterion standard of ongoing prospective collection of fall data using fall calendars or postcards. Patients with injurious falls were more likely to recall their falls. Lower Mini-Mental State Examination score was associated with poorer recall of falls in the one study addressing this issue. CONCLUSION: Whenever accurate data on all falls are critical, such as with interventions to decrease the rate of falls, researchers should gather information on falls every week or every month from study participants. The optimal method of fall monitoring--postcard, calendar, diary, telephone, or some combination of these--remains unknown.     

Nonpharmacological and nonsurgical approaches in OA

Osteoarthritis (OA) is a chronic, disabling, and common disease. Nonpharmacological and nonsurgical treatments are seen as the core treatments for OA. This paper presents an overview of the recommendations from international guidelines on nonpharmacological and nonsurgical interventions. Education, advice, or information about the etiology, progression, prognosis, and treatment options of OA are recommended to be an ongoing and integral part of care. Weight loss (if overweight) is an important core treatment in knee and hip OA. Exercise is a key core treatment in knee, hip, and hand OA and should be considered regardless of age, structural disease severity, functional status, pain levels, or the presence of comorbidities. Walking aids/devices are recommended for both hip and knee OA, while orthoses are recommended for patients with carpometacarpal (CMC) joint OA. Trained healthcare providers with the skills to provide the core treatments are essential. In addition, there should be a proactive management from the first consultation for OA symptoms. Tools for such proactive management and for better uptake of the core interventions are discussed.     

Neurally mediated syncope

The prevalence and incidence of syncope increases with advancing years due to age related physiological changes in the neurocardiovascular, endocrine and renal systems. Cardiovascular syncope can present as falls because of amnesia for loss of consciousness or postural instability due to hypotension. Drop attacks or non accidental falls should thus be investigated for causes of syncope. The most common causes of neurally mediated syncope in older adults are carotid sinus syndrome, orthostatic hypotension and vasovagal syncope.     

Falls in cognitive impairment and dementia

Older people with cognitive impairment and dementia are at increased risk for falls and subsequent adverse events. The most common risk factors for falls that are found specifically in patients with cognitive impairment and dementia are postural instability, medication, neurocardiovascular instability (particularly orthostatic hypotension), and environmental hazards. Based on data from studies in cognitively normal people who fall, modification of these risk factors may prevent falls in older people with cognitive impairment and dementia. Preliminary research in subjects with cognitive impairment and dementia suggests that physiotherapy may have a role in falls prevention. Additionally, risk-factor-targeted interventions may reduce the risk of falls in patients who have cardiovascular abnormalities and neurocardiovascular instability.     

Promoting continence: simple strategies with major impact

Urinary incontinence is a common problem, especially among women, yet it remains underreported and undertreated. This is partly due to patients' beliefs that little can be done and partly due to healthcare professionals' perception that treatment is limited to surgery, advanced behavioral strategies requiring specialized equipment, or containment devices. Nurses are in a strategic position to reduce the incidence of incontinence by teaching bladder health strategies (ie, fluid management, appropriate voiding intervals, constipation prevention, weight control, smoking cessation, and pelvic muscle exercises), actively assessing patients for incontinence, and initiating appropriate referrals and primary interventions. Patients with significant neurologic deficits, structural abnormalities such as pelvic organ prolapse, or urinary retention should be referred for further workup. However, most patients can be treated with primary continence restoration strategies, which include identifying and correcting reversible factors such as urinary tract infection or atrophic urethritis; instruction in pelvic floor muscle exercises; and instruction regarding urge inhibition strategies. Implementing these simple strategies can significantly improve bladder function and continence in the majority of patients.     

Managing respiratory symptoms at the end of life

Early and clear discussion and articulation of preferences about interventions with increasing burdens and diminishing benefits is helpful in identifying the goals of care and planning management for patients who have unremitting terminal illnesses. The development of respiratory symptoms such as dyspnea, cough, and hiccups is common and can often be anticipated. Aggressive evaluation and treatment should be pursued and offered to palliate symptoms at the end of life.     

Do continence management strategies reduce falls? A systematic review

Urinary incontinence is associated with increased fall risk, and fall prevention programs include recommendations to manage continence as one component of fall reduction. However, the evidence to support this recommendation is unclear. The aim of this study was to identify continence management interventions that are effective in decreasing falls. A systematic review of the literature was conducted. Studies were included if they evaluated the effect of any type of continence management strategy on falls in older adults. The included studies were assessed for quality, and data relating to participants, interventions and outcomes were extracted by two independent reviewers. Four articles met the inclusion criteria. Two studies were randomised controlled trials, one a retrospective cohort study and one an uncontrolled intervention study. Interventions included pharmacological agents, a toileting regime combined with physical activity and an individualised continence program. Only the study evaluating the combination of physical activity and prompted voiding found an effect on falls. It is surprising that there has been so little research into continence management interventions that include fall outcomes. A toileting regime combined with physical activity may reduce falls in residential care. There is a need for further studies investigating the impact of continence management on falls.     

Preventing Falls and Fall-related Injuries Among Older People

Abstract. Deaths and disability from falls are important contributors to the global burden of disease and injury. Consequently, there is a need to identify and implement strategies that have been shown to be effective in preventing falls and falls-related injuries. As the effects of such interventions are likely to be moderate, the identification of effective interventions can only be provided by randomised controlled trials and their meta-analyses. Currently, known effective interventions include risk assessment and targeted multi-factorial interventions, physical activity and, possibly, reductions in psychotropic medication, as well as the use of hip protective underwear, vitamin D and calcium, and alendronate. Substantial progress in reducing the incidence of falls and fall-related injuries globally is likely to occur if knowledge about currently known effective interventions is widely disseminated and implemented. Further progress will be made if large-scale randomised controlled trials are conducted, that can both confirm the effectiveness of these promising interventions and examine other interventions suggested from observational studies     

Device-Guided Breathing for Hypertension: a Summary Evidence Review

Persistently raised blood pressure is one of the major risk factors for diseases such as myocardial infarction and stroke. Uncontrolled hypertension is also associated with high rates of mortality, particularly in middle and high-income countries. Lifestyle factors such as poor diet, obesity, physical inactivity and smoking are all thought to contribute to the development of hypertension. As a result, the management of hypertension should begin with modifying these lifestyle factors. Beyond this, drug interventions are used as the predominant form of management. However, adherence to medications can be highly variable, medication side effects are common, and may require regular monitoring or, in some individuals may be ineffective. Therefore, additional non-pharmacologic interventions that lower blood pressure may be advantageous when combined with lifestyle modifications. Such interventions may include relaxation therapies such as slow breathing exercises, which can be initiated by means of specific devices. The technique of device-guided breathing (DGB) has been considered by guideline developers in the management of hypertension. One specific device, the Resperate, has received US FDA and UK NHS approval over the last few years. In this review, we summarise the evidence base on efficacy and find that although some clinical trials exist that demonstrate a BP-lowering effect, others do not. There is currently insufficient evidence from pooled data to recommend the routine use of device-guided breathing in hypertensive patients.