The prevalence of Neurally Mediated Syncope in older patients presenting with unexplained falls

AimsTo determine the prevalence and clinical significance of carotid sinus syndrome (CSS) and vasovagal syncope (VVS), the two common types of Neurally Mediated Syncope (NMS), in a cohort of older patients with unexplained falls.MethodsPatients presenting with unexplained and accidental falls were identified from 200 consecutive admissions of falls in patients aged 65 years and older admitted to the Rapid Assessment Medical Unit (RAMU) in a teaching hospital. A sample of unexplained and accidental fallers underwent carotid sinus massage (CSM) and tilt table testing (TTT) as per a standardised protocol. Baseline characteristics, clinical variables and the prevalence of NMS were compared between the two groups.ResultsFalls were unexplained in 26% of patients. The prevalence of NMS was 24% (5/21) among patients with unexplained falls who underwent assessment for NMS, whereas it was nil (0/17) in patients with accidental falls (P = 0.050). The prevalence of previous falls was significantly higher in patients with unexplained falls (P = 0.0025), but all other baseline characteristics were similar between the two groups.ConclusionFalls are unexplained in a significant number of older patients presenting to acute hospitals. The assessment of unexplained fallers for NMS is clinically important as this may be aetiologically related in nearly a quarter of these patients.     

Application pratique et intérêt des recommandations de prise en charge des syncopes : évaluation de pratiques professionnelles

AimsTo assess the practical implementation of international guidelines and their impact on syncope management in a 500-bed general hospital.Patients and methodsThree groups of 63 consecutive patients admitted for syncope to the emergency care unit (ECU) were studied: group 1, before the guidelines delivered to the practitioners, group 2 immediately after the diffusion of guidelines and group 3, one year later. The study evaluates the mean duration of stay (MDS) and the relevance of the diagnostic strategy.ResultsIn group 1 compared to group 2, MDS were respectively 6.8 ± 5.5 and 5.4 ± 2.8 days (P = 0.07) and the unexplained syncope number respectively 22% and 24% (P = 0.8). The search of orthostatic hypotension became more systematic (13% versus 86% in group 1 and 2 respectively, P < 0.001). The agreement (kappa coefficient) between initial and final diagnostic increased in 0.34 to 0.44. One year later MDS in group 3 was 7.1 ± 4.7 days (P = 0.8 versus group 1 and P = 0.015 versus group 2) with only 6.3% systematic search for orthostatic hypotension (P < 0.001).ConclusionsGuidelines optimize the syncope management in the ECU and the agreement between the emergency and discharge diagnostic without change of unexplained syncope and. MDS tend to be shorter when guidelines are actively implemented. Nevertheless, the positive impact of guidelines implementation is of limited duration.     

The role of postural instability/gait difficulty and fear of falling in predicting falls in non-demented older adults

IntroductionPostural instability/gait difficulty (PIGD) and fear of falling (FoF) frequently co-exist, but their individual predictive values for falls have not been compared in aging. This study aims to determine both independent and combined effect of PIGD and FoF to falls in older adults without dementia.MethodsPIGD and other extrapyramidal signs were systematically assessed in 449 community-dwelling participants without Parkinson’s disease (76.48 ± 6.61 ys; 56.8% female) enrolled in this longitudinal cohort study. Presence of FoF was measured by a single-item question (Do you have a FoF?) and self-confidence by the Activities-specific Balance Confidence scale (ABC scale).ResultsOne hundred sixty-nine participants (38%) had an incident fall over a mean follow-up of 20.1 ± 12.2 months. PIGD was present in 32% and FoF in 23% of the participants. Both PIGD (adjusted hazard ratio (aHR): 2.28; p = 0.016) and self-confidence (aHR: 0.99; p = 0.040) predicted falls when entered simultaneously in the Cox model. However, presence of FoF (aHR: 1.99; p = 0.021) and self-confidence (aHR: 0.98; p = 0.006) predicted falls only in individuals with PIGD.ConclusionsPIGD and FoF were associated with future falls in older adults without dementia but FoF was a fall’s predictor only in individuals with PIGD.     

Exercise improves gait,reaction time and postural stability in older adults with type 2 diabetes and neuropathy

AimsFor older adults with type 2 diabetes (T2DM), declines in balance and walking ability are risk factors for falls, and peripheral neuropathy magnifies this risk. Exercise training may improve balance, gait and reduce the risk of falling. This study investigated the effects of 12 weeks of aerobic exercise training on walking, balance, reaction time and falls risk metrics in older T2DM individuals with/without peripheral neuropathy.MethodsAdults with T2DM, 21 without (DM; age 58.7 ± 1.7 years) and 16 with neuropathy (DM-PN; age 58.9 ± 1.9 years), engaged in either moderate or intense supervised exercise training thrice-weekly for 12 weeks. Pre/post-training assessments included falls risk (using the physiological profile assessment), standing balance, walking ability and hand/foot simple reaction time.ResultsPre-training, the DM-PN group had higher falls risk, slower (hand) reaction times (232 vs. 219 ms), walked at a slower speed (108 vs. 113 cm/s) with shorter strides compared to the DM group. Following training, improvements in hand/foot reaction times and faster walking speed were seen for both groups.ConclusionsWhile falls risk was not significantly reduced, the observed changes in gait, reaction time and balance metrics suggest that aerobic exercise of varying intensities is beneficial for improving dynamic postural control in older T2DM adults with/without neuropathy.     

The Physiological Profile Assessment: Clinical validity of the postural sway measure and comparison of impairments by age

BackgroundThe Physiological Profile Assessment (PPA) assesses falls risk in older adults by measuring impairments most associated with multiple falls. To date, no study has investigated the change in PPA impairment profile with age.ObjectiveTo describe impairment profiles, by age and ability to complete the postural sway measure, of older adults fallers.ParticipantsWe note that 885 older adults referred to multidisciplinary falls clinics located within two inner London boroughs (UK).MethodsAnonymised data was extracted from the PPA falls risk database. For comparisons, data was grouped by gender, age, and ability to complete the postural Sway test.ResultsThere were significant differences between all age groups in PPA falls risk, edge contrast sensitivity, quadriceps strength (Quad), postural sway and reported falls within the previous year (P < 0.01). The oldest age group (90+) had the highest PPA falls risk (P < 0.01), yet reported significantly less falls than the youngest age group (60 to 69; P < 0.05). There was significant variability in test results, with younger age groups displaying greater variability across PPA measures, and older age groups displaying more consistency (P < 0.05); 15.1% (n = 134) of patients that were able to perform the postural sway measure received a higher risk score for this test than those unable to complete the task.ConclusionsGreater variability in younger age groups indicates that specific impairments may provide the cause of falls, whereas widespread global reduction in function and frailty may provide the cause for falls in the older age groups. The postural sway scoring does not reflect ability to perform the test.     

Évaluation de la fréquence et des facteurs associés à l’hypotension orthostatique chez les diabétiques de type 2

Orthostatic hypotension is a major criterion for diabetic autonomic cardiac neuropathy. It increases overall and cardiovascular mortality.PurposeThe aim of our study was to evaluate the orthostatic hypotension frequency in type 2 diabetics and to investigate the associated factors.MethodsThis prospective cross-sectional study included adult patients with type 2 diabetes. Orthostatic hypotension was defined as a decrease in the systolic arterial pressure > 20 mm-Hg or a decrease in the diastolic arterial pressure > 10 mm-Hg, after 3 minutes of standing position. The arterial pressure was measured with a validated electronic device. Vascular risk factors and micro and macro-vascular complications were systematically investigated by the appropriate diagnostic means.ResultsWe evaluated 300 diabetic patients. Of these women represented 57%. The mean age was 58 years old. The average duration of diabetes was 8 years. The antidiabetic drugs were metformin (82%), sulfonylureas (36%) and insulin (40%). High blood pressure was present in 49% among whom 50% of patients received angiotensin II receptor blockers, 47% diuretics, 24% angiotensin converting enzyme inhibitors, 17% beta blockers, and 17% calcium channel blockers. Orthostatic hypotension has been identified in 26 patients (8.6%). In multivariate analysis, the associated factors with orthostatic hypotension were elevated systolic blood pressure and insulin treatment.ConclusionThe frequency of orthostatic hypotension is relatively low in our patients with type 2 diabetes and it was significantly associated with systolic blood pressure and insulin treatment.     

Tilt training increases vasoconstrictor reserve in patients with neurocardiogenic syncope

Neurocardiogenic syncope (NCS) is a common clinical entity resulting from an excessive reflex autonomic response, particularly during orthostatism. Treatment options are controversial and of limited effectiveness. Tilt training (TT) is a promising option to treat these patients. However, its mechanism of action and clinical impact remain unclear.ObjectiveTo characterize hemodynamic and autonomic responses during a TT program in patients with NCS refractory to conventional measures.MethodsWe studied 28 patients (50% male, mean age 41 ± 14 years) without structural heart disease, with NCS documented by tilt testing. The TT program included 9 tilt sessions (3 times a week, 30 min) (60° – 6 sessions, 70° – 3 sessions), under ECG and blood pressure monitoring combined with home orthostatic self-training and 10° head-up during sleep. Systolic volume, cardiac output, total peripheral resistance, baroreflex sensitivity and heart-rate variability were computed. Patients were reassessed at 1 month and every 6 months for a maximum of 36 months (24 ± 12 months).ResultsOver the course of the TT program there was a significant increase in total peripheral resistance (1485 ± 225 vs. 1591 ± 187 dyn·s·cm^?5, p < 0.05), with a decrease in standard deviation (206 ± 60 vs. 150 ± 42, p < 0.05). During follow-up, syncope recurred in five patients (19%), with a significant reduction in the number of episodes (4.0 ± 3.2/patient in the 12 months before TT vs. 1.4 ± 0.8/patient post-TT, p < 0.05).ConclusionIn refractory NCS, TT may be an effective therapeutic option, with long-term benefits. These results appear to be due to an increase in vasoconstrictor reserve combined with a reduction in its variance.     

Efficacy of Midodrine Hydrochloride in Neurocardiogenic Syncope Refractory to Standard Therapy

Midodrine for Refractory Neurocardiogenic Syncope. introduction : Some patients with neurocardiogenic syncope continue to have recurrent syncope or presyncope despite the use of currently available drug therapy. The purpose of this study was to determine whether midodrine hydrochloride, a selective adrenergic agonist, could he effective in patients resistant to, or intolerant of, currently used medications in the treatment of neurocardiogenic syncope.
Methods and Results : Eleven patients with a history of recurrent syncope or presyncope in whom hypotension with syncope or presyncope could be provoked during head-up tilt testing were included. There were 4 men and 7 women with a mean age (± SD) age of 34 ± 13 years. In all patients, standard therapy with beta-adrenergic receptor blocking agents, ephedrine, theophylline, disopyramide, fludrocortisone, and sertraline hydrochloride, was either ineffective, poorly tolerated, or contraindicated. Midodrine was initially administered orally at a dose of 2.5 mg three times daily. After adjustment of dosage over 2 to 4 weeks, patients were followed-up clinically. Midodrine was discontinued in one patient because of side effects. Frequency of syncope or presyncope during the 3 months prior to starting treatment was compared during a mean follow-up of 17 ± 4 weeks after starting treatment with midodrine. There was significant (P < 0.01) reduction in syncopal and presyncopal episodes on midodrine. Five patients had complete resolution of symptoms, while four patients had significant improvement. Symptoms did not improve in one patient.
Conclusions : Midodrine hydrochloride can he effective in preventing recurrent symptoms in selected patients with neurocardiogenic syncope unresponsive to, or intolerant of, standard drug therapy.     

Recurrencia y mortalidad a largo plazo de los pacientes con síncope no cardiogénico

Introduction and objectivesThere are no in-depth studies of the long-term outcome of patients with syncope after exclusion of cardiac etiology. We therefore analyzed the long-term outcome of this population.MethodsFor 147 months, we included all patients with syncope referred to our syncope unit after exclusion of a cardiac cause.ResultsWe included 589 consecutive patients. There were 313 (53.1%) women, and the median age was 52 [34-66] years. Of these, 405 (68.8%) were diagnosed with vasovagal syncope (VVS), 65 (11%) with orthostatic hypotension syncope (OHS), and 119 (20.2%) with syncope of unknown etiology (SUE). During a median follow-up of 52 [28-89] months, 220 (37.4%) had recurrences (21.7% ≥ 2 recurrences), and 39 died (6.6%). Syncope recurred in 41% of patients with VVS, 35.4% with OHS, and 25.2% with SUE (P = .006). In the Cox multivariate analysis, recurrence was correlated with age (P = .002), female sex (P < .0001), and the number of previous episodes (< 5 vs ≥ 5; P < .0001). Death occurred in 15 (3.5%) patients with VVS, 11 (16.9%) with OHS, and 13 (10.9%) with SUE (P = .001). In the multivariate analysis, death was associated with age (P = .0001), diabetes (P = .007), and diagnosis of OHS (P = .026) and SUE (P = .020).ConclusionsIn patients with noncardiac syncope, the recurrence rate after 52 months of follow-up was 37.4% and mortality was 6.6% per year. Recurrence was higher in patients with a neuromedial profile and mortality was higher in patients with a nonneuromedial profile.Full English text available from:www.revespcardiol.org/en     

Determinants of a positive response to carotid sinus massage and head-up tilt testing

BackgroundOrthostatic hypotension (OH) and carotid sinus hypersensitivity (CSH) are common causes of syncope in older people. The aim of this study was to determine if patient's age, sex and presenting symptoms influence the result of carotid sinus massage and head-up tilt testing.MethodsRetrospective analysis of the database and reports was carried out between 1995 and 2006 at a tertiary referral centre. Patient's age, sex, presenting symptoms and test result were examined. Presenting symptoms were classified as syncope, falls or dizzy spells.ResultsOf the 1583 tests reported, OH was present in 402 patients (25.4%), of whom 175 (11.1%) were symptomatic. 188 of 1464 (12.8%) patients undergoing carotid sinus massage had evidence of CSH, of which 156 were symptomatic.Male patients were significantly more likely to have symptomatic CSH than female patients (odds ratio 2.28, 95% CI 1.54 to 3.04, p < 0.01).There were non-significant trends to increased diagnosis of symptomatic OH with increasing age, male sex and referral with syncope. There were non-significant trends to increased diagnosis of symptomatic CSH with increasing age and referral with syncope.ConclusionMale sex, increasing age and being referred with syncope were all associated with an increased likelihood of receiving a diagnosis of either OH or CSH. The overall prevalence of CSH was lower than in previous studies, which may reflect different patient populations.     

Cardiac causes for falls and their treatment

Cardiovascular disorders are a common cause of falls and syncope in older adults. The most common cardiac disorders linked to falls and syncope are carotid sinus syndrome, postprandial hypotension, orthostatic hypotension, vasovagal syncope, and bradyarrhythmias. It is important to recognize these conditions, because they may be associated with an increased mortality. Most are easily treatable.     

Reducing falls among older people in general practice: The ProAct65+ exercise intervention trial

BackgroundFalls are common in the older UK population and associated costs to the NHS are high. Systematic reviews suggest that home exercise and group-based exercise interventions, which focus on progressively challenging balance and increasing strength, can reduce up to 42% of falls in those with a history of falls. The evidence is less clear for those older adults who are currently at low risk of falls.AimProAct65+, a large, cluster-randomised, controlled trial, investigated the effectiveness of a home exercise programme (Otago Exercise Programme (OEP)) and a group-based exercise programme (Falls Management Exercise (FaME)) compared to usual care (UC) at increasing moderate to vigorous physical activity (MVPA). This paper examines the trial’s secondary outcomes; the effectiveness of the interventions at reducing falls and falls-related injuries.Setting & participants1256 community-dwelling older adults (aged 65 + ) were recruited through GP practices in two sites (London and Nottingham). Frequent fallers (≥3 falls in last year) and those with unstable medical conditions were excluded, as were those already reaching the UK Government recommended levels of physical activity (PA) for health.MethodsBaseline assessment (including assessment of health, function and previous falls) occurred before randomisation; the intervention period lasted 24 weeks and there was an immediate post-intervention assessment; participants were followed up every six months for 24 months. Falls data were analysed using negative binomial modelling.Outcome measuresFalls data were collected prospectively during the intervention period by 4-weekly diaries (6 in total). Falls recall was recorded at the 3-monthly follow-ups for a total of 24 months. Balance was measured at baseline and at the end of the intervention period using the Timed Up & Go and Functional Reach tests. Balance confidence (CONFbal), falls risk (FRAT) and falls self-efficacy (FES-I) were measured by questionnaire at baseline and at all subsequent assessment points.Results294 participants (24%) reported one or two falls in the previous year. There was no increase in falls in either exercise group compared to UC during the intervention period (resulting from increased exposure to risk). The FaME arm experienced a significant reduction in injurious falls compared to UC (incidence rate ratio (IRR) 0.55, 95% CI 0.31, 0.96; p = 0.04) and this continued during the 12 months after the end of the intervention (IRR 0.73, 95% CI 0.54, 0.99; p = 0.05). There was also a significant reduction in the incidence of all falls (injurious and non-injurious) in the FaME arm compared with UC (IRR 0.74, 95% CI 0.55, 0.99; p = 0.04) in the 12 month period following the cessation of the intervention. There was a non-significant reduction in the incidence of all falls in the OEP arm compared with UC (IRR 0.76, 95% CI 0.53, 1.09; p = 0.14) in the 12 months following the cessation of the intervention. The effects on falls did not persist at the 24 months assessment in either exercise arm. However, when those in the FaME group who continued to achieve 150 min of MVPA per week into the second post-intervention year were compared to those in the FaME group who did not maintain their physical activity, there was a significant reduction in falls incidence (IRR = 0.49, 95% CI 0.30, 0.79; p = 0.004). CONFbal was significantly improved at 12 months post intervention in both intervention arms compared with UC. There were no significant changes in any of the functional balance measures, FES-I or FRAT, between baseline and the end of the intervention period.ConclusionCommunity-dwelling older adults who joined an exercise intervention (FaME) aimed at increasing MVPA did not fall more during the intervention period, fell less and had fewer injurious falls in the 12 months after cessation of the intervention. However, 24 months after cessation of exercise, the beneficial effects of FaME on falls reduction ceased, except in those who maintained higher levels of MVPA. OEP exercise appears less effective at reducing falls in this functionally more able population of older adults.     

Le syndrome de tachycardie posturale (PoTS) : une maladie pour l’interniste

Postural tachycardia syndrome (PoTS) is a multifactorial syndrome defined by an increase in heart rate ≥ 30 bpm, within 10 minutes of standing (or during a head up tilt test to at least 60°), in absence of orthostatic hypotension. It is associated with symptoms of cerebral hypoperfusion that are worse when upright and improve in supine position. Patients have an intense fatigue with a high incidence on quality of life. This syndrome can be explained by many pathophysiological mechanisms. It can be associated with Ehlers-Danlos disease and some autoimmune disorders. The treatment is based on nonpharmacological measures and treatment with propranolol, fludrocortisone or midodrine.     

Midodrine in the prevention of hepatorenal syndrome type 2 recurrence: A case–control study

BackgroundHepatorenal syndrome is a severe complication of cirrhosis. Treatment with terlipressin has currently the best efficacy pedigree, inducing hepatorenal syndrome reversal in a high proportion of patients. However, hepatorenal syndrome recurrence after terlipressin withdrawal is very common, especially in type 2 hepatorenal syndrome. Midodrine, an oral adrenergic vasoconstrictor, has been suggested to be an effective therapy in hepatorenal syndrome.AimsTo analyse the impact of treatment with midodrine after hepatorenal syndrome type 2 reversal induced by terlipressin on the prevention of hepatorenal syndrome recurrence.Patients and methodsA case–control design was used. The outcome of 10 patients with hepatorenal syndrome type 2 treated successfully with terlipressin and then with midodrine (7.5–12.5 mg/tid) was compared with that of an historical control group of hepatorenal syndrome type 2 patients responders to treatment with terlipressin. Patients and controls were matched by age, plasma renin activity (PRA) levels and severity of renal and liver failure.ResultsCases and controls were similar with respect to pre-treatment with terlipressin. The hepatorenal syndrome recurrence probability was the same in the two groups (cases and control: 9/10, 90%, p = ns). No significant differences were found between cases and controls with respect to serum creatinine (1.9 ± 0.1 mg/dl vs. 2 ± 0.2 mg/dl), blood creatinine clearance (28 ± 5 ml/min vs. 24 ± 5 ml/min), urinary sodium excretion (12 ± 6 mequiv./d vs. 19 ± 4 mequiv./d) and PRA levels (17 ± 3 ng/ml/h) vs. 20 ± 3 ng/ml/h) after terlipressin withdrawal (p = ns).ConclusionsThese results show that in patients responders to terlipressin hepatorenal syndrome recurrence is not different between patients treated with midodrine and subjects who did not receive vasoconstrictor treatment after terlipressin withdrawal. These data suggest that midodrine is not effective in preventing hepatorenal syndrome type 2 recurrence.     

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.     

Prevalence and associative factors of orthostatic hypotension in older adults: Results from the Well-being of the Singapore Elderly (WiSE) study

BackgroundOrthostatic hypotension (OH) is commonly reported among older adults and is associated with an increased risk of mortality. This study aimed to describe the prevalence and investigate the possible associations between OH with sociodemographic variables, chronic medical conditions, health service utilisation, dementia and cognitive status among older adults residing in Singapore.MethodsData was collected from 2266 participants aged 60 years and older who participated in the Well-being of the Singapore Elderly (WiSE) study in 2013. Face-to-face interviews were conducted and data collected includes sociodemographic information, blood pressure measurements, medical history, health services utilisation, and cognitive status.ResultsThe prevalence of OH among older adults in Singapore was 7.8%. OH was highest in participants aged 85 years and above (OR: 2.33; 1.26–4.30; p = 0.007) compared to those aged 75–84 years (OR: 1.76; 1.08-2.85; p = 0.023). Participants with hypertension were more likely to have OH (OR: 3.03; 1.56–5.88, p = 0.001) than those without hypertension. Those with dementia were also more likely to have OH than those with normal cognitive status (p = 0.007).ConclusionsOlder age, hypertension, and dementia were independently associated with OH in the older adult population in Singapore. Interventions such as home safety assessment and preventive measures should be implemented to improve older adult’s functional capacity and quality of life to prevent injury.     

Multiple modes of assessment of gait are better than one to predict incident falls

BackgroundThough gait evaluation is recommended as a core component of fall risk assessments, a systematic examination of the predictive validity of different modes of gait assessments for falls is lacking.ObjectiveTo compare three commonly employed gait assessments – self-reported walking difficulties, clinical evaluation, and quantitative gait – to predict incident falls.Materials and methods380 community-dwelling older adults (mean age 76.5 ± 6.8 y, 55.8% female) were evaluated with three independent gait assessment modes: patient-centered, quantitative, and clinician-diagnosed. The association of these three gait assessment modes with incident falls was examined using Cox proportional hazards models.Results23.2% of participants self-reported walking difficulties, 15.5% had slow gait, and 48.4% clinical gait abnormalities. 30.3% had abnormalities on only one assessment, whereas only 6.3% had abnormalities on all three. Over a mean follow-up of 24.2 months, 137 participants (36.1%) fell. Those with at least two abnormal gait assessments presented an increased risk of incident falls (hazard ratio (HR): 1.61, 95% confidence interval (CI): 1.04–2.49) in comparison to the 169 participants without any abnormalities on any of the three assessments.ConclusionsMultiple modes of gait evaluation provide a more comprehensive mobility assessment than only one assessment alone, and better identify incident falls in older adults.     

Blunted baroreflex sensitivity: An underestimated cause of falls in the elderly?

BackgroundAutonomic nervous system disturbance and cardiovascular disorders may be underestimated causes of falls. Heart rate turbulence (HRT), heart rate variability (HRV) and QT dynamicity parameters are noninvasive cardiac autonomic activity markers. The aim of this study was to evaluate autonomic cardiovascular markers in falling older adults.MethodsThis was a case-control study conducted at a geriatric medicine outpatient clinic of a university hospital. Study group consisted of 33 older adults who had falls in the last 12 months and the control group included 31 subjects who had never experienced falls. The patients in the study group were examined with 24-hour Holter electrocardiogram (ECG) and carotid sinus massage was done under monitorization. The 24-hour Holter ECG data were recorded and assessed with the ELATEC software. HRV, QT dynamicity and HRT parameters were analysed.ResultsThirty-three faller and 31 non-faller patients were examined in this study. Age and gender were similar between groups. All patients and control subjects had normal ejection fraction. Carotid sinus massage was done to the patients in the study group and three of 33 were positive (9.09%). There was no significant difference in HRV and QT dynamicity parameters between groups. Both HRT onset (2.51 ± 1.48 vs. 7.29 ± 3.28 P < 0.001) and turbulence slope (0.15 ± 1.10 vs. ?0.73 ± 1.89; P = 0.031) were significantly different between the groups.ConclusionElderly subjects with recent falls have significantly worse HRT parameters than matched non-falling counterparts. Blunted baroreflex sensitivity and impaired cardiac autonomic function can be an important reason for falls in the geriatric age group.     

Syncope-related falls in the elderly

Age-related physiological impairments of heart rate, blood pressure and cerebral blood flow, in combination with comorbid conditions and concurrent medications, account for an increased susceptibility to syncope in older adults. Common causes of syncope are orthostatic hypotension, neurally-mediated syncope (including carotid sinus syndrome) and cardiac arrhythmias. A high proportion of older patients with cardiovascular syncope present with falls and deny loss of consciousness. Patients who are cognitively normal and have unexplained falls should have a detailed cardiovascular assessment. (J Geriatr Cardiol 2005; 2 (2): 74-83).     

Gait speed and risk assessment for falls among men aged 80 years and older: A prospective cohort study in Taiwan

PurposeTo evaluate the effectiveness of adding gait speed to the history of falls in predicting falls among men aged 80 years and older in Taiwan.MethodsThis prospective cohort study recruited 230 ambulatory men aged 80 years and older in 2012 and followed for 12 months. In addition to demographic characteristics and history of falls, a comprehensive geriatric assessment was performed for all study subjects. Gait speed was obtained by the 6-m walk and three different cut-offs (< 0.5, ≤ 0.8 and < 1.0 m/s) were tested in improving the ability of predicting subsequent falls by using history of falls.ResultsAmong all subjects (mean age: 85.5 ± 4.0 years), 26.1% (60/230) reported falls during follow-up period. Univariate analysis showed that polypharmacy, urinary incontinence, history of falls, pain, poorer baseline physical function, depressive mood, and gait speed < 0.5 m/s were associated with falls. Logistic regression showed that history of falls (OR: 4.255, 95% CI 2.089–8.667; P < 0.001), pain (OR: 2.674, 95% CI 1.332–5.369; P = 0.006), older age (OR: 1.128, 95% CI 1.031–1.234; P = 0.008), and slow gait speed (OR: 2.964, 95% CI 1.394–6.300; P = 0.005) were all independent risk factors for falls. Fast gait speed (defined as ≥ 1 m/s) was a protective factor for falls, even among subjects with history of falls, but slow gait speed (defined as < 0.5 m/s) was an independent risk factor even among subjects without history of falls.ConclusionsCombined history of falls and gait speed is a simple and effective tool in risk assessment of falls among older old population.