Cardiovascular associations of falls and syncope in the elderly

The principle aims of this doctoral investigation are to provide new insights into the relationship between cardiovascular disease (CVD) and falls in the elderly population in Ireland. The rapidly ageing global demographic has meant that there will be a significant increase in healthcare burden from chronic disease. Falls are currently the most common cause of injury and resulting morbidity in people over the age of 65 years. Risk factors for falls have been established, however there has been very little in the way of measures which have proven preventative. Initially I had performed a literature review aiming to discern cardiovascular disorders which were associated with falls in the elderly. This had allowed me to systematically evaluate what associations have already been reported in the literature and where inconsistency still exists. This demonstrated multiple reported associations of cardiovascular disorders with falls, unexplained falls and syncope in elderly people. I have focused on disorders which result in syncope but can present as a fall in elderly patients. For my second paper I have used the Irish longitudinal Study Ageing (TILDA) to calculate the prevalence of falls, unexplained falls and syncope in the community dwelling Irish population. Also using the TILDA database I have been able to formulate logistic regression models which can be used to calculate odds ratios for self-reported health conditions and the exposures above. This allowed me to explore some of the associations in more depth using an observational study design. My third paper looked a cohort of patients who had presented to the emergency department during the time that we were conducting the observational study. Using electronic data linked to their medical records number I was able to estimate what the prevalence of unexplained falls, explained falls and syncope was in the emergency department. Additionally I used pre-specified resource variables to give some insight into the differences in resource usage between these groups when they present to the emergency department. For my fourth paper I have looked in more depth at the exact causes of the overlap of syncope and falls in the elderly. To do this we designed a study which examined all patients over the age of 50 who had presented to an emergency department in an urban hospital (St. James?s Hospital Dublin) with two or more unexplained falls in the last year. We entered 70 of these patients into a clinical trial to examine in more detail for the presence of cardiac arrhythmia which may be the underlying cause of the fall or syncopal episode. Lastly I have explored one of the risk factors which have been identified in the fifth paper- namely depression and medications which may contribute to syncope. This was again done at a population level using the TILDA database in order to make associations and draw conclusions

Falls, non-accidental falls and syncope in community-dwelling adults aged 50 years and older: Implications for cardiovascular assessment.

To calculate the prevalence of all falls, non-accidental falls and syncope in an older population and characterize cardiovascular risk profiles.Prospective, longitudinal cohort study.The first two waves of data from the Irish Longitudinal Study on Ageing (TILDA).8172 community-dwelling adults aged 50 years and older resident in the Republic of Ireland.Self-reported history of all falls, non-accidental falls and syncope in the year preceding the first two waves of data collection. Demographic factors and self-reported cardiovascular conditions were used to characterize cardiovascular risk profiles.The prevalence of all falls in the past year was 19.2% or 192 per thousand persons and increased with age (50-64 years 17.5%; 65-74 years 19.4%; 75+ years 24.4%). Non-accidental falls had an estimated prevalence of 5.1% or 51 falls per thousand persons and accounted for 26.5% of all falls reported and also increased with age (50-64 years 4.0%; 65-74 years 5.5%; 75+ years 8.0%). The prevalence for syncope was estimated to be 4.4% or 44per thousand persons but did not show a similar age gradient. Participants with at least 5 cardiovascular conditions were more likely to report all falls (OR = 2.07, 95% CI 1.18-3.64, p<0.05) and NAF (OR = 2.89, 95%CI 1.28-6.52, p<0.05).The prevalence of all falls and non-accidental falls increases with age but the same pattern was not consistently observed for syncope. There is an increased odds of reporting all three outcomes with increasing number of self-reported cardiovascular conditions. Further work is needed to uncover the interplay between cardiovascular disease and subsequent falls

The Association of Cardiovascular Disorders and Falls:A Systematic Review

Objective: Cardiovascular disorders are recognized as risk factors for falls in older adults. The aim of this systematic review was to identify cardiovascular disorders that are associated with falls, thus providing angles for optimization of fall-preventive care. Design: Systematic review. Data Sources: Medline and Embase. Eligibility criteria for selecting studies: studies addressing persons aged 50 years and older that described cardiovascular risk factors for falls. Key search terms for cardiovascular abnormalities included all synonyms for the following groups: structural cardiac abnormalities, cardiac arrhythmia, blood pressure abnormalities, carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), vasovagal syncope (VVS), postprandial hypotension (PPH), arterial stiffness, heart failure, and cardiovascular disease. Quality of studies was assed using the Newcastle-Ottawa Scale. Results: Eighty-six studies were included. Of studies that used a control group, most consistent associations with falls were observed for low blood pressure (BP) (4/5 studies showing a positive association), heart failure (4/5), and cardiac arrhythmia (4/6). Higher prevalences of CSH (4/6), VVS (2/2), and PPH (3/4) were reported in fallers compared with controls in most studies, but most of these studies failed to show clear association measures. Coronary artery disease (6/10), orthostatic hypotension (9/25), general cardiovascular disease (4/9), and hypertension (7/25) all showed inconsistent associations with falls. Arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardiographic abnormalities. Conclusion: Several cardiovascular associations with falls were identified, including low BP, heart failure, and arrhythmia. These results provide several angles for optimizing fall-preventive care, but further work on standard definitions, as well as the exact contribution of individual risk factors on fall incidence is now important to find potential areas for preventive interventions. (c) 2016 AMDA - The Society for Post-Acute and Long-Term Care Medicine

Adjusted odds ratios ^† (OR) with confidence intervals (CI) for all falls (AF), non-accidental falls (NAF) and syncope in the 12 months prior to wave 1 (n = 8172).

<p>Adjusted odds ratios ^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0180997#t003fn001" target="_blank">†</a>} (OR) with confidence intervals (CI) for all falls (AF), non-accidental falls (NAF) and syncope in the 12 months prior to wave 1 (n = 8172).</p

Prevalence and incidence of all falls, non-accidental falls (NAF) and syncope.

<p>Prevalence (wave one) and incidence (wave two) based on self-reported data from TILDA participants (n = 8172).</p

Multi-variate analysis with odds ratios (OR) of participants reporting all falls (n = 1,579), non-accidental falls (NAF) (n = 406) and syncope (n = 363) in wave one of TILDA (n = 8,172).

<p>Multi-variate analysis with odds ratios (OR) of participants reporting all falls (n = 1,579), non-accidental falls (NAF) (n = 406) and syncope (n = 363) in wave one of TILDA (n = 8,172).</p

Baseline variables for all participants reporting all falls (n = 1,579), non-accidental falls (NAF)(n = 406) and syncope (n = 363) in wave one of TILDA.

<p>Baseline variables for all participants reporting all falls (n = 1,579), non-accidental falls (NAF)(n = 406) and syncope (n = 363) in wave one of TILDA.</p

Standing middle cerebral artery velocity predicts cognitive function and gait speed in older adults with cognitive impairment, and is impacted by sex differences

Upright posture challenges the cerebrovascular system, leading to changes in middle cerebral artery velocity (MCAv) dynamics which are less evident at supine rest. Chronic alterations in MCAv have been linked to hypoperfusion states and the effect that this may have on cognition remains unclear. This study aimed to determine if MCAv and oscillatory metrics of MCAv (ex. pulsatility index, PI) during upright posture are i) associated with cognitive function and gait speed (GS) to a greater extent than during supine rest, and ii) are different between sexes.Beat-by-beat MCAv (transcranial Doppler ultrasound) and mean arterial pressure (MAP, plethysmography) were averaged for 30-seconds during supine-rest through a transition to standing for 53 participants (73±6yrs, 17 females). While controlling for age, multiple linear regressions predicting MoCA scores and GS from age, supine MCAv metrics, and standing MCAv metrics, were completed. Simple linear regressions predicting Montreal Cognitive Assessment (MoCA) score and GS from MCAv metrics were performed separately for females and males. Significance was set to p<0.05.Lower standing diastolic MCAv was a significant (p = 0.017) predictor of lower MoCA scores in participants with mild cognitive impairment, and this relationship only remained significant for males. Lower standing PI was associated with slower GS (p = 0.027, r=-0.306) in both sexes. Our results indicate a relationship between blunted MCAv and altered oscillatory flow profiles during standing, with lower MoCA scores and GS. These relationships were not observed in the supine position, indicating a unique relationship between standing measures of MCAv with cognitive and physical functions