Healthcare professionals can recommend a variety of tools to help senior patients avoid falls, which are the leading cause of both fatal and nonfatal injuries in older adults. However, there’s another useful instrument you can add to your toolkit to reduce senior fall risk: cardiovascular screening.
Cardiovascular disorders are a major fall risk for the senior population. Cardiac problems can produce symptoms ranging from light-headedness to dizziness and shortness of breath, which can cause a senior to lose balance. These conditions may also induce a sudden loss of consciousness.
“As people age, unless they’re incredibly active, they don’t have the same leg strength or agility to be able to compensate for that little bit of dizziness,” says Jill Kapadia, RN.
Research shows that senior patients with a cardiovascular reason for falling have a higher mortality rate than those with unknown or non-cardiovascular causes. Specifically, neurally mediated syncope (NMS), orthostatic hypotension, cardiac arrhythmias, and structural heart disease may all present as unexplained falls in older adults. Here’s a look at each condition, including why seniors are particularly vulnerable, symptoms to watch for, and available cardiovascular screening tests and treatment options.
Neurally Mediated Syncope
Syncope, commonly called fainting, is defined as a transient (lasting anywhere from seconds to a few minutes) loss of consciousness, and it is usually accompanied by falling. According to an evaluation published in American Family Physician, the incidence of syncope increases twofold in seniors who are 70 to 79 years of age and threefold in those 80 or older, compared with those aged 50 to 59.
Neurally mediated syncope is a malfunction of the part of the nervous system that regulates heart rate and blood pressure. It occurs when blood pressure drops and circulation to the brain is reduced, resulting in a loss of consciousness and, typically, a fall. NMS often happens in response to a trigger such as dehydration or heat, and it usually occurs while standing. A 2011 study found that in a sampling of 200 patients aged 65 and over who suffered unexplained or accidental falls, NMS was prevalent in 24 percent of those who experienced an unexplained fall.
Assessment for NMS includes ruling out other possible causes of fainting, which can be done through blood tests, an electrocardiogram or echocardiogram, or a tilt table test to measure blood pressure with postural changes. Always be sure to monitor your senior patients for pre-syncope — nausea, feelings of warmth such as sweaty palms, and light-headedness — and assist them in sitting or lying down if they begin to feel any of these syncope warnings.
Treatment for NMS may be as simple as avoiding known triggers of the condition, according to the Rare Diseases Clinical Research Network. Caution your senior patients to avoid becoming dehydrated, overheated, emotionally stressed, or exhausted, which the American Heart Association lists as potential causes of syncope. The Rare Diseases Network also recommends mild aerobic exercise and compression stockings, which can help keep blood in the upper body rather than collecting in the legs.
Urge senior patients with any history of syncope to consider various forms of remote care technology that can be used in the case of a fainting episode, such as Lifeline with AutoAlert, which will automatically call for help if a fall is detected.1
Orthostatic hypotension, also called postural hypotension, is a sudden and extreme drop in blood pressure that occurs upon standing. It can cause feelings of light-headedness, weakness, and dizziness. This drop in blood pressure can also lead to visual changes and syncope. All these factors increase the likelihood of a fall for a senior.
The risk of developing orthostatic hypotension increases with age, making it a major concern for seniors; Clinical Correlations estimates that 5 to 30 percent of those aged 65 and older who live in the community and 50 percent who live in long-term care facilities are diagnosed with the condition. As the body ages, its ability to effectively regulate blood pressure can be hindered, making it more difficult for the heart to beat fast enough to compensate for drops in blood pressure. A variety of medical conditions can further increase the risk of developing orthostatic hypotension, including varicose veins, hypertension, chronic kidney disease, and autonomic nervous disorders. Medications often taken by senior patients can also cause or aggravate this condition.
Orthostatic hypotension is commonly seen in seniors with comorbidities, and it is one of the most common causes of falls in this population. In one small study of 40 patients who had orthostatic hypotension and were an average age of 77, 68 percent presented with unexplained falls, while 32 percent presented with syncope. A larger patient series found that orthostatic hypertension accounted for 14 percent of all diagnosed cases of unexplained falls and syncope. And a study of nursing home residents found that, among seniors who had fallen in the previous six months, those with orthostatic hypotension were at greater risk of recurrent falls.
If your senior patient complains of light-headed or dizzy episodes, orthostatic hypotension may be the cause. It is diagnosed simply by measuring blood pressure, first after the patient lies down for about three minutes and then again after the patient has been standing for three minutes. If there is greater than a 20 mmHg fall in systolic blood pressure or 10mmHg in diastolic blood pressure, orthostatic hypotension is diagnosed.
The key to treatment of this condition is identifying its underlying cause. Once known, it can usually be treated effectively with simple lifestyle changes. Kapadia suggests that senior patients with orthostatic hypotension keep hydrated with nonalcoholic beverages. “If seniors have issues with having to go to the bathroom at night, they may restrict their fluids to try not to use the bathroom as frequently,” she notes, adding, “That makes them what we call ‘dry,’ which causes low blood pressure.”
Kapadia also encourages educating seniors on how to properly change body positions. “Teach patients that when they get out of bed in the morning, they should get up on their side and then sit on the side of their bed for a minute or two, allowing their blood pressure to even out before they proceed to stand up and take their first steps.” The same goes, Kapadia says, for moving from sitting to standing: Advise your patient to take a moment and allow his body to slowly adjust, rather than rising rapidly.
Kapadia cautions that seniors on blood pressure medications may need more frequent monitoring of their blood pressure to keep it in check. She often recommends that patients have a blood pressure machine in their own home: “The best thing patients can provide for their physician is a log of their blood pressures.” Doing so, she says, can help doctors adjust medication and prevent dizziness and falls.
A cardiac arrhythmia is when the heart’s rhythm is too slow, too fast, or otherwise irregular. Those with arrhythmia may have noticeable symptoms, including a racing heartbeat, a fluttering in their chest, and light-headedness, dizziness, or syncope. Some seniors don’t feel any abnormalities, however, meaning that this condition could go undetected and pose a major fall risk.
Kapadia says that seniors and their caregivers can find an arrhythmia by taking the senior’s pulse in the neck or wrist. Arrhythmias may also be detected when an automatic blood pressure cuff, used during routine cardiovascular screening, shows an error message if the machine has difficulty reading where the blood pressure starts and stops.
The most serious arrhythmias occur in people over the age of 60, according to the National Heart, Lung, and Blood Institute. Seniors are more likely to have heart disease and other cardiovascular concerns that can lead to arrhythmias, and they may also be more susceptible to developing an arrhythmia as a medication side effect. Cardiac arrhythmias have been found in up to 20 percent of senior syncope cases.
Atrial fibrillation is the most common abnormal heart rhythm, and its incidence increases with age. Kapadia notes that patients with atrial fibrillation are often put on blood thinners, which can make falling much more dangerous.
Because many seniors with an arrhythmia don’t feel an abnormality, and thus don’t report feeling any dizziness or palpitations before a fall, arrhythmias are often overlooked as a cause of falls. A variety of diagnostic tools, such as an electrocardiogram or a Holter or event monitor, can be used to detect arrhythmias. Treatment ranges from medication to surgically implanted devices, depending on the severity of the condition.
According to the Mayo Clinic, many arrhythmias are caused by underlying heart disease, so heart-healthy lifestyle changes can be very important for seniors with this condition. Advise your senior patients to eat a diet high in fruits and vegetables, whole grains, and lean protein. Additionally, the diet should be low in sodium, fats, refined grains, and sugar. The Mayo Clinic also cites that practices such as meditation and yoga may be helpful in reducing stress, in turn helping the heart.
Structural Heart Disease
Structural heart disease most often refers to congenital heart defects present at birth. But it can also describe cardiac changes that develop due to aging. For example, a thickening and dilation of large arteries can occur as we age, of which seniors are at greater risk.
In addition, signs and symptoms of structural heart problems may not show up until later in life, or they may reappear even after childhood treatment for a heart defect, according to the Mayo Clinic. Older adults with a cardiovascular defect may tire quickly upon exertion and feel dizzy, weak, or faint, and fall as a result. Clinics in Geriatric Medicine reports that structural cardiac abnormalities may account for about 5 to 10 percent of those with syncope or unexplained falls.
Physical exams and diagnostic tests, including cardiac catheterization and echocardiography, can be used to identify structural heart abnormalities. Treatment is generally aimed at repairing or ameliorating the underlying abnormality through surgery.
When giving your patient a cardiovascular screening, ask whether she was diagnosed with structural heart disease in youth. The National Heart, Lung, and Blood Institute notes that even if a patient was treated for a structural deficit, she will likely need to continue seeing a specialist, which she may not realize. Review your patients’ medical histories with them regularly.
Because these cardiovascular disorders are associated with increased fall risk and mortality, the involvement of healthcare professionals in educating their senior patients is vitally important. Ask your senior patients during their routine office visits whether they’ve experienced symptoms that might indicate a cardiac issue, and perform regular cardiovascular screenings. Early diagnosis and treatment can save lives.
For seniors at risk of falling, a medical alert device can help increase their safety and security. If you know a senior patient who would benefit from information about medical alert system, refer your patients to Philips Lifeline.