Patients with heart failure who fall: Why, how and what to do about it? The great conundrum BACPR Oct 5 th 2017 London

Transcription

1 Patients with heart failure who fall: Why, how and what to do about it? The great conundrum BACPR Oct 5 th 2017 London

2 Ward B21 Falls and Heart Failure

3 Davies sign

4 What do you want from me? A practical tip(s) to apply in your clinical practice Knowing what you can do and what to pass on. An idea of what is common or otherwise. Some useful clinic and out-patient tests. In minutes..

5 What do you want to take away from this session? What do I do when my HF patient: Falls? Is dizzy? May need drugs changing? Falls and they might break a bone? Has Orthostatic hypotension? Summary

6 Background Why Heart Failure and Falls?

7 Why we Fall Bones & Joints Brain and nervous System Heart and BP Vision Muscle strength

8 Heart Failure and Falls Problem Osteoporosis Cerebral function Heart Failure & Falls Immobility/reduced mobility Co-existent vasculopathy Heart function/ dysrhythmia Hypotension Ventricular dysrhythmia, Low output low BP Medication and volume depletion Muscle weakness Reduced mobility

9 Evidence Intervention Studies Quality of evidence Recommend The effective multifactorial / or multicomponent interventions included the following components: environmental adaptation and/or modification (9 studies out of 11); balance, strength, and gait training (7 out of 11); assistive devices; reducing psychoactive medications; reviewing and reducing other medications; managing vision problems; managing orthostasis; and addressing cardiovascular and other medical problems. Campbell, 1999 Chang, 2004 Clemson, 2004 Close, 1999 Davison, 2005 Day, 2002 Gillespie, 2003 Nikolaus, 2003 Steinberg, 2000 Tinetti, 1994 Wagner, 1994 Whitehead, 2003 good A

10 AGS/BGS 2010 A strategy to reduce the risk of falls should include multifactorial assessment of known fall risk factors and management of the risk factors identified.[a] The components most commonly included in efficacious interventions were: Adaptation or modification of home environment [A] Withdrawal or minimization of psychoactive medications [B] Withdrawal or minimization of other medications [C] Management of postural hypotension [C] Management of foot problems and footwear [C] Exercise, particularly balance, strength, and gait training [A] All older adults who are at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. Flexibility and endurance training should also be offered, but not as sole components of the program. [A] Multifactorial/multicomponent intervention should include an education component complementing and addressing issues specific to the intervention being provided, tailored to individual cognitive function and language. [C] The health professional or team conducting the fall risk assessment should directly implement the interventions or should assure that the interventions are carried out by other qualified healthcare professionals. [A]

11 What do you want to take away from this session? What do I do when my HF patient: Falls? Is dizzy? May need drugs changing? Falls and they might break a bone? Has Orthostatic hypotension? Summary

12 MY HF PATIENT IS FALLING AND MIGHT BREAK A BONE.

13 Bone health The fractured neck of femur is at the end of a long path of care.

14 It s only a minor fracture so what What % of those with a new hip fracture have had a previous fracture? A 10% B 30% C 50% By identifying and treating osteoporosis after the first fracture how many fractured hips could be prevented? A 5% B 10% C 25% In a population of 300,000 identifying and treating osteoporosis after the first fracture would save how many fractured hips? A up to 30 B up to 50 C up to 100

15 It s only a minor fracture so what What % of those with a new hip fracture have had a previous fracture? A 10% B 30% C 50% By identifying and treating osteoporosis after the first fracture how many fractured hips could be prevented? A 5% B 10% C 25% In a population of 300,000 identifying and treating osteoporosis after the first fracture would save how many fractured hips? A up to 30 B up to 50 C up to 100

16 What if they break a bone? You are in a great position to reduce fracture risk. If everyone who broke a bone had a fracture risk assessment and treatment we could potentially cut fracture neck of femur by 25% So in those with falls and/or fracture think FRAX or Q fracture

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20 What if I send them home and they fracture something? At least I thought of it and I risk assessed!

21 What do you want to take away from this session? What do I do when my HF patient: Falls? Is dizzy? May need drugs changing? Falls and they might break a bone? Has Orthostatic hypotension? Summary

22 MY PATIENT MAY NEED DRUGS CHANGING..

23 Poly Pharmacy ACE inhibitors Beta Blockers Duiretics MRA s* (Spironolactone & eplerenone) Ivabradine Digoxin Anti-coagulants Statins ARNI * Mineralocorticoid receptor antagonists

24 Do the simple things-heart failure. Get the diagnosis right. Renal failure. Valvular disease. Hypoalbuminaemia. Pulmonary disease.

25 Target doses or just getting the tablet? We need to get patients on the right tablets but ensure we carefully manage BP, Heart rate and fluid volume. Ambulatory BP, ECG and lying and standing BP help to establish levels of hypotension and bradycardia to make more informed decisions. Involve the patients in the discussion about their treatment.

26 Correct Information

27 Informed discussions Trial comparator study popn outcome duration NNT annualised NNT comment

28 Help patients to make informed choices ACE inhibitor Falls and dizziness

29 Death SOB Oedema Chest pain Fear of falls Reduced mobility injury

30 What do you want to take away from this session? What do I do when my HF patient: Falls? Is dizzy? May need drugs changing? Falls and they might break a bone? Has Orthostatic hypotension? Summary

31 MY PATIENT HAS ORTHOSTATIC HYPOTENSION

32 Sunderland HF clinic 37 consecutive patients assessed by medical student using phasic beat to beat BP monitor. 45% (17/36) male Mean age 83 years 45% had OH (17/36) Average BP drop -37.5mmHg SBP In a consecutive subset (n=12) 9 falls over preceding year.

33 Poly Pharmacy ACE inhibitors Beta Blockers Duiretics MRA s* (Spironolactone & eplerenone) Ivabradine Digoxin Anti-coagulants Statins ARNI * Mineralocorticoid receptor antagonists

34 Medication causing orthostatic hypotension Fluid depletion- careful monitoring no Fludrocortisone. Think long and hard about adding spironolactone and Eplerenone in symptomatic OH. Lowest effective doses (usually managed by careful follow up in the heart failure service) Measuring lying and standing BP in HF service. Consider compression hosiery.

35 24 hour BP

36 Autonomic Function

37 What do you want to take away from this session? What do I do when my HF patient: Falls? Is dizzy? May need drugs changing? Falls and they might break a bone? Has Orthostatic hypotension? Summary

38 MY HF PATIENT FALLS

39 AGS/BGS 2010

40 Repeat Fallers Assuming these people have no account of a blackout or possible blackout and no dizziness.. Watch them get up from a chair without using hands (if possible) and walk turn round and come back (TUG).

41 Would you like a demo?

42 Simply put If they can t walk-you ve got your answer. If they scare you-you ve got your answer. If they walk through the door quicker than you can catch them their falls are not gait and balance related. If they bump into the desk ask about vision Use your physio and ask your nurses if in-patients.

43 What do you want to take away from this session? What do I do when my HF patient: Falls? Is dizzy? May need drugs changing? Falls and they might break a bone? Has Orthostatic hypotension? Summary

44 MY PATIENT IS DIZZY

45 Dizzy or possibly a blackout? Make sure you ask about blackouts and dizziness. If they fall and can t tell you they ve not blacked out, assume they have.

46 Not all dizziness is the same. Ask the right questions to get to the bottom of it. Dizzy?

47 Dizzy Spinning like on a roundabout Vertigo Stumbling like a drunkard- instability/unsteadiness Fading away like a near faint

48 Commonly Spinning- Benign positional paroxysmal vertigo Unsteadiness- cerebrovascular disease Near blackout- low BP (check lying and standing BP), dizziness is less common with dysrhythmia (usually sudden collapse)

49 What do you want to take away from this session? What do I do when my HF patient: Falls? Is dizzy? May need drugs changing? Falls and they might break a bone? Has Orthostatic hypotension? Summary

50 Summary Ask about falls, dizziness and fractures. Common sense exam and include Get up and go Lying and standing BP ECG (of course)

51 Summary Falls and Heart Failure are here to stay and will have a massive overlap. There is plenty of things to do other than stopping medication. Think bone health! Get other information before embarking on rationalising meds. Always ask Is this really heart failure? Involve the patients in tricky treatment choices.

52 Best of Friends