Falls Assessment and Medication
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1 Falls Assessment and Medication Professor T.Masud President-Elect British Geriatrics Society Nottingham University Hospitals NHS Trust, UK Visiting Professor University of Southern Denmark
2 Mrs GH is a 84 year old woman who is having recurrent falls MMSE 20/30 Vascular Parkinsonism CKD-3 AMD Hypertension DH: Bendroflumethiazide 2.5mg, Amlodipine 10mg BP lying 180/90 BP standing immediate 140/70 (slightly dizzy) BP standing 3 mins 175/90 Would you : 1. Reduce antihypertensives? 2. Increase antihypertensives? 3. Make no change?
3 Introduction Cardiovascular Risk Factors and falls Cardiovascular Medications and Falls Interventions to Reduce FRIDs
4 Occurrence - Annual incidence 65+ yrs : 28-35% - Campbell Prudham Blake yrs : 32-42% - Tinetti Downton 1991 Previous Fallers 60-70% - Nevitt 1989 Institutional care >50% - Tinetti 1989
5 IMPACT OF FALLS
6 CAUSES OF FALLS Falls are Often Multifactorial INTRINSIC FACTORS FALLS EXTRINSIC FACTORS Co-morbidity increases the risk of falls
7 Intrinsic (personal) Factors Causing Falls
8 Extrinsic (Environmental) Factors
9 MEDICATIONS & FALLS Polypharmacy (association of 5+ drugs and falls) Sedative-hypnotics, especially long acting benzodiazepines Antipsychotics Antidepressants Anticholinergic Burden Cardiovascular Drugs
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11 Antidepresssants and Falls- the SOMA study Masud T, Frost M, Ryg J, Matzen L, Ibsen M, Abrahamsen B, Brixen K. Central nervous system medications and falls risk in men aged years: the Study on Male Osteoporosis and Aging (SOMA). Age Ageing 2013; 42: Antidepressants Overall Tricyclics SSRIS Fallers OR (95%CI)
12 Opiates and Falls - The SOMA study Opiates Overall Opiates 67 yrs Opiates < 67 yrs Fallers OR (95%CI)
13 Introduction Cardiovascular Risk Factors and falls Cardiovascular Medications and Falls Interventions to Reduce FRIDs
14 Cardiovascular Risk Factors for Falls Cerebral Hypoperfusion Orthostatic Hypotension Cardiac Dysrhythmias Structural Heart Disease (eg aortic stenosis) Reflex Syncope (eg vasovagal, carotid sinus syndrome) Autonomic failure Heart failure Hypovolaemia Cardiovascular Mediciations (Adapted from Thijs 2004)
15 Cardiovascular Risk Factors for Falls Other Mechanisms: Interacting Framework CV Disorders eg Arrhythmias Hypoperfusion (near) Syncope LV function (Orthostatic) Hypotension Carotid sinus Syndrome WML Stroke Cognition Depression Gait / Mobility FALL Interacting Risk factors eg (Adapted from S. Jansen PhD 2015) FRIDS Vision OA Urinary Urgency
16 Introduction Cardiovascular Risk Factors and falls Cardiovascular Medications and Falls Interventions to Reduce FRIDs
17 Cardiovascular Drugs and Falls CV Conditions Hypertension Ischaemic Heart Disease Arrhythmias Heart Failure CV Drugs Diuretics B-Blockers Alpha Adrenergic Blockers Ca Channel Blockers ACE Inhibitors Angiotensin II receptor Blockers Peripheral Vasodilators Anti-arrhythmics
18 Anti-hypertensives and Falls Antihypertensives were one of the major risk factors for falls in Geriatric rehabilitation settings (Vieira 2011 systematic Review) Diuretics and B Blockers associated with falls in hospitalised patients (Costa-Dias 2014, retrospective Portugese study) In individuals with recurrent falls at baseline: higher intensity anit-hypertensive treatment is associated with future serious falls (longitudinal studies, Callisaya 2014, Tinetti 2014)
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20 Initiation of Hypertensives Current prescribing of thiazides is associated with an increased risk of falling and that this is strongest in the 3 weeks following the first prescription (Gribbin 2010, UK, case controlled, GPRD, n= 9682) The risk of falls on initiation of antihypertensive drugs in the elderly First 14 Days (Butt 2012, population based Canadian case controlled)
21 Anti-hypertensives and Falls Meta-analysis no clear relationship between antihypertensives and serious injurious falls (Zang 2013, 42 studies) ACEIs, ARBs, Ca Blockers may be protective against injurious falls (Kuschel 2014, case controlled Swedish study n=64000) ACEIs and ARBs protective against falls (Wong 2013, prospective Australian study n= 520)
22 Hypertension (HT), Orthostatic Hypotension (OH) and AntiHypertensives HYVET - survival benefits in treating HT in very elderly (Beckett 2008) Isolated Systolic HT associated with OH (Rutan 1992) Uncontrolled HT associated with OH (Kamaruzzaman 2010) Those with OH had higher SBP and DBP than those without OH Those with normal or controlled BP had lower prevalence of OH (PARTAGE study, n=994, > 80 years) OH and Falls were 2.5 fold in those with uncontrolled HT (>140/90) compared to those with controlled HT (MOBILIZE Boston study, n=722, 70 years) Proposed Mechanism: Normal BP and controlled HT individuals have less arterial stiffness and improved baroreflex sensitivity and therefore less OH
23 Ogliari et al, Age Ageing 2015 n=1581 Furthermore higher SBP was correlated with increased survival especially in participants with impairment of functional and cognitive status
24 Systolic Blood Pressure Intervention Trial (SPRINT) (Whelton, J Hypert, USA, 2016 abstract) N =9361, > 50 yrs + additional CV risk factor Excluded DM, stroke, advanced CKD Randomised to Intensive therapy (SBP< 120) or Standard (SBP<140) Primary endpoint composite of CV and CV mortality Results Overall 30% reduction in primary outcome with intensive Rx Stratification in >75 yrs by frailty and gait speed gave similar results Intensive Group led a greater SAEs hypotension, syncope, AKI
25 But... CLARIFY study Lancet 2016 (Vidal-Petiot et al) In people with Coronary Artery Disease: Systolic BP >140 or Diastolic BP >80 associated with increased cardiovascular events Systolic BP <120 or Diastolic BP < 70 associated with cardiovascular events Evidence for a J shaped curve Reduced myocardial perfusion if BP too low
26 ESH & ESC Guidelines 2013 Treatment of HT in Elderly I
27 Relationship between BP and Frailty in Older Hypertensives (Basile 2016, Italy) Inverse relationship between Frailty Index (>0.25) and : Systolic BP Orthostatic Systolic BP Orthostatic Diastolic BP Orthostatic Pulse Pressure Conclusion: Frailer patients appeared to be overtreated according to the new European guidelines
28 Tendency towards increasing polypharmacy over time, with associated risk of adverse events without demonstrable benefit in terms of BP control Treating Hypertension in Dementia Systematic Review, Beishan LC et al, 2014, 6 trials We found no evidence to confirm or refute the hypothesis that treatment of hypertension in people with dementia leads to overall health benefit New Horizons article, Harrison et al 2016 Age Ageing High BP a risk factor for cognitive decline in midlife Low BP a risk factor for cognitive decline in later life Therefore, possible that excessive BP lowering in older people with dementia might harm cognition Treating Hypertension in Care Homes- Systematic Review of Observational studies, Welsh T et al 2014, 16 studies HT is common in care home residents and is commonly treated with anti-hypertensives but with no better BP control
29 My Current Conclusions on Treating Hypertension In Older People in Relation to Falls Risk Conflicting Data (rapidly changing evidence) ARBs, ACEIs, Ca blockers - least harmful or even beneficial? Initiation - high falls risk, monitor carefully Dose and extent of BP control important Frailty and Dementia- reassess target and goals Individualise treatment
30 Introduction Cardiovascular Risk Factors and falls Cardiovascular Medications and Falls Interventions to Reduce FRID
31 Withdrawal of CV Drugs Fotherby et al (1994) withdrew anti-ht drugs in 47 subjects with BP 175/100: OH prevalence compared to the group that stayed on treatment Alsop et al (2001) Withdrawal of all CV drugs led to a 78% reduction in Syncope, Falls and OH No renewal needed in 70% Withdrawal only if BP 120/80
32 Br J ClinPharmacol 2007 Cohort study, n= 139, 1+ prior falls, mean age 78.6 yrs, females 76% Cost saving of 491 per prevented fall (2008)
33 Mrs GH is a 84 year old woman who is having recurrent falls MMSE 20/30 Vascular Parkinsonism CKD-3 AMD Hypertension DH: Bendroflumethiazide 2.5mg, Amlodipine 10mg BP lying 180/90 BP standing immediate 140/70 (slightly dizzy) BP standing 3 mins 175/90 Would you : 1. Reduce antihypertensives? 2. Increase antihypertensives? 3. Make no change?
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35 Thank You for Listening
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