Cardiac Enzyme Changes in Elderly Fallers

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1 Cardiac Enzyme Changes in Elderly Fallers DAVID G. SWAIN, PETER G. NIGHTINGALE, RUSSEAU GAMA, BRENDAN M. BUCKLEY Summary The pattern of enzyme changes in elderly fallers admitted to an acute geriatric unit was investigated. Creatine kinase (CK), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) activities were measured daily for 3 days after admission in all patients in whom a fall preceded admission. f 270 patients, 52 (19%) had fallen prior to admission, of whom five (10%) had an acute myocardial infarction (AMI). In fallers without an AMI in whom a history was available, CK and AST activities were significantly higher (p < 0.05) in patients who had spent more than 1 hour on the floor than in those who had spent less than 1 hour. No other clinical factor affected enzyme activities. CK and AST activities were raised in 66% and 40%, respectively, of fallers without an AMI. Elevation of CK and AST activities in elderly fallers is likely to be a result of the fall itself rather than of an AMI. Falls in the elderly in the community are common [1-4] and the vast majority do not require medical attention [5]. However, falls are a common reason for elderly patients to be admitted to hospital [6, 7]. Rhabdomyolysis may occur in elderly patients who fall [8-10], and is thought to be caused by pressure necrosis of muscle secondary to the immobilization following the fall. ne consequence of rhabdomyolysis is the elevation of serum muscle enzyme activities. In a study of patients aged 65 and over who had fallen and remained on the floor for over 1 hour, creatine kinase (CK) and aspartate aminotransferase (AST) values were raised in 14 out of 18 cases [8]. In another study, elevated CK and AST levels were found in ten patients who had fallen and been immobilized for between 3 and 6 hours [10]. In this study we report enzyme changes in a series of fallers admitted to an acute geriatric unit. Methods All 279 patients admitted to an acute geriatric unit between May and July 1988 were considered for inclusion in the study. Clinical assessment placed particular emphasis on falls prior to admission. For the purposes of this study a faller was defined as anyone who had been found lying on the floor on the day of admission, or who had fallen within 2 days prior to admission. In fallers, the following were recorded: (a) location of fall, (b) surface fallen on to, (c) duration of time on surface, (d) level of consciousness, (e) body weight, (0 presence or absence of bruising, (g) approximate area of bruising, (h) muscle tenderness, (i) main diagnosis. The activities of C K, AST, and lactate dehydrogenase (LDH) serum enzymes were each measured within, 48, and 72 h of admission, with standard techniques using a Cobas FARA (Roche Products, Welwyn Garden City, Herts.) and reagents supplied by Roche Products and BCL (Lewes, Sussex). Reference ranges for CK ( U/l), AST (12-32 U/l) and LDH ( U/l) were established from 60 fit residents of local private rest homes of mean age 83.1 years. Serial 12-lead electrocardiograms (ECGs) were Age and Ageing 1990;19:

2 28 D. G. SWAIN ET AL. performed, on days 1, 2, and 3 of admission. The diagnosis of acute myocardial infarction (AMI) was made independently by three clinicians using the criteria of Rowley and Hampton [11]. Enzymatic values were compared using the MannWhitney U test. Results are given as means or medians, with 95% confidence intervals in parenthesis. GRUP A GRUP B Results TIME (hours) Figure 1. Frequency distribution of time on the floor for all fallers excluding those with acute myocardial infarction. the conscious level at the time of the fall was unknown. Twenty-one fallers (40%) had bruising, which in total area ranged from 5 cm2 to 970 cm2. No patient had focal muscle tenderness. No patient developed acute renal failure as a result of rhabdomyolysis. Three patients sustained fractures as a result of the fall. Biochemical characteristics: The Table shows the values of CK, AST, and LDH for all fallers on days 1, 2, and 3. In fallers without an AMI, CK and AST elevation above the upper limit of normal occurred in 66% and 40% respectively, and above twice the upper limit of normal in 23% and 13%, respectively, on any of the first 3 days. Elevation of CK and AST was highest in fallers with an AMI, and in patients in group B. In general, LDH values were not raised in fallers, unless they had also had an AMI. Direct statistical comparisons between fallers with and without an AMI was not possible because of the small number of patients in the former group. CK, AST, and LDH values on day 1, and CK and AST values on day 2 are all significantly higher (p < 0.05) in group B than in group A (Figure 2). There was no significant difference between groups A and B for LDH on day 2, or CK, AST and LDH on day 3. Regression analysis showed that CK, AST, and L D H values on any day were not linearly related to duration of time on the floor. There was no statistically significant relationship between elevation of CK, AST, and LDH Two hundred and seventy-nine patients were admitted to the acute geriatric unit over the 3month study period. Nine patients were excluded because of failure to have either ECGs or cardiac enzymes performed. Thus 270 patients were entered into the study, 91 men and 179 women of mean age 81.2 years ( ). Clinical characteristics: Fifty-two (19%) patients had fallen prior to admission, 18 men and 34 women of mean age 82.9 years (range ). In 48 patients (18% of admissions), the fall was the reason for admission and had occurred on that same day. Ten fallers (20%) presented with a new stroke, six (12%) a possible AMI, five (10%) a definite AMI, five (10%) confusion, five (10%) dementia, and four (8%) with convulsions. The remainder had locomotor, balance or visual problems, or were suffering from an acute medical condition. ne half had more than one reason for falling. In the 47 fallers without a definite AMI, the time on the floor was known in 32 (68%) and is shown in Figure 1. These patients were subsequently analysed as two subgroups: group A (four men and 13 women of mean age 83.0 years) had spent less than 1 h on the floor, and group B (four men and 11 women of mean age 84.2 years) had spent > 1 h on the floor. The age difference between the two groups was not significant. The remaining 15 fallers with no AMI were classed as group C. Forty-one patients fell in the home, three outside the home, and in eight the location was unknown. Thirty-one patients had fallen on to carpet, one each on to a tiled floor, grass or tarmac, and in 18 patients the surface was unknown. Thirty-seven patients were conscious at the time of the fall, four were drowsy, eight were unconscious, and in three patients

3 All fallers (n = 52) Fallers with AMI (n = 5) Fallers without AMI (n = 47) Group A (n = 17) Group B (n=15) Group C (n = 15) Table. Activities of CK, AST, and LDH for fallers on the first 3 days of admission 160 (96-216) 1157 "( ) 140 (85-212) 90 (70-172) 212 (1-1622) 146 (73-309) CK(U/1) 211 (145-8) 1130 ( ) 186 ( ) 136 (56-228) 219 ( ) 213 ( ) 170 ( ) 676 (7-1762) 117 ( ) 115 (41-376) 175 (103-19) 102 (71-356) 26 (23-34) 53 (29-232) (23-32) (18-36) 43 (20-77) (20-32) AST(U/1) Vnlnpe nrp mphinnc w 1Q in nnrpnt Values in parentheses in this group are ranges (owing to small sample sizes). (22-34) 83 (36-206) (22-28) 21 (19-) 43 (22-80) (20-33) 30 (21-36) 61 (36-151) (20-33) 27 (17-36) 36 (17-80) (17-43) 485 ( ) 935 ( ) 464 (4-526) 447 (3-464) 509 ( ) 489 ( ) LDH (U/l) 456 ( ) 854 ( ) 452 ( ) 452 ( ) 474 ( ) 440 ( ) 465 ( ) 856 ( ) 446 ( ) 434 ( ) 469 ( ) 475 ( ) CAR DIAC ENZ < PI X d $ y. tn o PI 33 r -n r

4 D. G. SWAIN ET AL Hi rr o w HI a: u I.I CK on (u/l) CK on (u/l) AST on (u/l) Figure 2. Distribution of CK and AST levels on days 1 and 2 for group A (open bars) and group B (solid bars). Enzyme activity scales are logarithmic. Groups A and B are statistically significantly different (p < 0.05; Mann-Whitney U test) for each set of CK and AST values on both days. and the following: age, sex, presence or absence of bruising, area of bruising, location of bruising, or body weight. The location of the fall, nature of the surface fallen on to, and level of consciousness at the time of fall did not appear to influence elevation of enzymes. This study has found that falls cause 18% of admissions to an acute geriatric unit. This is comparable to a previous report of 21 % [7], and reflects the fact that illness in the elderly often presents as a fall [6]. We have demonstrated that CK and AST activities are frequently elevated in elderly fallers admitted acutely. CK and AST values on days 1 and 2 were significantly greater if the patient had been lying on the floor for more than 1 h. This supports the view that muscle damage ill AST on (u/l) is related to pressure necrosis of muscle secondary to immobilization rather than a result of the initial trauma of the fall. The absence of a relationship between body weight and enzyme changes confirms the findings of Ratcliffe et al. [8]. This might be explained by the cushioning by fat of underlying muscle, counteracting the increased pressure in heavier patients. Forty per cent of the fallers had bruising to a variable degree but there was no significant correlation between any measure of bruising and enzymes, further supporting the contention that enzyme changes are not primarily due to the initial trauma of the fall. Mallinson and Green found a similar lack of relationship between bruising and enzyme levels [10]. The enzyme values we report are lower than those reported in previous studies [8, 10]. However, although Ratcliffe et al. [8] studied patients who had fallen and remained on the

CARDIAC ENZYME CHANGES IN ELDERLY FALLERS floor for longer than 1 h, their patients were preselected by having 'collapsed', whereas this study prospectively reported all falls occurring within the

5 CARDIAC ENZYME CHANGES IN ELDERLY FALLERS floor for longer than 1 h, their patients were preselected by having 'collapsed', whereas this study prospectively reported all falls occurring within the preceding 2 days in unselected admissions to the acute geriatric unit. Eight of the 10 patients studied by Mallinson and Green had been on the floor for at least 3 h [10]. In the current study, 17 of the 52 patients had been on the floor for less than 1 h (group A). The presentation of AMI in the elderly is often atypical [12-15], and the diagnosis frequently depends on the results of biochemical investigations. ne consequence of raised CK and AST activities in elderly fallers is the incorrect diagnosis of AMI, on the presumption that the increased enzyme activity is cardiac in origin. The prevalence of AMI amongst fallers in this study was 10%. However, CKand AST elevation occurred in 66% and 40%, respectively, of the remaining 90% of fallers who had no AMI. Thus enzyme elevation in fallers in the absence of clinical features suggesting AMI is more likely to be due to the fall itself than to an AMI, and especially so if the time on the floor exceeds 1 h. Care must therefore be taken in the interpretation of 'cardiac enzymes' in elderly fallers. Acknowledgements We thank Drs M. H. Shakeel and M. A. S. Hussain for allowing us to study their patients, and acknowledge the help of the nursing and medical staff of the acute geriatric wards, and the staff of Sandwell Hospital ECG, biochemistry and medical illustration departments. We thank Dr P. J. Cadigan for his advice, and assistance in classifying the patients. Drs R. Gama and P. G. Nightingale acknowledge financial support by the Department of Health. References 1. Prudham D, Grimley Evans J. Factors associated with falls in the elderly: a community study. Age Ageing 1981 ;10: Blake AJ, Morgan K, Bendall MJ, el al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17: Campbell AJ, Reinken J, Allan BC, Martinez GS. Falls in old age: a study of frequency and related clinical factors. Age Ageing 1981;10: Droller H. Falls among elderly people living at home. Geriatrics 1955;10: Gryfe CI, Amies A, Ashley MJ. A longitudinal study of falls in an elderly population: I. Incidence and morbidity. Age Ageing 1977;6: Isaacs B. Some characteristics of geriatric patients. Scott Med J 1969;14: Isaacs B. Falls. In: Exton-Smith AN, Weksler ME, eds. Practical geriatric medicine. Edinburgh: Churchill Livingstone, 1985; Ratcliffe PJ, Ledingham JGG, Berman P, Wilcock GK, Keenan J. Rhabdomyolysis in elderly people after collapse. Br Med jf 1984;288: Ratcliffe PJ, Berman P, Griffiths RA. Pressure induced rhabdomyolysis complicating an undiscovered fall. Age Ageing 1983;12: Mallinson WJW, Green MF. Covert muscle injury in aged patients admitted to hospital following falls. Age Ageing 1985;14: Rowley JM, Hampton JR. Diagnostic criteria for myocardial infarction. Br J Hosp Med 1981;26: Bayer AJ, Chadha JS, Farag RR, Pathy MS. Changing presentation of myocardial infarction with increasing old age. J Am Geriatr Soc 1986;34: Wroblewski M, Mikulowski P, Steen B. Symptoms of myocardial infarction in old age: clinical case, retrospective and prospective studies. Age Ageing 1986;15: Pathy MS. Clinical presentation of myocardial infarction in the elderly. Br Heart J 1967;29: MacDonald JB. Presentation of acute myocardial infarction in the elderly a review. Age Ageing 1984;13: Authors' addresses D. G. Swain* Department of Geriatric Medicine, B. M. Buckley Department of Biochemistry, Sandwell District General Hospital, West Bromwich B71 4HJ P. G. Nightingale, R. Gama, B. M. Buckley Wolfson Research Laboratories, Queen Elizabeth Medical Centre, Birmingham B15 2TH 8 Address correspondence to Dr D. G. Swain, Department of Geriatric Medicine, Arden Lodge Annexe, East Birmingham Hospital, Yardley Green Road, Birmingham B9 5PX Received in revised form 29 September 1989

ACUTE MYOCARDIAL INFARCTION: DIAGNOSTIC DIFFICULTIES AND OUTCOME IN ADVANCED OLD AGE

ACUTE MYOCARDIAL INFARCTION: DIAGNOSTIC DIFFICULTIES AND OUTCOME IN ADVANCED OLD AGE Age and Ageing 1987;1:239-23 J. J. DAY Research Registrar A. J. BAYS* Research Lecturer rssssffl 1^^' J. S. CHADRA Locum Consultant Geriatrician St Tydftl's Hospital, Merthyr Tydfll, Mid Glam. CF7 OSJ