AHA scientific statement looks at preventing, managing falls

All clinicians who care for patients with cardiovascular disease (CVD) have the opportunity to mitigate risks for falling, according to a recent scientific statement from the American Heart Association.

The scientific statement considered the association of falling with medications, structural heart disease, orthostatic hypotension, arrhythmias, abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. It is intended to provide consensus on evaluation, prevention, and management of falls among adults with cardiac disease and cardiovascular care when patients are at risk. The statement was published May 19 by Circulation: Cardiovascular Quality and Outcomes.

Physicians should ask the patient and relatives about recent falls and should conduct a comprehensive review of medications and alcohol use to taper, remove, or substitute when appropriate, the statement said. The basic physical assessment of fall risk should include observation of the patient's gait and standing balance, and a brief physical frailty assessment should involve asking about unintentional weight loss, assessing weakness with standing from a chair five times without using arms and asking about physical exhaustion. Slow gait speed (<0.8 m/s) also identifies frail individuals, according to the statement, and any gait instability, any loss of balance, or a positive frailty screen should lead to a physical therapy referral for a more in-depth evaluation, strengthening exercises, and potential assistive devices.

Clinicians should screen older adults with CVD for orthostatic hypotension, measuring blood pressure supine, seated, and standing for three minutes at least once, the statement recommended. Standing blood pressure will identify significant hypotension, and when hypotension is identified in the standing position, clinicians should measure and then monitor supine blood pressure and heart rate, the authors noted. Clinicians should perform an evaluation for orthostatic hypotension in patients with a suspected neurodegenerative disorder associated with autonomic dysfunction such as Parkinson's disease, those with unexplained falls or syncope, patients with peripheral neuropathies associated with autonomic dysfunction (such as diabetes), patients with hypertension, those ≥age 70 years, those on multiple medications, and those with postural dizziness or symptoms when standing, according to the statement.

Nonpharmacological treatment of orthostatic hypotension includes increased fluid and salt intake, compression stockings or abdominal binders, Valsalva maneuver on standing, and exercise. Bed rest worsens this condition and should be avoided except during sleep, the statement said. Elevating the head of the bed, even by a few inches, can decrease supine hypertension. Adults who fall after a meal should be evaluated for postprandial hypotension and at a minimum should be instructed to avoid standing for 30 minutes after a meal. Medication for orthostatic hypotension includes three drugs that increase supine hypertension: volume expansion with fludrocortisone, which is contraindicated in patients with hypertension and heart failure; midodrine, a short-acting alpha-1 agonist that raises blood pressure for about four hours; and droxidopa, which increases norepinephrine in the peripheral nervous system and raises blood pressure for about four hours. Both standing and supine blood pressure should be monitored on an ongoing basis in patients who are prescribed these drugs.

Evaluation for syncope should include an assessment of heart rhythm disturbances, a cardiac examination and echocardiogram to detect structural disease, orthostatic vital signs, carotid sinus massage, and a comprehensive medication review, the statement said. Clinicians should also address home environmental safety, including trip hazards such as throw rugs and pets, uneven surfaces, and poorly lit areas, and should evaluate patients for appropriate use of assistive devices such as walkers and canes, the statement said. They should also regularly screen and monitor adults with CVD for problems with cognitive function, according to the statement.

“Clinicians caring for patients with CVD should carefully review medications that increase fall risk, address cardiovascular risk factors for falling, and develop referral links to physical and occupational therapists and other health care team members who can act on other identified fall risks. Given the increasing numbers of older adults with CVD and the significant CVD and non-CVD risk factors for falling in adults with CVD, falls should be on the radar of all cardiology clinicians,” the statement said.