Depressive Symptoms and Orthostatic Hypotension Are Risk Factors for Unexplained Falls in Community-Living Older People

Jasmine C. Menant, PhD; Alfred K. W. Wong, MD; Julian N. Trollor, MD; Jacqueline C. T. Close, MD; Stephen R. Lord, DSc

Disclosures

J Am Geriatr Soc. 2016;64(5):1073-1078. 

In This Article

Abstract and Introduction

Abstract

Objectives: To investigate risk factors for unexplained falls in older community-dwelling individuals.

Design: Prospective cohort study.

Setting: Community population, Sydney, Australia.

Participants: Older adults (N = 529; mean age 79.8 ± 4.4, 52.2% female).

Measurements: Participants provided information demographic, medical, and medication characteristics and completed cardiovascular (tilt table test, pulse wave velocity), cognitive, and sensorimotor assessments at baseline. Falls were then recorded in monthly fall diaries for 12 months. Unexplained fallers (UFs) were those who reported falls due to a blackout, dizziness, feeling faint, or "found themselves suddenly on the ground."

Results: Of the 523 participants available at follow-up, 238 (45.5%) reported one or more falls; 35 participants fulfilled the definition of UFs. UFs were more likely than balance-related fallers (BFs) (n = 203) and nonfallers (n = 291) to have orthostatic hypotension (39.4%, 20.5% and 22.4%, respectively) and depressive symptoms (24.2%, 10.1%, and 7.9% respectively). More UFs (88.6%) than BFs (70.9%) had injurious falls. A multivariate logistic regression model revealed that depressive symptoms and orthostatic hypotension were significant and independent determinants of UF status.

Conclusion: Approximately 15% of fallers had unexplained falls, which were more likely to result in injuries. Depressive symptoms and orthostatic hypotension increased the risk of unexplained falls, whereas cognitive deficits and sensorimotor and balance impairments did not. Future research should investigate whether psychotherapy and physical exercise to improve mood and medication reviews and nonpharmacological therapies for the treatment of orthostatic hypotension and depression are effective at reducing the risk of unexplained falls in older people.

Introduction

Although slips, trips, and loss of balance contribute to the majority of falls in older community-dwelling people,[1] a significant proportion of falls remain unexplained, that is, falls due to a blackout, dizziness, feeling faint, or when the person reports "finding themselves suddenly on the ground," all possibly subsequent to a syncopal or presyncopal episode. Estimates of unexplained falls vary from 14% to 26%[1–3] depending on the study setting: community,[1] hospital[3] or emergency department.[2]

Only a few research studies[2–6] have examined risk factors for unexplained falls. Two major syncope risk factors—orthostatic hypotension[3,5] and carotid sinus hypersensitivity[3,5–7]—have been identified as likely contributors to unexplained falls. A comparison of age-matched individuals admitted to a hospital's syncope unit with unexplained falls or unexplained syncope revealed that both groups tested positive on assessments of carotid sinus massage and orthostatic hypotension.[5] In addition, medications,[2] gait abnormalities,[2] history of falls[3,6] or syncope,[4,6] and depressive symptoms[4] were found to significantly differentiate unexplained fallers from other fallers.

Although the above studies suggest cardiovascular conditions as the primary risk factor for unexplained falls, these findings might be biased because participants were primarily attendees of hospital clinics specifically designed to investigate cardiovascular causes of falls. The generalizability of current knowledge regarding risk factors and effective prevention interventions for unexplained falls in community-based settings is therefore uncertain. No studies have examining a broad range of factors regarding unexplained falls in a community-dwelling sample. The aim of the present study was to investigate medical, medication-related, physiological, and neuropsychological risk factors for prospectively determined unexplained falls in a large sample of older community-living people.

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