Clot Chronicles: Preventing and Managing Falls in Adults with Cardiovascular Disease — Guidance from the AHA
I’m Dr. Sarah Goodlin, I’m a Professor of Medicine at Oregon Health and Sciences University, and Medical Director of Geriatrics and Palliative Care at the VA Portland Healthcare System. I was honored to serve as the chair of a writing group from the American Heart Association on this statement regarding falls in patients with cardiovascular disease and really happy to share with you some of the key information there.
So, falls are actually highly prevalent amongst individuals with cardiovascular disease—in younger patients as well as older patients—and the risk for falling is substantial in one population study that looked at a group of individuals with cardiovascular diagnoses hospitalized; they calculated a 60% risk of falling amongst those individuals.
There are several studies that have documented rates of falling of about 25% in individuals who’ve had stroke, about 40% in individuals with heart failure, and so forth. So it’s a real problem that clinicians need to be aware of and address proactively.
One of the key points we tried to make in this paper is that falls are devastating for patients even if they don’t suffer an injury from the fall, so it’s really important to simply ask the patient whether they’ve fallen recently or fallen within the last 6 months or a year. Any endorsement of a fall should promote further evaluation.
Additionally, it’s important to conduct certain evaluation in a preventative way, even amongst individuals who don’t admit to having fallen. The kinds of things that are important to do are to check standing blood pressure because the prevalence of orthostatic hypotension amongst individuals with cardiovascular disease is at least 30%.
There’s also a poorly recognized entity called postprandial hypotension where patients drop their blood pressures within about 30 minutes of a meal, and so it’s important when someone has a history of falling to get a good history for when did it occur, and certainly if it occurs around the time of a meal, you can initiate behavioral changes with the patient to avoid future falls.
In addition to checking orthostatic blood pressures, we recommend that you watch the patient walk and evaluate their gait. Any concern about gait or balance should precipitate a referral to physical therapy and occupational therapy for further evaluation and consideration of interventions.
Interventions to prevent falls might include exercise—both to address balance and also to address strengthening—because it’s very clear that when individuals have lower-extremity weakness, they’re much more at risk of falling.
As individuals age, or certainly when someone has a history of falls, it’s important to consider safety issues at home. There’s a website called STEADI run by the Centers for Disease Control that has a number of handouts, including a home safety evaluation sheet. So, you can download those things and provide them to patients.
One of the big causes of falling is medications, and some medications are really obvious. Medications that affect gait and balance like benzodiazepines and other sedatives commonly are associated with falling. And, in fact, many psychoactive medicines, including antidepressants, are associated with falling because virtually every antidepressant—tricyclics, selective serotonin reuptake inhibitors, and so forth—are associated with an orthostatic drop in blood pressure.
Some cardiovascular medications clearly have a greater risk of falling. There’s concern that medications like digoxin may impact balance particularly when the patient is frail. Antihypertensive agents may cause a drop in systolic blood pressure.
And I will just quickly say that the presence of orthostatic hypotension should provoke the clinician to look for supine hypertension. At least half of people who drop their blood pressures when they stand have supine hypertension. I frequently see patients who are being treated by somebody who only ever checks a seated blood pressure, and so they address any hypertensive medication to that seated blood pressure. The standing blood pressure is important to evaluate, and then we know that treatment of supine hypertension actually improves orthostatic hypotension. There are things you can do such as dosing antihypertensive medications at bedtime, so the major effect of the antihypertensive medication is when the patient is supine.
You can also use short-acting antihypertensive agents for that time frame, but there are also some mechanical things that can be done such as elevating the head of the bed slightly. That alone can improve the baroreceptor response and decrease orthostatic hypotension, as well as decrease supine hypertension.
Well, what about anticoagulation? I know that your group, in particular, has patients who receive anticoagulants. There is an ongoing concern when a patient falls and they’re on an anticoagulant, or when they’re deemed to be at risk of falling, whether they should be continued on that anticoagulant, and multiple studies have looked at this.
It is clear that the risk of stroke, for example, with atrial fibrillation, or the risk of consequences associated with not administering anticoagulation for appropriate indications, are substantially higher than the risk of a dangerous bleeding episode with falling. So, yes, people that fall who are on anticoagulants have more bleeding and bruising than those who don’t take anticoagulants, but simply a risk of falling should not promote discontinuation of the anticoagulant.
Well, then, what do you do? And, again, it’s really important if you deem a patient to be at risk of falling, that you pretty aggressively help them and their significant others consider how to manage their risk. Many patients are reluctant to use assistive devices like canes or walkers because they think that makes them look old. I tell patients they’ll look a whole lot older with a hip fracture lying in a hospital bed than they do if they walk with an appropriate assistive device.
So aggressively, if you will, referring your patients to physical therapy and occupational therapy to address gait and balance, and encouraging use of assistive devices is really important. And sometimes you need to actively engage in shared decision-making with the patient and their family. Many people who have fallen or had a near fall are afraid of falling again, and simply identifying that fear and saying “look, here’s something that will help you, we can prevent a fall if we do these things,” is very beneficial.
We really, unfortunately, lack adequate interventional studies specific to cardiovascular disease to know exactly what we should be doing to prevent falls, so much of the statement that we wrote is gleaned from data in geriatrics and secondary analyses of studies, and there’s a real need to look at a systemic approach to fall prevention.
Falls occur in many different places; they certainly occur in the hospital when patients are in an unfamiliar environment, they also occur in familiar environments like home. And so making sure that you’re aware of fall risks, working with a team of providers, and trying to both evaluate medications, assess clear risks such as an orthostatic drop in blood pressure, or a gait and balance problem, and then partnering with patients and the extended healthcare team is really what we need to do for now.
Hopefully in the future, studies will address falling prospectively and we’ll have even more information to help us. Thank you.