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Falling: should one blame the heart?

Jansen, Sofie

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CHAPTER

ONE

INTRODUCTION

THE ASSOCIATION OF CARDIOVASCULAR DISORDERS AND FALLS:

A SYSTEMATIC REVIEW

1110 CHAPTER 1falling: should one blame the heart?

INTRODUCTION

Falls in older people form an increasing health care burden. Approxima-tely one in three people over the age of 65 will suffer a fall each year; one in five of these falls will lead to significant injury. As the world’s ageing population increases, healthcare costs associated with falls are set to rise over the next 30 years. It is estimated that over a third of falls may be preventable and evidence for causative, treatable factors is therefore essential. Cardiovascular disorders are among the several risk factors which have been identified to cause falls; in particular unexplained falls (defined as those for which no obvious attributable cause such as a trip or slip can be found) and recurrent falls. In part, this is due to the overlap between falls and syncope (a transient loss of consciousness due to de-creased blood supply to the brain) secondary to underlying cardiovascu-lar disease. Approximately one in three older people with syncope have amnesia for loss of consciousness and therefore present with a fall, rather than a faint or blackout.

Despite the overlap between falls and syncope in older adults, few well-designed studies have studied cardiovascular risk factors and their ma-nagement in falls prevention. Although causal associations between car-diac abnormalities, such as arrhythmias and structural cardiac abnormali-ties, and syncope have been well established, only few studies have as-sessed the association between these abnormalities and falls. Furthermo-re, very little evidence regarding the effectiveness of treatment of these conditions in reducing fall incidents exists. If we could establish the ex-tent of the associations between cardiac abnormalities and falls, this would aid into further determining which cardiovascular abnormalities deserve increased awareness in the assessment of older fallers, potential-ly leading to optimization of the care of older fallers.

Aim and outline of this thesisThe main aim of this thesis is to study the association between cardiovas-cular conditions and falls, in particular cardiac arrhythmia, conduction abnormalities and structural abnormalities. Because these conditions could lead to falls via several pathways, another aim was to study poten-tial mechanisms responsible for these associations.

In CHAPTER ONE we therefore examine which cardiovascular conditions have already been associated with falls through a systematic review of the literature. In CHAPTER TWO we report on the association between se-veral self-reported cardiovascular conditions and falls in community dwelling older adults. CHAPTER THREE AND FOUR describe the findings of a hospital study, in which clinically relevant ECG abnormalities and echo-cardiographic abnormalities were studied in hip-fracture patients compa-red with healthy controls. CHAPTER FIVE describes the findings of a general population study, in which the association between atrial fibrillation (AF), the most common cardiac arrhythmia in older adults, and falls and syn-cope was studied. The findings of chapter five led to the design of the studies described in CHAPTER SIX AND SEVEN, in which the association between AF and two important fall-related outcomes is studied. Firstly, the link between AF and mobility impairments is described. Secondly, it is shown that AF is associated with postural blood pressure changes. The second aim of this thesis is to explore the optimization of prevention of falls in older adults. Firstly, in CHAPTER EIGHT, the efficacy of extending the routine falls assessment with a comprehensive cardiovascular evalua-tion and treatment is studied. Secondly, in CHAPTER NINE it is studied which older people are aware of their increased fall risk, and wish to un-dergo a GP-based preventive treatment for falls. CHAPTER TEN provides a summary of the main findings of this thesis, and a discussion of the po-tential consequences of these findings for clinical practice and future re-search.


ABSTRACT

BACKGROUND AND OBJECTIVE Cardiovascular disorders are recognized as risk factors for falls in older adults. The aim of this systematic review is to identify cardiovascular disor-ders that are associated with falls, thus providing several angles for opti-mization of fall-preventive care.

DESIGN Systematic review. A search was performed in Medline and Embase and included studies addressing persons aged 50 years and older that descri-bed cardiovascular risk factors for falls. Key search terms for cardiovascu-lar abnormalities included all synonyms for the following groups: structu-ral cardiac abnormalities, cardiac arrhythmia, blood pressure abnormali-ties, carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), vasovagal syncope (VVS), postprandial hypotension (PPH), arterial stiff-ness, heart failure and cardiovascular disease. Quality of studies was as-sed using the Newcastle-Ottawa-Scale.

RESULTS Eighty-six studies were included. Of studies that used a control group, most consistent associations with falls were observed for low blood pres-sure (4/5 studies showing a positive association), heart failure (4/5) and cardiac arrhythmia (4/6). Higher prevalences of CSH (4/6), VVS (2/2) and PPH (3/4) were reported in fallers compared to controls in the majority of studies, but most of these studies failed to show clear association measu-res. Coronary artery disease (6/10), orthostatic hypotension (9/25), gene-ral cardiovascular disease (4/9) and hypertension (7/25) all showed in-consistent associations with falls. Arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardio-graphic abnormalities.

CONCLUSION Several cardiovascular associations with falls were identified, including low BP, heart failure and arrhythmia. These results provide several angles for optimizing fall-preventive care, but further work on standard definiti-ons, as well as the exact contribution of individual risk factors on fall inci-dence is now important to find potential areas for preventive interventi-ons.

THE ASSOCIATION OF CARDIOVASCULAR DISORDERS AND FALLS:

A SYSTEMATIC REVIEW

Sofie Jansen*Jaspreet Banghu*

Sophia E.J.A. de RooijJoost G. Daams

Rose Anne KennyNathalie van der Velde

*Joint first authors

Accepted for publication, J Am Med Dir Assoc


METHODS

A systematic search was conducted to include all articles that addressed the question of possible cardiovascular contributions to falls in adults over the age of 50 years. Our review methodology and reporting follo-wed standard guidance 12.

Search strategyIn collaboration with a clinical librarian (JD), a systematic search was conducted in PubMed and Embase for articles published until the date of the search (March 30, 2015). A customized search strategy was conduc-ted for each database. A manual search of references in the selected arti-cles was also conducted to identify additional studies. Key search terms were ‘falls’, ‘aged’ and ‘cardiovascular’. Full details of the search strategy are available as Supplementary data, Appendix S1 as well as the actual search strategy used; Supplementary data, Appendix S2. Two reviewers (SJ and JB) first independently screened titles and abstracts for inclusion and then read the full text of the eligible articles found during this first selection. In case of differences between the two reviewers, a third inde-pendent reviewer was consulted (NV).

Inclusion/exclusion criteriaStudies were included if they were published as a primary research paper in a peer reviewed journal, included persons aged 50 years or older, de-fined falls as an outcome measure and included diagnosis or assessment of cardiovascular abnormalities. Search terms for cardiovascular abnormalities included all synonyms and differentiations for: structural cardiac abnormalities (impaired ventricular function, heart valve abnormalities), cardiac arrhythmia (CA), blood pres-sure abnormalities (SBP and DBP), carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), postprandial hypotension (PPH), arterial stiffness (AS), heart failure (HF), angina, myocardial infarction (MI) and general cardiovascular or circulatory disease (CVD). Cardiovascular as-sessments included: Electrocardiogram (ECG), holter monitoring (HM), prospective external event recorders, external loop recorders (ELR), im-plantable loop recorders (ILR), remote telemetry, echocardiogram, caro-tid sinus massage (CSM), assessment of orthostatic hypotension or im-paired BP recovery upon active stand, tilt table testing (HUT), electrop-hysiological studies, exercise stress testing and/or cardiac catheterization. Articles using self-report of doctor-diagnosed cardiovascular abnormali-ties or disease were included also, but only for the following conditions:

INTRODUCTION

Falls are the leading cause of injury in older people 1, 2. Approximately one in three people over the age of 65 will suffer a fall each year, with injuries occurring in at least one in five of these 3. As the world’s ageing population increases, healthcare costs associated with falls are set to rise over the next 30 years 4. As it is estimated that up to 40% of falls may be preventable, evidence for causative, treatable factors is essential 5.

Cardiovascular disorders are among the several risk factors which have been identified to cause falls; in particular unexplained falls (defined as those for which no attributable mechanical cause such as a trip or slip can be found) and recurrent falls 6. Syncope secondary to underlying car-diovascular disease is more common in older adults and may lead to in-jurious falls 7.

As there is considerable overlap between the symptoms of falls and syn-cope in older adults, there is likely an underestimation for the role of cardiovascular abnormalities in fall risk 8. Orthostatic hypotension, caro-tid sinus hypersensitivity, vasovagal syncope and cardiac arrhythmias are the main cardiovascular disorders that can cause syncope in older adults, but evidence linking these abnormalities to falls included in current falls guidelines is scarce.

Up to now, one systematic review has been published that addressed car-diovascular causes of falls 9. However, no quality assessment of included articles was performed in this review, and a first selection of articles was based on titles alone, potentially causing certain articles to have been overlooked. Two recent reviews have studied the association between or-thostatic hypotension and falls, but these studies did not assess other po-tential cardiovascular causes of falls 10, 11. Furthermore, as the subject has gained attention in the last five years, there is a need to update earlier reports. The aim of this review was to identify cardiovascular risk factors for falls systematically and to thereby provide a broad overview of the available literature.


Data Synthesis and AnalysisAs included studies were heterogeneous in design and assessment me-thods, a descriptive approach was used to summarize study characteris-tics and outcomes. Studies that were included were categorized per ex-posure. No statistical pooling was conducted.

RESULTS

Search resultAfter removing duplicates, the initial combined search retrieved 5,420 journal articles. Of these, 194 full-texts were assessed for eligibility of which 86 were included in this systematic review (FIGURE 1).

hypertension, general cardiovascular disease, angina, arrhythmia and heart failure. We also included studies in institutions, nursing homes, hospitals or other non-community dwelling settings, which were perfor-med on cognitively intact participants. Hospital-based studies were only included if falls had occurred prior to admission. Articles were excluded if the sample comprised a specific disease-de-fined population (such as Parkinson’s disease, diabetes or subjects with significant cognitive impairment), if they were intervention studies, if they were reviews, case reports or conference abstracts, and if they were not written in English. If two or more articles had included the same popula-tions for the same exposure, only one was included. For the latter, priori-ty was given to studies that used a control group or larger sample size.

Data extraction and Quality AssessmentData were collected on study design, setting, type of and method of car-diovascular assessment and definition of cardiovascular abnormality. De-mographic data, clinical characteristics, number of falls and method and interval for reporting of falls were also collected. If applicable, data on the association between cardiovascular abnormalities and falls was col-lected. To appropriately describe reported associations, a breakdown into categories was made: ++ denoted association multivariably adjusted for potential confounders, + denoted univariable association or higher preva-lence compared to control group, - denoted an absent association or si-milar prevalence.

To reduce the risk of reporting bias, all cardiovascular exposures that were evaluated were extracted from individual studies, even if they were not part of the main outcome variables. Cardiovascular exposures that were not included in a multivariable model because they were not asso-ciated with falls in the univariable model were considered to not be as-sociated with falls. Quality of included studies was assessed by the same reviewers (SJ, JB). Because of the variety of nonrandomized study designs included, the Newcastle-Ottawa Scale (NOS) was used to evaluate risk of bias in the case controlled and cohort studies 13. A detailed description of the quality assessment can be found in appendix S3. A score of 0-3 was considered low quality, 4-6 intermediate and 7 or above high quali-ty. No studies were excluded based on their grading of quality, but quali-ty grades were used in the critical review of the results.

Records identified through database searching Medline in Process &

other non-indexed materials (n = 2703) and EMBASE (n= 3833)

(total 6536)

Additional records identified through other sources

(n= 2)

Records after duplicates removed (n = 5420)

Records screened (n = 5420)

Records excluded (n = 5226)

§ Not related to falls and/or cardiovascular abnormalities

§ Editorials, reviews, intervention studies, case reports or conference abstracts

§ Did not meet one or more inclusion criteria

Full-text articles assessed for eligibility

(n = 194)

Full-text articles excluded (n = 106)

§ Wrong study design n=4 § Wrong outcomes n= 26 § Specific disease defined population n=36 § Overlapping populations n=3 § Duplicate n=17 § Not in English n=8 § Intervention study n=4 § Conference abstract n=1 § Not meeting inclusion criteria n=9

Studies included in qualitative synthesis

(n = 86)

FIGURE 1. FLOW DIAGRAM OF STUDY SCREENING AND INCLUSION


Carotid sinus hypersensitivity (CSH)Twenty-one studies had investigated CSH as an exposure (TABLE 3). Five were designed as case-control studies; one reported a positive associati-on between neurally mediated syncope and unexplained falls compared to accidental falls; three reported a higher prevalence of CSH in fallers compared to controls. Fifteen observational series were performed which reported a prevalence of between 8-73%. Eighteen studies performed both supine and upright (70⁰) carotid sinus massage; two were supine only. All studies defined CSH as asystole greater than 3 seconds on ECG or a vasodepressor drop of 50mmHg in systolic blood pressure. Five stu-dies used symptom reproduction during carotid sinus massage to diffe-rentiate carotid sinus syndrome from carotid sinus hypersensitivity. All studies had a low to intermediate NOS quality level.

Vasovagal syncope (VVS)Ten studies had investigated vasovagal syncope as an exposure for falls (TABLE 4); two used a case control design, both of which reported that VVS was more common in fallers. Eight observational series reported a prevalence of VVS between 3-46%. All studies had used a head up tilt table test as the measurement method. All were graded as low to inter-mediate on the NOS quality score.

Hypertension (HTN)Twenty-seven studies assessed hypertension as an exposure for falls; 22 were designed as cohort studies, three as case controls (TABLE 5). Of the 25 studies with a control group, five reported a positive multivariably ad-justed association between HTN and falls and two reported a higher pre-valence of HTN among fallers compared to controls. Two studies repor-ted a negative association between HTN and falls.

The two observational series reported a prevalence of HTN among fallers between 34-73%. Nine studies only used self-report of HTN; five used medical charts only, six studies used an objective measurement of BP and/or use of anti-hypertensive to diagnose HTN, five used a combinati-on of self-report and medical charts, one used both objective and self-reporting methods and one study did not report the measurement me-thod. Of studies that used an objective measurement, different cut-offs for HTN were used, ranging from >130/80 mmHg to >160/95 mmHg. Only two studies were considered high quality on the NOS scale, neither of which showed a positive association between HTN and falls.

Characteristics of the Studies TABLE 1 shows the characteristics of included studies. Forty-eight stu-dies were cohort studies, thirteen were case–control studies and 25 were observational series. Numbers of study participants in each study varied from 13 to 135,433. Mean age varied from 50 to 88 years.

Of included studies, 39 were conducted in the community, nine in long-term care facilities, one in both community and long term care, 24 in outpatient clinics (20 in specialized falls- and syncope clinics), eight in emergency departments and five in acute hospital settings. Fifty-one studies used any falls as an outcome measure, eight used recur-rent falls, eight used unexplained falls, twelve studies used falls and/or syncope as an outcome, and two studies used unexplained falls descri-bed as ‘drop attacks’.Eleven types of cardiovascular abnormalities (exposures) were identified with 39 studies assessing more than one risk factor. OH as a risk factor for falls was examined in (36), followed by hypertension (27), CSH (21), general cardiovascular disease (9), Angina and MI (grouped as coronary artery disease) (14), arrhythmia (12), vasovagal syncope (10), heart failure (6), low BP (5), post prandial hypotension (4), and structural cardiac ab-normalities (3).

TABLES 2-11 show results of includes studies, categorized per cardiovas-cular risk factor and type of study

Orthostatic hypotension (OH)OH was studied as an exposure in 36 studies; 23 of which were designed as cohort studies and two as case-control studies (TABLE 2). Six studies reported a positive multivariably adjusted association with falls; three stu-dies reported a higher prevalence of OH in fallers. Eleven observational design studies reported a prevalence of between 5-56% of fallers.

OH was defined as a drop of greater than 20 mmHg SBP and/or greater than or equal to 10 mmHg DBP drop in twenty studies, greater than 20mmHg SBP drop in twelve studies while the four studies did not report a value. Fifteen studies used intermittent BP measurements, twelve stu-dies used continuous measurement with photopletysmography, two stu-dies used both methods, and seven studies did not specify their study in-strument. Seven studies were scored as high quality with the remainder (how many) scoring low and intermediate on the NOS scale


one reported no association. The case control studies both reported a higher prevalence of PPH in fallers compared to controls. PPH was de-fined and measured in different ways in all studies. All studies were rated as low to moderate on the quality rating scale.

Arrhythmia Twelve studies studied cardiac arrhythmia as an exposure; three were de-signed as cohort studies, three were case-control studies (TABLE 10). Of these six studies, four reported a positive, multivariably adjusted associa-tion between arrhythmia and falls, of which three were studies on AF.

Six observational design studies reported a prevalence of between less than 1% and 27%. There was a variety of measurements performed; Im-plantable loop recorder (ILR)(for extended arrhythmia monitoring beyond 30 days) in one study, external loop recorder (ELR) (for arrhythmia moni-toring up to 30 days) in one study, holter monitoring (for arrhythmia mo-nitoring up to 24 hours), 12-lead ECG, cardiac telemetry (in-patient arr-hythmia monitoring) and medical chart review. This resulted in a variety of definitions used for cardiac arrhythmia. Two studies were graded as high quality on the NOS scale whilst the remainder were of low or inter-mediate quality.

Heart failureSix studies looked at heart failure as an exposure; five cohort studies, with four reporting a positive, multivariably adjusted association between CHF and falls (TABLE 11). One study used the New York Heart Associati-on Classification for heart failure and one study used the NHS–Read co-ding for classification. All studies that reported an association measure were of intermediate or high quality.

Structural abnormalitiesThree studies looked at exposures that could not be categorized under other exposures (TABLE 12). Wong et al. studied arterial stiffness in a prospective cohort, and found that the top quintile of pulse wave velocity (indicating arterial stiffness) was an independent predictor of future falls.

Schoon et al. studied head-turning induced hypotension in a case control study in a falls and syncope clinic. Prevalence of a drop in SBP following these movements was high, but not different between cases and controls.

Low blood pressure (LBP)Five studies looked at low blood pressure as an exposure in cohort stu-dies (TABLE 6). Four showed a positive, multivariably adjusted associati-on between low BP and falls; one did not. Prevalence of hypotension among fallers varied, from 7% to 74%. All studies used an objective mea-surement of blood pressure, but various thresholds for diagnosing hypo-tension were used, ranging from 100 mmHg to 142 mmHg for systolic blood pressure (SBP), and from 60 mmHg to 80mmHg for diastolic blood pressure (DBP). The one study that did not show an association also used the lowest BP cut-off (SBP/DBP ≤100/60). Four out of five studies were rated high quality on the NOS scale.

Coronary artery disease (CAD)Fourteen studies assessed the association between MI or angina (grouped as coronary artery disease) and falls (TABLE 7). Ten studies used a control group, of which five reported a positive multivariably adjusted associati-on between CAD and falls and four reported no association. The four observational series reported a prevalence of 0.9% for acute MI, to 76% for IHD. Six studies used self-reported history of MI or angina; four used medical chart history of MI or angina, three used a combination of medical re-cords and self-report and one used a clinical definition to define MI (myocardial infarct evidenced by chest pain and/or serial ECG’s). All co-hort studies scored intermediate or high on the NOS scale whilst the ob-servational series scored low to intermediate on the NOS scale.

General Cardiovascular Disease (CVD)Nine studies looked at general CVD without breakdown into specific car-diovascular diseases (TABLE 8). Seven used a cohort design; one was a case control study. Two out of these nine studies showed a multivariably adjusted association between cardiovascular disease and falls, two stu-dies showed a higher prevalence of cardiovacular disease among fallers and four studies did not show an association. The one observational stu-dy reported a prevalence of cardiovascular disease of 52%. Four used self-report of CVD, three used medical records while two used both me-thods. All studies were graded as low to intermediate on the NOS scale.

Postprandial hypotensionFour papers studied post-prandial hypotension (PPH) as an exposure for falls; two cohort and two case control studies (TABLE 9). One reported a positive, multivariably associated association between PPH and falls and


nic damage to the areas of the brain which govern balance and gait 14 through neurodegeneration. In addition to an association with falls, LBP has been associated with stroke and cognitive impairment 15-17. Conver-sely, hypertension was associated with falls after adjustment for confoun-ders in only a small number of studies reviewed, and hypertension even showed a protective effect on fall incidence in two studies. It has been reported previously that blood pressure behaviour is not uniform throug-hout all age groups and may demonstrate a U shaped curve, especially with regard to its effect on the incidence of stroke and mortality 18, 19. Adults in the oldest age categories have not been shown to benefit from aggressive lowering of their blood pressure and in fact may be harmed by low blood pressure 19. However, whether LBP, or conditions causing LBP can been seen as causative or contributory factors to falls remains unclear. A consistent association with falls was also seen for heart failure (4/5). HF can lead to a reduction in cardiac output in demanding situati-ons such as exertion and postural changes, which may explain this fin-ding, and strengthens the finding of the association between LBP and falls. Further work on the effects of transient changes in blood pressure is needed to delineate thresholds by which older adults are more prone to falling and elucidate treatment strategies for this.

The majority of studies on arrhythmia and falls showed a positive associ-ation. Both length of monitoring time and the definition used for CA had a large influence on the reported associations. Those studies that em-ployed a monitoring time longer than 24 hours showed a positive correla-tion with CA and falls. Studies that focused on finding a causative arr-hythmia detected a prevalence of between 15-46%. However these were in predominantly observational series, limiting the applicability of this finding. Interestingly, the three studies which exclusively defined atrial fi-brillation as an arrhythmia reported a positive association with falls. As these were done in cross-sectional studies, causation could not be ascri-bed. Cardiac arrhythmias are a potentially treatable cause of falls and this review highlights the inconsistencies with which they are reported on, li-miting the ability to make a definitive statement of the contribution of CA to falls risk.

Although OH is a commonly accepted cardiovascular cause of falls in older persons, only a minority of studies reported a positive association with falls. However, quality of included studies varied and several assess-ment methods to detect OH were used. We included studies that used intermittent methods of BP detection as well as continuous methods, nei-

Van der Velde et al. assessed the association between echocardiographic abnormalities and future falls. Several heart valve abnormalities were in-dependent predictors of future falls: mitral-, tricuspid and pulmonary val-ve regurgitation and pulmonary hypertension.

DISCUSSION

Main resultsA systematic review of the literature shows strong associations between cardiovascular disorders and falls. Of studies that used a control group, the most consistent associations with falls were observed for low blood pressure (4/5), heart failure (4/5) and cardiac arrhythmia (4/6), as the ma-jority of these studies showed a positive association with falls after per-forming multivariable adjustment for potential confounders. For carotid sinus hypersensitivity (4/6), vasovagal syncope (2/2) and post-prandial hypotension (3/4), the majority of studies reported a higher prevalence of the exposure in fallers compared to controls, but only few multivariable adjusted associations were reported. Coronary artery disease (6/10), or-thostatic hypotension (9/25), general cardiovascular disease (4/9) and hy-pertension (7/25) all showed inconsistent associations with falls, with a similar or smaller amount of studies reporting positive associations as stu-dies reporting no associations with falls. Hypertension even showed a protective effect on falls in two out of 25 studies. Finally, arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardiographic abnormalities.Although orthostatic hypotension, carotid sinus syndrome and vasovagal syncope are most frequently cited as important cardiovascular causes of falls, the evidence on the association between these blood pressure syn-dromes and falls was inconsistent, mainly due to a lack in adequate con-trol groups and reporting of association measures that were adjusted for potential confounders. Surprisingly, more consistent positive associations were found for LBP, heart failure and cardiac arrhythmia. A range of stu-dies examining the association of blood pressure and falls was evaluated. Although these studies differed significantly in their methods, certain trends were apparent.

Low blood pressure showed a consistent association with falls. It has been hypothesized that transient reduction in cerebral perfusion pressure may not only lead to immediate effects of cerebral hypoperfusion (e.g. synco-pe or falls during exertion or postural changes) but may also lead to chro-


There is a lack of evidence regarding interventions to reduce falls risk by treating cardiovascular disorders alone. Up to now, only OH and CSH (which are commonly classified as syncope syndromes 25) have been in-cluded in intervention trials, which have shown benefit in preventing re-current syncope and falls. Multifactorial interventions that include recog-nition and treatment of OH have been shown to be effective in reducing falls 6. Furthermore, a recent Cochrane review on interventions aimed at reduction of falls rates has identified only dual chamber pacemaker inser-tion as having a proven benefit for reduction of falls in those patients with CSS 26. This review demonstrates a strong overlap between CV conditions that commonly lead to syncope and those that lead to falls. It thus enhan-ces previous guideline conclusions that have aimed to incorporate the potential impact that cardiovascular abnormalities were thought to have on falls 6.

The European Society of Cardiology (ESC) has stated the need to consider syncope as the cause of a fall in those with unexplained falls 25. Syncope mistaken for falls presents a difficult clinical challenge as up to 50% of ol-der persons suffer from retrograde amnesia after vasovagal syncope, and eye-witnesses are often absent 27. This may in part have accounted for the large variation in prevalence rates of VVS reported. Carotid sinus hyper-sensitivity is a condition that is also considered a form of reflex syncope 25. Prevalence rates of between 10-40% were consistently reported in fal-lers with two notable outliers. In addition, studies conducted in patients with unexplained and recurrent falls were able to attribute CSH as the cause of these falls. As dual chamber pacemaker insertion has been found to be beneficial for treating cardio inhibitory CSS, this has important impli-cations for clinical practice 28. Controversy exists over terminology and definitions, as some authors define carotid sinus syndrome (CSS) as an ab-normal response to carotid sinus massage (CSM) only when accompanied by symptom reproduction of syncope 29. This is distinct from carotid sinus hypersensitivity (CSH), which would produce an abnormal response to CSM without definite symptom reproduction. In this review only five studies had included the presence of symptoms in their definition of CSS but thirteen studies reported on CSS as being present. Despite difficulties in ter-minology this review does reveal a higher incidence of CSH in fallers. Ho-wever, the prevalence rates reported may be skewed by definitions used.

ther of which showed a consistent association with falls. Finucane et al. have recently reported new normative data for definitions of OH, using non-invasive, beat-to-beat BP measurements 20. Whilst they reported that initial OH (within 15 seconds) occurred in up to a third of the population, impaired blood pressure stabilization at 40 seconds was present in 16% of subjects and ‘classical’ OH at or after one minute of standing was pre-sent in a much smaller number of subjects (7%). Most studies included in this review assessed OH at one minute of standing or beyond, potentially explaining why only a minority of studies found a positive association between OH and falls. In addition, only a small amount of studies inclu-ded symptom correlation for diagnosing OH or did not specifically report these results, leaving a gap regarding the value of symptom correlation in diagnosing OH. It does appear that OH does not follow a uniform distri-bution in the population, and intermittent measurements (such as those with a standard sphygmomanometer) may underestimate the true preva-lence of OH and its clinical importance. With the rise of the use of conti-nuous measurement of OH, more complete research can be performed to determine the full association between OH and falls.Cardiovascular disease, which comprised angina, ischemic heart disease and arterial disease, showed a positive association with falls in a few stu-dies, as did arterial stiffness. However, cardiovascular disease represents a diverse group of disorders, rendering it difficult to establish individual mechanisms that may contribute to falls risk. Potential interacting mecha-nisms include direct damage to affected end organs, such as the heart or brain or downstream impacts on physiological homoeostasis.

Macro- or microvascular arterial disease may impair muscle capacity and motor- and sensory nervous function with deleterious effects on gait. Frailty syndromes have also been shown to have a higher prevalence in cardiovascular diseases contributing to increased falls risk 21. Lastly, treat-ments used for cardiovascular disorders have been linked to increases in falls both through direct effects of drugs on the cardiovascular system as well as polypharmacy 22. There is evidence that drug withdrawal of CV drugs may reduce falls rates in practice 23, potentially through an impro-vement in postural blood pressure changes 24. Although the exact mecha-nisms remain difficult to elucidate, this review has shown that clinicians should regard those patients with a diagnosis of cardiovascular disease at a higher risk of falls.


CONCLUSION

Cardiovascular disease has a high prevalence in older adults with falls. There is a clear association between hypotension and falls, whilst conver-sely those patients with hypertension demonstrate a lower prevalence of falls in some studies. Furthermore, both heart failure and arrhythmia (in particular AF) are consistently associated with falls. There is also a posi-tive association demonstrated between syndromes that cause syncope such as CSH, VVS and OH, and falls, although the evidence regarding the association between OH and falls remains inconsistent. Efforts at un-locking the exact contribution of each variable to falls risk are hampered by a lack of standard definitions, methods of assessment and the low quality of available studies. Further work on standard definitions as well as the exact contribution of individual risk factors is of major importance to find potential areas for intervention.

Clinical implications and Future perspectivesThis systematic review has highlighted a number of studies, which have shown easily measurable cardiovascular parameters that may contribute to falls risk in older patients. The clinical implications of these associati-ons are important in evaluation of falls risk reduction. Consensus is nee-ded to adopt standard definitions of cardiovascular risk factors, as well as the resources and settings needed to systematically evaluate older adults at risk of falls, for the presence of cardiovascular disease. As up to 40% of falls may be preventable, a standardised assessment of cardiovascular risk factors is essential for falls prevention 5. There is a need for treatment tri-als to be designed and carried out in order to gauge the treatment bene-fits, which may accrue by systematic review and treatment of underlying CV abnormalities in older patients.

LimitationsDifferences in disease definition and the disparities between the quality of included studies make it impossible to perform a proper meta-analy-ses. This in turn limits our ability to describe the strength of associations between cardiovascular disorders and falls. Therefore, as mentioned abo-ve, it is of major importance to reach consensus for standard definitions. As we have pointed out, falls can be very difficult to distinguish as a dis-tinct clinical entity and overlap syndromes such as syncope have been reported. Therefore, caution is warranted when interpreting the data. A large majority of the studies only used self- reported falls that had occur-red in the past, and only a small minority studied falls in a prospective manner. As such, it is difficult to attribute causation to any one risk factor in isolation. Further prospective studies are therefore needed. The exact effect of cardiovascular drugs on falls risk remains a confounder in most studies. As this review specifically excluded articles where there were therapeutic interventions made, the contribution of individual medicati-ons to falls risk is beyond the scope of this article.


Gra

afm

ans

1996

57

354

70+

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Any

and

re

curr

ent f

alls

du

ring

28

wee

k FU

Supi

ne a

nd s

tand

ing

at 1

min

ute,

20/

10

O

H &

falls

: OR

1.4

(0

.8-4

.8) (

n/s)

. OH

&

rec

urre

nt fa

lls:

OR

2.0

(1.0

-4.2

)

OH

was

as

soci

ated

with

fu

ture

rec

urre

nt

falls

but

not

with

an

y fa

lls

+

+

8

Hei

ttera

chi

2002

59

70

77 [

±6]

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Any

fall

duri

ng 1

2 m

onth

FU

HU

T at

60

degr

ees,

co

ntin

uous

, 20

SBP

OH

at 3

min

.: 22

% o

f fa

llers

, 6%

of n

on-

falle

rs.

OH

at 3

min

. &

falls

: RR

1.7

[±

1.1-

2.6]

.

OH

at 3

min

. afte

r H

UT

was

as

soci

ated

with

fu

ture

falls

.

§ +

+

7

Kar

io

2001

66

266

76 [

±5]

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l

Any

fall

duri

ng 1

2 m

onth

FU

Supi

ne, i

mm

edia

tely

af

ter

stan

ding

and

at

2 m

in.

Sphy

ogm

oman

omet

er, 2

0/10

OH

not

diff

eren

t be

twee

n fa

llers

and

no

n-fa

llers

O

H w

as n

ot

asso

ciat

ed w

ith

futu

re fa

lls

∞

- 9

Law

lor

2003

73

405

0 71

(9

5% C

I 70

-71

)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

and

re

curr

ent f

alls

in

the

past

12

mon

ths

Mea

n of

two

stan

ding

m

easu

rem

ents

with

sp

hyg,

20/

10

17.6

% o

f fal

lers

and

17

.1%

of n

on-f

alle

rs

O

H w

as n

ot

asso

ciat

ed w

ith

falls

in th

e pa

st

year

∞

- 6

Liu

1995

79

100

83 [

±6]

, ra

nge

62-9

6

Coh

ort,

Com

mun

ity,

Pros

pect

ive

Any

fall

duri

ng 1

2 m

onth

s FU

Imm

edia

tely

on

stan

ding

and

afte

r 5

min

., sp

hyg,

20/

10

Prev

alen

ce O

H 3

-15

%, n

o di

ffere

nce

betw

een

falle

rs a

nd

non-

falle

rs

O

H is

not

as

soci

ated

with

fu

ture

falls

∞

- 6

Luuk

inen

19

96 80

10

16

76 [

±5]

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Rec

urre

nt

falls

dur

ing

12 m

onth

FU

Sitti

ng a

nd s

tand

ing

at 1

min

ute,

sph

yg,

20 S

BP

35%

in fa

llers

, 29%

in

non

-fal

lers

R

R 1

.3 (0

.8-1

.9)

OH

was

not

as

soci

ated

with

fu

ture

falls

∞

- 8

Mad

er

1987

81

300

70

(ran

ge

56-9

3)

Coh

ort

outp

atie

nt

com

mun

ity

clin

ic, c

ross

-se

ctio

nal

Any

fall

in

past

12

mon

ths

Supi

ne a

nd s

tand

ing

at 1

min

ute

sphy

g,

20 S

BP.

7% o

f fal

lers

, 12%

of

non-

falle

rs

n/s

OH

was

not

as

soci

ated

with

fa

lls in

the

past

ye

ar

∞

- 3

Mau

rer

2004

83

111

88 [

±7]

C

ohor

t, lo

ng-

term

car

e,

pros

pect

ive

Any

fall

duri

ng a

m

edia

n FU

of

270

days

Sitti

ng a

nd s

tand

ing

for

5 m

in.,

cont

inuo

us, 2

0/10

O

H a

t 1-m

inut

e &

fa

lls H

R 0

.98

(0.5

–2.

0), O

H a

t 3 m

in.

& fa

lls H

R 1

.3 (0

.7–

2.5)

OH

was

not

as

soci

ated

with

fu

ture

falls

-

6

Ooi

20

00 89

84

4 60

+

Coh

ort,

long

-te

rm c

are,

pr

ospe

ctiv

e

Any

fall

duri

ng 1

8 m

onth

s

Supi

ne a

nd s

tand

ing

at 1

& 3

min

., 8

mea

sure

men

ts

sphy

g. 2

0/10

50%

in fa

llers

and

no

n-fa

llers

. O

H &

rec

urre

nt fa

lls

in p

revi

ous

falle

rs

aRR

2.1

(1.4

- 3

.1).

Ris

k of

sub

sequ

ent

falls

was

gre

ates

t in

prev

ious

falle

rs w

ith

OH

at t

wo

or m

ore

OH

was

as

soci

ated

with

re

curr

ent f

alls

in

thos

e w

ho h

ad

prev

ious

falls

∞

++

5

TABLE 1 (CONTINUED)

Tabl

e 1.

Ove

rvie

w o

f st

udie

s pu

blis

hed

on c

ardi

ovas

cula

r ab

norm

alit

ies

and

falls

, inc

lude

d in

sys

tem

atic

rev

iew

A

utho

r Y

ear

Des

ign

Sett

ing

Dat

a ga

ther

ing

Out

com

e of

fa

lls

Mea

sure

men

t of

fal

ls

Rep

orti

ng

inte

rval

N

A

ge, y

ears

%

fe

mal

e Ex

posu

re(s

)

Ala

mgi

r 30

20

15

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 3

m

onth

s 59

96

65+

no

t gi

ven

CV

D

Allc

ock

31

2000

O

bser

vatio

nal

seri

es

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

and

sy

ncop

e

Ref

erre

d fo

r un

expl

aine

d fa

lls a

nd

sync

ope

n/a

120

78 (r

ange

66-

94)

70%

C

SH, O

H,

VV

S, C

A

Anp

alah

an

32

2011

C

ase-

cont

rol

Acu

te h

ospi

tal

Ret

rosp

ectiv

e U

nexp

lain

ed

and

acci

dent

al

falls

in E

R o

r ad

mitt

ed fo

r fa

lls

n/a

21 /

17

80 [

±6]

/ 77

[±5]

55

%

CSH

, VV

S,

CA

D

Arm

stro

ng

33

2003

O

bser

vatio

nal

seri

es

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

and

sy

ncop

e

Ret

rosp

ectiv

e n/

a 15

73

, ran

ge 6

1-89

87

%

CA

Aro

now

34

1997

C

ohor

t Lo

ng-t

erm

car

e Pr

ospe

ctiv

e A

ny fa

ll In

cide

nt

repo

rts

29 [

±10

] m

onth

s 49

9 80

[±

9]

Not

gi

ven

PPH

Ass

anta

chai

35

20

03

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 6

m

onth

s 10

43

Men

69

[± 6

],

wom

en 6

8 [±

7]

64%

H

TN

Ben

chim

ol

36

2007

C

ase-

cont

rol

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

and

sy

ncop

e

Ref

erre

d fo

r un

expl

aine

d fa

lls a

nd

sync

ope

n/a

259

/ 55

50 [

±24

], 5

7 [±

21]

66%

/ 58

%

CSH

, VV

S

Ber

g 37

19

97

Coh

ort

Com

mun

ity

(hom

e)

Pros

pect

ive

Rec

urre

nt fa

lls

Pros

pect

ive

2-w

eekl

y fo

r 12

mon

ths

96

72 [

±7]

, ra

nge

60-8

8 60

%

Low

BP

Ber

glan

d 38

20

03

Coh

ort

Com

mun

ity

(hom

e)

Pros

pect

ive

Any

fall

Pros

pect

ive

3-m

onth

ly fo

r 12

mon

ths

307

81 (r

ange

75-

93)

100%

H

TN

Bod

daer

t 39

2004

O

bser

vatio

nal

seri

es

Acu

te h

ospi

tal

Cro

ss-s

ectio

nal

Any

fall

In E

R o

r ad

mitt

ed fo

r fa

lls

n/a

57

84 [

±7]

81

%

OH

Bra

ssin

gton

40

20

00

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e n/

a 15

26

64-9

9 64

%

HTN

, CV

D

Bum

in 41

20

02

Coh

ort

Long

-ter

m c

are

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Ev

er

33

falle

rs 7

3 [±

2], n

on-

falle

rs 6

8 [±

2]

Not

gi

ven

OH

Cam

pbel

l 42

1981

C

ohor

t C

omm

unity

(h

ome

and

resi

dent

ial

faci

lity)

, Acu

te

hosp

ital

Cro

ss-s

ectio

nal

Any

fall

R

etro

spec

tive

Past

12

mon

ths

559

65+

N

ot

give

n O

H

TABLE 1. OVERVIEW OF STUDIES PUBLISHED ON CARDIOVASCULAR ABNORMALITIES AND FALLS, INCLUDED IN A SYSTEMATIC REVIEW


Lee

75

2006

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l A

ny fa

ll an

d re

curr

ent f

alls

R

etro

spec

tive

Past

12

mon

ths

4000

73

[±

5]

50%

C

VD

Lee

76

2009

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l R

ecur

rent

falls

R

etro

spec

tive

Past

12

mon

ths

11,1

13

65-7

5 ye

ars

55%

, 76

plus

45

%

58%

C

AD

Liao

77

2012

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l A

ny fa

ll R

etro

spec

tive

Past

12

mon

ths

1165

75

[±

7)

54%

H

TN

Lips

itz 78

19

91

Cas

e-co

ntro

l Lo

ng-t

erm

car

e C

ross

-sec

tiona

l R

ecur

rent

falls

R

etro

spec

tive

Past

6

mon

ths

70 /

56

87 [

±6]

/ 87

[±

5]

73%

/ 48

%

OH

, HTN

Liu

79

1995

C

ohor

t C

omm

unity

(r

esid

entia

l fa

cilit

y)

Pros

pect

ive

Any

fall

Pros

pect

ive

Wee

kly

for

12 m

onth

s 10

0 83

[±

6],

rang

e 62

-96

83%

O

H

Luuk

inen

80

1996

C

ohor

t C

omm

unity

(h

ome)

Pr

ospe

ctiv

e R

ecur

rent

falls

Pr

ospe

ctiv

e 3-

mon

tly

duri

ng 1

2 m

onth

s

1016

/ 65

0 76

[±

5]

63%

O

H

Mad

er 81

19

87

Coh

ort

Out

patie

nt

clin

ic,

com

mun

ity

clin

ic

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 1

2 m

onth

s 30

0 70

(ran

ge 5

6-

93)

77%

O

H

Mar

echa

ux

82

2009

O

bser

vatio

nal

seri

es

Emer

genc

y de

part

men

t Pr

ospe

ctiv

e A

ny fa

ll in

ER

or

adm

itted

for

falls

imm

edia

te

60

81+

/- 8

yea

rs

58,4

H

TN

Mau

rer

83

2004

C

ohor

t Lo

ng-t

erm

car

e Pr

ospe

ctiv

e A

ny fa

ll In

cide

nt

repo

rts

Wee

kly

duri

ng 2

70-

day

FU

(ran

ge 8

–657

)

111

88 [

±7]

82

%

OH

Mau

rer

84

2005

C

ohor

t Lo

ng-t

erm

car

e Pr

ospe

ctiv

e A

ny fa

ll In

cide

nt

repo

rts

12 m

onth

s 13

9 88

+/-

7 85

%

HTN

Mid

ttun

85

2011

O

bser

vatio

nal

seri

es

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

R

etro

spec

tive

not g

iven

20

7 83

yea

rs (5

8–

95)

70%

C

A

Milt

on 86

20

09

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Cro

ss-s

ectio

nal

Une

xpla

ined

fa

lls

Ret

rosp

ectiv

e no

t giv

en

1464

78

[±

10]

72%

C

SH, O

H

Mitc

hell

87

2013

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l A

ny fa

ll R

etro

spec

tive

12 m

onth

s 56

81

65+

55

%

CA

D, H

TN

Mur

phy

88

1986

C

ohor

t Lo

ng-t

erm

car

e Pr

ospe

ctiv

e A

ny fa

ll In

cide

nt

repo

rts

33 m

onth

s 10

0 80

, ran

ge 6

3-

97 /

83,

rang

e 61

-97

75%

C

SH

Ooi

89

2000

C

ohor

t Lo

ng-t

erm

car

e Pr

ospe

ctiv

e A

ny fa

ll an

d re

curr

ent f

alls

In

cide

nt

repo

rts

Inci

dent

re

port

s du

ring

18

844

60+

80

%

OH

TABLE 1 (CONTINUED)

h 58

(h

ome)

H

F H

eitte

rach

i 59

20

02

Coh

ort

Com

mun

ity

(hom

e)

Pros

pect

ive

Any

fall

Pros

pect

ive

Mon

thly

for

12 m

onth

s 70

77

[±

6]

80%

O

H

Her

ndon

60

1997

C

ase-

cont

rol

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Inju

riou

s fa

lls

in E

R o

r ad

mitt

ed fo

r fa

lls

Past

7 d

ays

467

/ 69

1 65

+

Not

gi

ven

H

TN, C

AD

Hun

g 61

20

13

Obs

erva

tiona

l se

ries

Acu

te h

ospi

tal

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 3

yea

rs

401

82 [

±0.

2]

24%

C

A, H

TN

Jans

en 62

20

15

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

and

recu

rren

t fal

ls

Ret

rosp

ectiv

e Pa

st 1

2 m

onth

s 81

73

64 [

10],

ra

nge

51-1

05

54%

H

F, H

TN,

CA

D

Jans

en 63

20

15

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 1

2 m

onth

s 48

86

62 [

8]

54%

C

A

Jitap

unku

l 64

19

98

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 6

m

onth

s 44

80

69 [

±8)

60

%

HTN

Kao

65

2012

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l R

ecur

rent

and

in

juri

ous

falls

R

etro

spec

tive

Past

12

mon

ths

360

76 (r

ange

64

-91

) 61

%

HTN

, CV

D

Kar

io 66

20

01

Coh

ort

Com

mun

ity

(hom

e)

Pros

pect

ive

Any

fall

Pros

pect

ive

and

retr

ospe

ctiv

e

Mon

thly

for

12 m

onth

s 26

6 76

[±

5]

54%

H

TN, L

ow

BP,

OH

Kel

ly 67

20

03

Cas

e-co

ntro

l C

omm

unity

(h

ome)

R

etro

spec

tive

Inju

riou

s fa

lls

reco

rdin

g of

fa

ll in

med

ical

hi

stor

y

1 ye

ar

2278

/ 91

12

78.5

(7.7

) /

74.5

(6.7

) 69

%,

57%

H

TN, C

VD

Ken

ny 68

19

91

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

and

sy

ncop

e

Ref

erre

d fo

r fa

lls

not g

iven

13

0 77

(67-

89)

55%

C

SH

Kle

in 69

20

13

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 3

m

onth

s 35

44

70 (6

0-97

) 56

%

HTN

, Low

B

P K

umar

70

2003

C

ase-

cont

rol

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

R

efer

red

for

falls

no

t giv

en

265

/ 44

79

.5 (6

0–9

2)

/ 71.

3 (6

3–8

6 76

%,

36%

C

SH

de C

astr

o La

cerd

a 71

20

08

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Pros

pect

ive

Une

xpla

ined

fa

lls

Ref

erre

d fo

r fa

lls

Past

12

mon

ths

502

65 [

±10

] 49

%

CSH

Lagr

o 72

20

13

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Cro

ss-s

ectio

nal

Any

fall

Ref

erre

d fo

r fa

lls

not g

iven

17

5 (w

ith

falls

)

75+

N

ot

give

n

OH

, PPH

, C

SH

Law

lor

73

2003

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l A

ny fa

ll R

etro

spec

tive

Past

12

mon

ths

4050

71

10

0%

OH

, CA

D,

HTN

, Low

B

P Le

Cou

teur

74

20

03

Obs

erva

tiona

l se

ries

Com

mun

ity

(res

iden

tial

faci

lity)

Cro

ss-s

ectio

nal

Any

fall

Inci

dent

re

port

s Pa

st 1

2 m

onth

s 17

9 83

[±

7]

80%

PP

H

TABLE 1 (CONTINUED)


Scho

on 10

4 20

13

Cas

e-co

ntro

l Fa

lls &

sy

ncop

e cl

inic

C

ross

-sec

tiona

l A

ny fa

lls a

nd

sync

ope

Ref

erre

d fo

r fa

lls

n/a

105

/ 25

79 [

±7]

/ 74

[±

4]

67%

, 20

%

HTI

H

Sibl

ey 10

5 20

14

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e 12

mon

ths

16.3

57

65+

55

%

HTN

, CA

D

Smeb

ye 10

6 20

14

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Cro

ss-s

ectio

nal

Any

fall

Ref

erre

d fo

r fa

lls

n/a

111

82 [

±7]

82

%

OH

, CV

D,

CSH

, CA

Sten

hage

n 10

7 20

13

Coh

ort

Com

mun

ity

(hom

e)

Pros

pect

ive

Any

fall

Ret

rosp

ectiv

e Pa

st 6

m

onth

s, a

t 3

and

6 ye

ars

1763

60

-93

54%

H

F, C

AD

Tan

108

2008

O

bser

vatio

nal

seri

es

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

and

sy

ncop

e

Ret

rosp

ectiv

e n/

a 30

2 71

[±

11]

(ran

ge 3

8–

98)

Not

gi

ven

OH

, VV

S

Tan

109

2009

O

bser

vatio

nal

seri

es

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

and

sy

ncop

e

Ret

rosp

ectiv

e n/

a 30

2 71

[11

],

rang

e 38

–98

56%

C

SH

Tine

tti 11

0 19

86

Coh

ort

Long

-ter

m c

are

Pros

pect

ive

Rec

urre

nt fa

lls

Inci

dent

re

port

s 3

mon

ths

79

81 [

±7]

, 78

[±7]

78

%,

62%

O

H

van

der

Vel

de 11

1 20

07

Coh

ort

Out

patie

nt

clin

ic

Pros

pect

ive

Any

fall

Pros

pect

ive

Mon

thly

du

ring

3

mon

th F

U

215

77.4

[±

6.0

] 65

%

HV

abn

van

der

Vel

de 11

2 20

07

Coh

ort

Out

patie

nt

clin

ic

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e 12

mon

ths

217

Falle

rs 7

9 [±

6], n

on

falle

rs 7

5 [±

6]

66%

O

H

van

Nie

uwen

huiz

en 11

3

2010

O

bser

vatio

nal

seri

es

Emer

genc

y de

part

men

t C

ross

-sec

tiona

l A

ny fa

ll an

d R

ecur

rent

falls

In

ER

or

adm

itted

for

falls

n/a

639

79 [

±8]

73

%

CA

D, H

TN

Vu

114

2011

O

bser

vatio

nal

seri

es

Acu

te h

ospi

tal

Ret

rosp

ectiv

e In

juri

ous

falls

In

ER

or

adm

itted

for

falls

n/a

44.9

42

med

ian

82

(IQR

76-

87)

70%

H

F, C

AD

Won

g 11

5 20

14

Coh

ort

Com

mun

ity

(hom

e)

Pros

pect

ive

Any

fall

Pros

pect

ive

Mon

thly

for

12 m

onth

s 48

1 80

[±

4]

51%

A

rter

ial

stiff

ness

, O

H, H

TN,

CA

D

Pros

pect

ive

falls

rep

ortin

g: fa

ll di

arie

s or

cal

enda

rs a

nd/o

r fr

eque

nt te

leph

one

inte

rvie

ws

CA

, car

diac

arr

hyth

mia

. CA

D, c

oron

ary

arte

ry d

isea

se (a

ngin

a, Is

chem

ic h

eart

dis

ease

, myo

card

ial i

nfar

ctio

n). C

VD

, gen

eral

car

diov

ascu

lar

dise

ase

(uns

peci

fied)

. CSH

, ca

rotid

sin

us h

yper

sens

itivi

ty/s

yndr

ome.

HF,

hea

rt fa

ilure

. HTN

, hyp

erte

nsio

n. H

TIH

, hea

d tu

rnin

g in

duce

d hy

pote

nsio

n. H

V, h

eart

val

ve a

bnor

mal

ity. O

H, o

rtho

stat

ic

hypo

tens

ion.

Low

BP,

low

blo

od p

ress

ure.

VV

S, v

asov

agal

syn

cope

. N

/A: N

ot a

pplic

able

. 95%

CI:

95%

con

fiden

ce in

terv

al.

SD (±

): st

anda

rd d

evia

tion.

IQR

: int

erqu

artil

e ra

nge.

TABLE 1 (CONTINUED)

mon

ths

Palin

g 90

20

11

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Cro

ss-s

ectio

nal

Une

xpla

ined

fa

lls

Ref

erre

d fo

r un

expl

aine

d fa

lls

n/a

111

(with

fa

lls)

82, r

ange

61-

99

59%

C

SH, V

VS,

O

H

Parr

y 91

20

05

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Cro

ss-s

ectio

nal

Any

falls

and

sy

ncop

e R

efer

red

for

falls

nd

sync

ope

n/a

34 (f

alls

) / 3

4 (s

ynco

pe)

77 [

9] /

75

[9]

79%

, 47

%

CSH

Parr

y 92

20

05

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Cro

ss-s

ectio

nal

Dro

p at

tack

s (u

nexp

lain

ed

falls

)

Ret

rosp

ectiv

e Pa

st 6

m

onth

s 93

77

[±

9],

rang

e 55

-92

75%

C

SH, O

H,

VV

S, C

A

Pasm

a 93

20

14

Coh

ort

Out

patie

nt

clin

ic

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e Pa

st 1

2 m

onth

s 19

7 82

60

%

OH

Phili

ps 94

19

99

Obs

erva

tiona

l se

ries

Emer

genc

y de

part

men

t C

ross

-sec

tiona

l A

ny fa

lls a

nd

sync

ope

in E

R o

r ad

mitt

ed fo

r fa

lls

n/a

142

83, r

ange

76-

99

63%

C

AD

Prud

ham

95

1981

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l A

ny fa

ll R

etro

spec

tive

Past

12

mon

ths

2357

65

+

59%

C

VD

, HTN

Puis

ieux

96

2000

C

ase-

cont

rol

Acu

te h

ospi

tal

Cro

ss-s

ectio

nal

Any

fall

in E

R o

r ad

mitt

ed fo

r fa

lls

n/a

45 /

36

80.9

[8.

5] /

78.5

[7.

2]

73%

, 68

%

PPH

Raf

anel

li 97

20

14

Obs

erva

tiona

l se

ries

Falls

&

sync

ope

clin

ic

Ret

rosp

ectiv

e U

nexp

lain

ed

falls

R

efer

red

for

falls

n/

a 29

8 75

[±

11]

not

give

n C

SH, O

H,

VV

S

Raf

iq 98

20

14

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

GP

visi

t for

fall

30 m

onth

s ba

selin

e, 3

0 m

onth

s FU

135.

433

75 [

±8]

, ra

nge

65-1

04

56%

C

AD

, HF

Ric

hard

son

99

1997

O

bser

vatio

nal

seri

es

Emer

genc

y de

part

men

t C

ross

-sec

tiona

l U

nexp

lain

ed

falls

and

re

curr

ent f

alls

in E

R o

r ad

mitt

ed fo

r fa

lls

in E

R fo

r fa

ll

279

50+

no

t gi

ven

CSH

Rom

ero-

Ort

uno

100

2011

C

ohor

t C

omm

unity

(h

ome)

C

ross

-sec

tiona

l A

ny fa

ll R

etro

spec

tive

Past

6

mon

ths

598

72

72%

O

H

Ros

ado

101

1989

C

ase-

cont

rol

Long

-ter

m

care

, C

omm

unity

(r

esid

entia

l fa

cilit

y)

Cro

ss-s

ectio

nal

Any

fall

Inci

dent

re

port

s Pa

st 7

day

s 51

/ 27

86

no

t gi

ven

CA

Rut

an 10

2 19

92

Coh

ort

Com

mun

ity

(hom

e)

Cro

ss-s

ectio

nal

Any

fall

Ret

rosp

ectiv

e 12

mon

ths

4931

O

H+

: 73.

6,

OH

-: 7

2.6

56%

O

H

Sand

ers

103

2012

C

ase-

cont

rol

Emer

genc

y de

part

men

t R

etro

spec

tive

Une

xpla

ined

fa

lls a

nd

acci

dent

al fa

lls

Ret

rosp

ectiv

e n/

a 21

1 /

231

82 [

±9]

/ 79

[±

7]

62%

, 62

%

CA

TABLE 1 (CONTINUED)


Gra

afm

ans

1996

57

354

70+

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Any

and

re

curr

ent f

alls

du

ring

28

wee

k FU

Supi

ne a

nd s

tand

ing

at 1

min

ute,

20/

10

O

H &

falls

: OR

1.4

(0

.8-4

.8) (

n/s)

. OH

&

rec

urre

nt fa

lls:

OR

2.0

(1.0

-4.2

)

OH

was

as

soci

ated

with

fu

ture

rec

urre

nt

falls

but

not

with

an

y fa

lls

+

+

8

Hei

ttera

chi

2002

59

70

77 [

±6]

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Any

fall

duri

ng 1

2 m

onth

FU

HU

T at

60

degr

ees,

co

ntin

uous

, 20

SBP

OH

at 3

min

.: 22

% o

f fa

llers

, 6%

of n

on-

falle

rs.

OH

at 3

min

. &

falls

: RR

1.7

[±

1.1-

2.6]

.

OH

at 3

min

. afte

r H

UT

was

as

soci

ated

with

fu

ture

falls

.

§ +

+

7

Kar

io

2001

66

266

76 [

±5]

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l

Any

fall

duri

ng 1

2 m

onth

FU

Supi

ne, i

mm

edia

tely

af

ter

stan

ding

and

at

2 m

in.

Sphy

ogm

oman

omet

er, 2

0/10

OH

not

diff

eren

t be

twee

n fa

llers

and

no

n-fa

llers

O

H w

as n

ot

asso

ciat

ed w

ith

futu

re fa

lls

∞

- 9

Law

lor

2003

73

405

0 71

(9

5% C

I 70

-71

)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

and

re

curr

ent f

alls

in

the

past

12

mon

ths

Mea

n of

two

stan

ding

m

easu

rem

ents

with

sp

hyg,

20/

10

17.6

% o

f fal

lers

and

17

.1%

of n

on-f

alle

rs

O

H w

as n

ot

asso

ciat

ed w

ith

falls

in th

e pa

st

year

∞

- 6

Liu

1995

79

100

83 [

±6]

, ra

nge

62-9

6

Coh

ort,

Com

mun

ity,

Pros

pect

ive

Any

fall

duri

ng 1

2 m

onth

s FU

Imm

edia

tely

on

stan

ding

and

afte

r 5

min

., sp

hyg,

20/

10

Prev

alen

ce O

H 3

-15

%, n

o di

ffere

nce

betw

een

falle

rs a

nd

non-

falle

rs

O

H is

not

as

soci

ated

with

fu

ture

falls

∞

- 6

Luuk

inen

19

96 80

10

16

76 [

±5]

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Rec

urre

nt

falls

dur

ing

12 m

onth

FU

Sitti

ng a

nd s

tand

ing

at 1

min

ute,

sph

yg,

20 S

BP

35%

in fa

llers

, 29%

in

non

-fal

lers

R

R 1

.3 (0

.8-1

.9)

OH

was

not

as

soci

ated

with

fu

ture

falls

∞

- 8

Mad

er

1987

81

300

70

(ran

ge

56-9

3)

Coh

ort

outp

atie

nt

com

mun

ity

clin

ic, c

ross

-se

ctio

nal

Any

fall

in

past

12

mon

ths

Supi

ne a

nd s

tand

ing

at 1

min

ute

sphy

g,

20 S

BP.

7% o

f fal

lers

, 12%

of

non-

falle

rs

n/s

OH

was

not

as

soci

ated

with

fa

lls in

the

past

ye

ar

∞

- 3

Mau

rer

2004

83

111

88 [

±7]

C

ohor

t, lo

ng-

term

car

e,

pros

pect

ive

Any

fall

duri

ng a

m

edia

n FU

of

270

days

Sitti

ng a

nd s

tand

ing

for

5 m

in.,

cont

inuo

us, 2

0/10

O

H a

t 1-m

inut

e &

fa

lls H

R 0

.98

(0.5

–2.

0), O

H a

t 3 m

in.

& fa

lls H

R 1

.3 (0

.7–

2.5)

OH

was

not

as

soci

ated

with

fu

ture

falls

-

6

Ooi

20

00 89

84

4 60

+

Coh

ort,

long

-te

rm c

are,

pr

ospe

ctiv

e

Any

fall

duri

ng 1

8 m

onth

s

Supi

ne a

nd s

tand

ing

at 1

& 3

min

., 8

mea

sure

men

ts

sphy

g. 2

0/10

50%

in fa

llers

and

no

n-fa

llers

. O

H &

rec

urre

nt fa

lls

in p

revi

ous

falle

rs

aRR

2.1

(1.4

- 3

.1).

Ris

k of

sub

sequ

ent

falls

was

gre

ates

t in

prev

ious

falle

rs w

ith

OH

at t

wo

or m

ore

OH

was

as

soci

ated

with

re

curr

ent f

alls

in

thos

e w

ho h

ad

prev

ious

falls

∞

++

5

TABLE 2 (CONTINUED)

Tabl

e 2.

Ort

host

atic

hyp

oten

sion

and

falls

Fi

rst

auth

or

N

Age

, Y

ears

Po

pula

tion

, se

ttin

g, d

esig

n Fa

lls

Out

com

e A

sses

smen

t m

etho

d

Mai

n fin

ding

s an

d pr

eval

ence

of O

H

OR

/RR

/HR

C

oncl

usio

n O

H

* N

OS

Coh

orts

Bum

in

2002

41

33

Falle

rs

73 [

±2]

, no

n-fa

llers

68

[±

2]

Coh

ort,

long

-te

rm c

are,

cr

oss-

sect

iona

l

Any

fall,

eve

r Si

tting

and

sta

ndin

g at

3 m

in, 2

0 SB

P 44

% o

f fal

lers

, 18%

of

non

falle

rs

O

H w

as

univ

aria

tely

as

soci

ated

with

fa

lls

+

3

Cam

pbel

l 19

81 42

55

9 65

+

Coh

ort,

com

mun

ity a

nd

acut

e ho

spita

l, cr

oss-

sect

iona

l

Any

fall

in

the

past

12

mon

ths

Supi

ne a

nd s

tand

ing

at 1

and

3 m

in,

sphy

g., 2

0 SB

P

13%

(74/

559)

of t

otal

sa

mpl

e, c

onsi

dere

d at

trib

utab

le c

ause

of a

fa

ll in

3%

.

O

H c

onsi

dere

d an

at

trib

utab

le c

ause

of

a fa

ll in

3%

.

∞

- 4

Cam

pbel

l 19

89 43

76

1 70

+

Coh

ort,

com

mun

ity,

pros

pect

ive

Any

fall

duri

ng 1

2 m

onth

FU

Lyin

g an

d st

andi

ng

at 1

and

3 m

in.

sphy

g, 2

0 SB

P

40%

in fe

mal

e fa

llers

an

d 31

% in

fem

ale

non-

falle

rs, 2

2% in

m

ale

falle

rs a

nd 2

9%

in m

ale

non-

falle

rs.

Post

ural

hy

pote

nsio

n &

falls

R

R 1

.5 (0

.95-

2.3)

in

wom

en

OH

was

not

si

gnifi

cant

ly

asso

ciat

ed w

ith

futu

re fa

lls.

∞

- 8

Cha

n 19

97 44

40

1 69

(r

ange

60

-90)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

the

past

12

mon

ths

Stan

ding

at 3

min

., sp

hyg,

20

SBP

7.2%

(n=

5) in

falle

rs

and

10.5

% (n

=35

) in

non-

falle

rs.

OH

& fa

lls

unad

just

ed O

R 0

.7

(0.3

-1.8

)

OH

was

not

as

soci

ated

with

fa

lls.

∞

- 4

Cha

ng

2010

45

136

1 72

[±

5]

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

inju

riou

s fa

ll in

the

past

12

mon

ths

Supi

ne a

nd

stan

ding

, im

med

iate

ly,2

0/10

36%

in fa

llers

, 24%

in

non

-fal

lers

. Pr

eval

ence

of O

H in

in

juri

ous

falle

rs

high

er th

an in

non

-in

juri

ous

falle

rs.

OH

& in

juri

ous

falls

vs

non

-inj

urio

us

falls

OR

2.3

(1.1

-5.

12) O

H &

re

mar

kabl

e in

jury

vs

. no

inju

ry: O

R

4.0

(1.6

-10.

0).

OH

and

any

falls

w

ere

not

asso

ciat

ed. O

H

was

ass

ocia

ted

with

inju

riou

s fa

lls

com

pare

d to

non

-in

juri

ous

falls

+

+

6

Dow

nton

19

91 52

203

83 [

±5]

, ra

nge

75-9

7

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

the

past

12

mon

ths

Sitti

ng a

nd s

tand

ing

at 1

and

2 m

in.,

20

SBP

31%

of s

ubje

cts;

eq

ual b

etw

een

falle

rs

and

non-

falle

rs.

O

H w

as n

ot

asso

ciat

ed w

ith

falls

-

4

Ensr

ud

1992

54

970

4 72

(r

ange

65

-99)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

the

past

12

mon

ths

Supi

ne a

nd s

tand

ing

at 1

min

ute,

sph

yg,

20 S

BP

Fa

lls a

nd O

H: O

R

1.0

(0.9

-1.2

) O

H w

as n

ot

asso

ciat

ed w

ith a

hi

stor

y of

falls

∞

- 5

Gan

gava

ti 20

11 56

72

2 78

[±

5]

Coh

ort,

com

mun

ity

(hom

e),

pros

pect

ive

Rec

urre

nt

falls

dur

ing

FU (m

in. 1

83

days

)

Supi

ne a

nd s

tand

ing

at 1

and

3 m

in.,

sphy

g, 2

0/10

Falls

sim

ilar

in th

ose

with

and

with

out O

H.

: 39%

of p

artic

ipan

ts

with

unc

ontr

olle

d H

TN a

nd O

H h

ad

recu

rren

t fal

ls, v

s.

17%

in th

ose

with

out

OH

.

Rec

urre

nt fa

lls &

O

H a

t 1 m

in in

un

cont

rolle

d H

TN:

HR

2.5

(95%

CI

1.3–

5.0)

.

OH

was

as

soci

ated

with

fu

ture

rec

urre

nt

falls

in th

ose

with

un

cont

rolle

d H

TN.

∞

++

8

TABLE 2. ORTHOSTATIC HYPOTENSION AND FALLS


Won

g 20

14 11

5 48

1 80

[±

4]

Coh

ort,

com

mun

ity,

pros

pect

ive

Any

fall

duri

ng 1

2 m

onth

FU

Pass

ive

(HU

T),

supi

ne a

nd a

t 70

deg,

imm

edia

tely

an

d at

1,2

,3,4

,5

min

, sph

yg, 2

0/10

23%

of f

alle

rs, 2

1%

of n

on-f

alle

rs

OH

& fa

lls:

univ

aria

te R

R 1

.1

(0.9

–1.4

)

OH

was

not

as

soci

ated

with

fu

ture

falls

∞

- 9

Cas

e co

ntro

l

Dav

ies

2001

49

26

79 [

±7]

, 78

[±

7]

Cas

e-co

ntro

l, Em

erge

ncy

depa

rtm

ent,

cros

s-se

ctio

nal

Cas

es: n

on-

acci

dent

al

falls

. C

ontr

ols:

ac

cide

ntal

fa

lls o

r ot

her

Act

ive

stan

d fo

r 2

min

, con

tinuo

us, 2

0 SB

P

31%

cas

es, 1

9%

cont

rols

Prev

alen

ce o

f OH

w

as h

ighe

r in

ac

cide

ntal

falle

rs

than

con

trol

s.

§ +

6

Lips

itz

1991

78

70

87 [

±6]

/ 8

7 [±

5]

Cas

e-co

ntro

l, lo

ng-t

erm

car

e,

cros

s-se

ctio

nal

Cas

es:

recu

rren

t fal

ls

in p

ast s

ix

mon

ths,

co

ntro

ls: n

o fa

lls in

pas

t si

x m

onth

s,

or n

o m

ore

than

one

in

past

2 y

ears

Supi

ne a

nd s

tand

ing

at 1

& 3

min

. sph

yg,

20/1

0

21%

of f

alle

rs, 2

0%

in n

on-f

alle

rs

OR

1.0

(0.4

-2.6

) O

H w

as n

ot

asso

ciat

ed w

ith

recu

rren

t fal

ls

∞

- 5

Seri

es

A

llcoc

k 20

00 31

12

0 78

(r

ange

66

-94)

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, re

tros

pect

ive

Ref

erre

d fo

r un

expl

aine

d fa

lls a

nd

sync

ope

Act

ive

stan

d,

imm

edia

tely

afte

r an

d at

30-

seco

nd

inte

rval

s fo

r 2

min

. co

ntin

uous

, 20/

10

29%

OH

is c

omm

on in

pa

tient

s w

ith

unex

plai

ned

falls

an

d sy

ncop

e

§

3

Bod

daer

t 20

04 39

57

84

[±

7]

Obs

erva

tiona

l se

ries

, acu

te

hosp

ital,

cros

s-se

ctio

nal

In E

R o

r ad

mitt

ed fo

r fa

lls

Supi

ne a

nd s

tand

ing

at 1

,2 &

3 m

in.,

auto

mat

ic

osci

llom

etri

c m

onito

r. 2

0/10

32%

OH

is c

omm

on in

pa

tient

s ad

mitt

ed

for

falls

3

Dav

ies

1996

48

26

79 (S

E 8)

O

bser

vatio

nal

seri

es,

emer

genc

y de

pt.,

cros

s-se

ctio

nal

Une

xpla

ined

an

d re

curr

ent

falls

(RF)

Supi

ne a

nd s

tand

ing

at 1

min

ute,

co

ntin

uous

. 20

SBP

19%

OH

was

a

freq

uent

find

ing

in

thos

e w

ith

unex

plai

ned

falls

§

3

Dey

19

97 51

35

75

(r

ange

50

-95)

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Dro

p at

tack

s (u

nexp

lain

ed

falls

)

Mor

ning

act

ive

stan

ding

, co

ntin

uous

.

14%

OH

was

not

ver

y co

mm

on in

this

se

ries

§

3

TABLE 2 (CONTINUED)

mea

sure

men

ts, R

R

2.6

(1.7

- 4

.6)

Pasm

a 20

14 93

19

7 82

C

ohor

t, ou

tpat

ient

cl

inic

, cro

ss-

sect

iona

l

Any

fall

in

the

past

12

mon

ths

Supi

ne a

nd s

tand

ing

at 1

& 3

min

. with

sp

hyg

&

cont

inuo

us,2

0/10

Inte

rmitt

ent O

H n

ot

diffe

rent

bet

wee

n fa

llers

and

non

-fal

lers

. Pa

tient

s w

ith a

larg

er

drop

in B

P du

ring

15-

60 s

econ

ds a

fter

stan

ding

mor

e lik

ely

to h

ave

falle

n in

the

past

12

mon

ths.

Con

tinuo

us: O

H

over

all (

0-18

0 s)

&

falls

, OR

2.4

5 (0

.75-

8.06

). SB

P de

crea

se

15-6

0s: O

R 1

.95

(1.0

8-1.

45),

DB

P de

crea

se 1

5-60

s (O

R 2

.08

(1.2

0-3.

61).

Con

tinuo

us O

H

was

not

ass

ocia

ted

with

a h

isto

ry o

f fa

lls. G

reat

er D

BP

and

SBP

drop

at

15-6

0 se

cond

s w

ere

asso

ciat

ed

with

a fa

lls.

Inte

rmitt

ent O

H

was

not

ass

ocia

ted

with

falls

.

∞§

- 5

Rom

ero-

Ort

uno

2011

10

0

598

72

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

6

mon

ths

Act

ive

stan

d fo

r 3

min

, con

tinuo

us.

CO

H: >

20 S

BP

or

10 D

BP

drop

. IO

H:

40 S

BP

/ 20

DB

P dr

op <

15

seco

nds

Falls

in th

ose

with

IO

H (2

4.7%

) vs

no-

IOH

(10.

4%),

p<0.

001.

No

diffe

renc

e in

falls

be

twee

n th

ose

with

co

nsen

sus

OH

IO

H w

as

univ

aria

tely

as

soci

ated

with

a

hist

ory

of fa

lls in

th

e pa

st 6

mon

ths

§ +

3

Rut

an

1992

102

493

1 O

H+

: 74

, OH

-: 7

3

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Freq

uent

falls

in

the

past

12

mon

ths

Supi

ne a

nd s

tand

ing

at 3

min

., sp

hyg.

20

/10

OH

in fr

eque

nt

falle

rs: 2

7%, O

H in

no

n-fa

llers

: 17%

OR

1.5

(1.0

- 2

.2)

OH

was

as

soci

ated

with

a

hist

ory

of fr

eque

nt

falls

in th

e pa

st

year

∞

++

5

Tine

tti

1986

110

79

Rec

. fa

llers

81

[±

7],

sing

le/n

on-

falle

rs

78 [

±7]

Coh

ort,

long

-te

rm c

are,

pr

ospe

ctiv

e

Rec

urre

nt

falls

dur

ing

3 m

onth

FU

Supi

ne a

nd s

tand

ing

at 1

& 3

min

., 20

SB

P.

12%

(3/2

5) o

f re

curr

ent f

alle

rs, 0

%

(0/5

4) o

f sin

gle/

non

falle

rs

O

H w

as m

ore

prev

alen

t in

recu

rren

t fal

lers

th

an s

ingl

e/no

n-fa

llers

+

3

Van

der

V

elde

20

07 11

2

217

Falle

rs

79 [

±6]

, no

n fa

llers

75

[±

6]

Coh

ort,

outp

atie

nt

clin

ic, c

ross

-se

ctio

nal

Any

fall

in

past

12

mon

ths

Pass

ive

(HU

T) a

t 70

°, c

ontin

uous

. Su

pine

and

sta

ndin

g at

1,2

& 3

min

. with

sp

hyg.

20/

10

Sphy

g O

H 2

7% o

f fa

llers

(n=

33),

17%

(n

=12

) of n

on-f

alle

rs.

Con

tinuo

us O

H: 7

2%

(n=

89) o

f non

-fal

lers

vs

50%

(n=

34) o

f no

n-fa

llers

.

Sphy

g O

H &

falls

O

R 1

.9 (0

.8–4

.4).

Con

tinuo

us 1

-s

aver

age

& fa

lls O

R

2.3

(1.1

–4.7

). C

ontin

uous

5 s

ec

aver

age

& fa

lls O

R

2.5

(1.4

–4.7

). U

nadj

uste

d fo

r co

nfou

nder

s.

Con

tinuo

us

mea

sure

d O

H w

as

asso

ciat

ed w

ith

falls

in th

e pa

st

year

, sph

yg

mea

sure

d O

H w

as

not.

∞§

+

3

TABLE 2 (CONTINUED)


Tabl

e 3.

Car

otid

sin

us h

yper

sens

itiv

ity

and

falls

Fi

rst

auth

or

N

Age

, ye

ars

Popu

lati

on,

desi

gn, s

etti

ng

Falls

out

com

e A

sses

smen

t m

etho

d M

ain

find

ings

and

pr

eval

ence

of

CSH

C

oncl

usio

n C

SS

* N

OS

Coh

orts

Mur

phy

1986

88

100

80, (

63-

97) /

83,

(6

1-97

)

Coh

ort,

Long

- te

rm c

are,

pr

ospe

ctiv

e

Any

fall

duri

ng

33 m

onth

FU

C

SM L

+R

, sup

ine

&

upri

ght (

70°)

Pr

eval

ence

of C

I CSH

w

as 1

1% in

fal

lers

and

21

% in

non

falle

rs,

diffe

renc

e n/

s. V

D C

SS

not m

easu

red.

CI C

SH w

as n

ot

asso

ciat

ed w

ith fu

ture

fa

lls

¥ -

5

Cas

e co

ntro

l

Anp

alah

an

2011

32

38

80 [

±6]

/ 77

[±5]

C

ase-

cont

rol ,

R

etro

spec

tive,

A

cute

hos

pita

l

Ref

erre

d fo

r un

expl

aine

d an

d ac

cide

ntal

falls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

19%

of u

nexp

lain

ed

falle

rs h

ad C

SS (2

CI,

2 V

D),

0% o

f acc

iden

tal

falle

rs. O

vera

ll di

agno

sis

of N

MS

& u

nexp

lain

ed

falls

: OR

5.3

(95%

CI

0.6-

10.4

, p 0

.050

)

Neu

rally

med

iate

d sy

ncop

e (C

SS o

r V

VS)

w

as a

ssoc

iate

d w

ith

unex

plai

ned

falls

whe

n co

mpa

red

to a

ccid

enta

l fa

lls

¥ +

+

5

Ben

chim

ol,

2007

36

259

/ 55

50

[±

24],

57

[±

21]

Cas

e-co

ntro

l, fa

lls &

syn

cope

cl

inic

, re

tros

pect

ive

Ref

erre

d fo

r un

expl

aine

d fa

lls

and

sync

ope

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

11%

of f

alle

rs h

ad C

SH

(28/

259)

com

pare

d to

7%

(4/5

5) o

f con

trol

s

CSH

was

not

ass

ocia

ted

with

falls

¥

- 5

Dav

ies

2001

49

26 /

54

79 [

±7]

, 78

[±

7]

Cas

e-co

ntro

l, Em

erge

ncy

depa

rtm

ent,

cr

oss-

sect

iona

l

In E

D fo

r un

expl

aine

d (n

on-a

ccid

enta

l) or

acc

iden

tal

falls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

CI C

SS: 4

6% (1

2/26

) ca

ses,

13%

(7/5

4) o

f co

ntro

ls. V

D C

SS: 6

9%

(18/

26) c

ases

, 22

%

(16/

54) c

ontr

ols

CSS

was

mor

e pr

eval

ent

in n

on-a

ccid

enta

l fal

lers

th

an a

ccid

enta

l fal

lers

an

d ot

her

cont

rols

¥ +

6

Frei

tas

2004

55

386

/ 10

8 40

+

Cas

e-co

ntro

l, fa

lls &

syn

cope

cl

inic

, cr

oss-

sect

iona

l

Ref

erre

d fo

r ue

xpla

ined

falls

an

d sy

ncop

e

CSM

sup

ine,

re

peat

ed if

neg

ativ

e af

ter

45 m

inut

es o

f H

UT

at 7

0º, C

SM

left

and

righ

t for

10

seco

nds

with

an

inte

rval

of 2

min

utes

CSM

+ in

20%

, re

prod

uctio

n of

sy

mpt

oms

in 1

9% o

f ca

ses

(Mix

ed 5

0%, C

I re

spon

se 2

8%, V

D

resp

onse

22%

). O

ne

cont

rol (

<1%

) had

CSM

+

with

out s

ympt

om

repr

oduc

tion.

Patie

nts

with

un

expl

aine

d fa

lls a

nd

sync

ope

mor

e of

ten

had

CSS

com

pare

d to

hea

lthy

cont

rols

∞

+

5

Kum

ar

2003

70

265

/ 44

80

(60–

92) /

71

(63–

86)

Cas

e-co

ntro

l, fa

lls &

syn

cope

cl

inic

, re

tros

pect

ive

Ref

erre

d fo

r fa

lls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

Prev

alen

ce o

f CSS

in

falle

rs w

as 1

7% a

nd 0

%

in a

sym

ptom

atic

co

ntro

ls.

CSS

was

mor

e pr

eval

ent

in fa

llers

com

pare

d to

as

ympt

omat

ic c

ontr

ols

¥ +

6

Seri

es

TABLE 3. CAROTID SINUS HYPERSENSITIVITY AND FALLS

Lagr

o 20

13 72

17

5 (w

ith fa

lls)

75+

Obs

erva

tiona

l se

ries,

falls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Refe

rred

for

falls

A

ctiv

e st

and

for 1

0 m

in.,

cont

inuo

us,

20/1

0

55%

OH

is c

omm

on in

pa

tient

s w

ith fa

lls

§

3

Milt

on

2009

86

146

4 78

[±

10]

Obs

erva

tiona

l se

ries,

falls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Refe

rred

for

unex

plai

ned

falls

Pass

ive

(HU

T) fo

r 3

min

., co

ntin

uous

. 20

/10

8%

O

H w

as p

rese

nt in

a

smal

l am

ount

of

falle

rs

§

2

Palin

g 20

11 90

11

1 82

(ra

nge

61-9

9)

Obs

erva

tiona

l se

ries,

falls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Refe

rred

for

unex

plai

ned

falls

and

sy

ncop

e

Act

ive

stan

d w

ith

cont

inuo

us

reco

rdin

g, 2

0/10

7%

O

H w

as n

ot v

ery

com

mon

in

patie

nts

with

un

expl

aine

d fa

lls

and

sync

ope

§

3

Parr

y 20

05 92

93

77

[±9]

, ra

nge

55-9

2

Obs

erva

tiona

l se

ries,

falls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Dro

p at

tack

s (3

or m

ore

unex

plai

ned

falls

in th

e pa

st 6

m

onth

s)

Act

ive

stan

d fo

r 3

min

., co

ntin

uous

, 20

/10

5%

O

H w

as n

ot

diag

nose

d fre

quen

tly in

pa

tient

s w

ith

recu

rren

t dro

p at

tack

s

§

3

Rafa

nelli

20

14 97

29

8 75

[±

11]

Obs

erva

tiona

l se

ries,

falls

&

sync

ope

clin

ic,

retro

spec

tive

Refe

rred

for

unex

plai

ned

falls

Pass

ive

(HU

T),

Supi

ne a

nd ti

lted

at

0,1

& 3

min

. C

ontin

uous

, 20/

10.

35%

OH

is c

omm

on in

pa

tient

s w

ith

unex

plai

ned

falls

§

3

Smeb

ye

2014

106

111

82 [±

7]

Obs

erva

tiona

l se

ries,

falls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Any

fall

Supi

ne a

nd s

tand

ing

at 1

& 5

min

. 20/

10

24%

OH

is c

omm

on in

ol

der f

alle

rs

3

Tan

2008

108

302

71

[±11

] O

bser

vatio

nal

serie

s, fa

lls &

sy

ncop

e cl

inic

, re

trosp

ectiv

e

Refe

rred

for

unex

plai

ned

falls

and

sy

ncop

e

Act

ive

stan

d fo

r 2

min

., co

ntin

uous

re

cord

ing.

20/1

0

56%

OH

is c

omm

on in

pa

tient

s w

ith

unex

plai

ned

falls

an

d sy

ncop

e

§

3

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR:

odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: re

lativ

e ris

k. O

R/H

R/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: in

terq

uarti

le r

ange

. NO

S, N

ewca

stle

Otta

wa

Scal

e.

∞, s

phyg

mom

anom

eter

BP

mea

sure

men

t §,

con

tinuo

us B

P m

easu

rem

ent

20/1

0, ≥

20 m

mH

g SB

P an

d/or

≥10

mm

Hg

DBP

dro

p cu

t-off

for O

H

20 S

BP, >

20m

mH

g SB

P dr

op c

ut-o

ff fo

r OH

++

Ass

ocia

tion

mul

tivar

iabl

y ad

just

ed fo

r pot

entia

l con

foun

ders

, + u

niva

riabl

e as

soci

atio

n or

hig

her p

reva

lenc

e co

mpa

red

to c

ontro

l gro

up, -

abs

ent a

ssoc

iatio

n or

sim

ilar

prev

alen

ce, !

neg

ativ

e as

soci

atio

n

TABLE 2 (CONTINUED)


2005

92

rang

e 55

-92

seri

es, f

alls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

or m

ore

unex

plai

ned

falls

)

upri

ght (

70°)

n=

2 V

D)

patie

nts

with

dro

p at

tack

s

Parr

y 20

05 91

34

(fa

lls)/

34

(syn

cop

e)

77 [

9] /

75 [

9]

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Ref

erre

d fo

r un

expl

aine

d fa

lls

or s

ynco

pe

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

CSS

in fa

llers

71%

, with

LO

C 6

4%. C

SS in

thos

e w

ith s

ynco

pe: 8

5%, w

ith

LOC

44%

CSS

was

com

mon

in

patie

nts

with

un

expl

aine

d fa

lls a

nd

sync

ope

¥

3

Raf

anel

li 2

014

97

298

75 [

±11

] O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

retr

ospe

ctiv

e

Ref

erre

d fo

r un

expl

aine

d fa

lls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

CSS

14.

3% (n

=42

), C

I n=

34, V

D n

=5,

mix

ed

n=3.

CSS

was

com

mon

in

patie

nts

with

un

expl

aine

d fa

lls

∞

3

Ric

hard

son

1997

99

279

50+

O

bser

vatio

nal

seri

es, e

mer

genc

y de

part

men

t,

cros

s-se

ctio

nal

Une

xpla

ined

fa

lls, r

ecur

rent

fa

lls (3

or

mor

e in

the

past

yea

r)

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

23%

with

(2

3% C

I/mix

ed a

nd 1

1%

VD

)

CSH

was

com

mon

in

patie

nts

with

un

expl

aine

d an

d re

curr

ent f

alls

¥

3

Smeb

ye

2014

106

111

82 [

±7]

O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Ref

erre

d fo

r fa

lls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

11%

C

SH w

as c

omm

on in

ol

der

falle

rs

¥

3

Tan

2009

109

302

71

[±11

],

rang

e 38

–98

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, re

tros

pect

ive

Une

xpla

ined

fa

lls, F

alls

and

sy

ncop

e, d

rop

atta

cks

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

CSH

25%

, CSS

14%

. C

SH w

as c

omm

on in

pa

tient

s w

ith

unex

plai

ned

falls

∞

3

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk

. OR

/HR

/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. N

OS,

New

cast

le O

ttaw

a Sc

ale

C

I: ca

rdio

inhi

bito

ry, V

D: v

asod

epre

ssor

, CSM

: car

otid

sin

us m

assa

ge, C

SH: c

arot

id s

inus

hyp

erse

nsiti

vity

, CSS

: car

otid

sin

us s

yndr

ome,

NM

S: n

eura

lly m

edia

ted

sync

ope

¥ C

SS d

efin

ed a

s ei

ther

vas

odep

ress

or d

rop

of 5

0mm

HG

SB

P an

d/or

>3

seco

nd a

syst

ole

on E

CG

∞

CSS

def

ined

as

eith

er v

asod

epre

ssor

dro

p of

50m

mH

G S

BP

or

>3

seco

nd a

syst

ole

on E

CG

with

sym

ptom

rep

rodu

ctio

n *+

+ A

ssoc

iatio

n m

ultiv

aria

bly

adju

sted

for

pote

ntia

l con

foun

ders

, + u

niva

riab

le a

ssoc

iatio

n or

hig

her

prev

alen

ce c

ompa

red

to c

ontr

ol g

roup

, - a

bsen

t ass

ocia

tion

or s

imila

r pr

eval

ence

TABLE 3 (CONTINUED)

Allc

ock

2000

31

120

78

(ran

ge

66-9

4)

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, re

tros

pect

ive

Ref

erre

d fo

r un

expl

aine

d fa

lls

and

sync

ope

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

37%

CSH

(22%

CI a

nd

15%

VD

) C

SS w

as c

omm

on in

pa

tient

s w

ith

unex

plai

ned

falls

¥

3

Dav

ies

1996

48

26

79 (S

E 8)

O

bser

vatio

nal

seri

es, e

mer

genc

y de

part

men

t,

cros

s-se

ctio

nal

Une

xpla

ined

an

d re

curr

ent

falls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

73%

C

SH w

as c

omm

on in

pa

tient

s w

ith

unex

plai

ned

falls

¥

3

Dey

19

97 51

35

75

(r

ange

50

-95)

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Dro

p at

tack

s (u

nexp

lain

ed

falls

)

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

CSH

51%

, CI o

r m

ixed

C

SS in

15,

VD

CSS

in 3

C

SS w

as c

omm

on in

th

ose

with

une

xpla

ined

fa

lls

∞

3

Eltr

afi

1999

53

139

66 [

±20

] O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

retr

ospe

ctiv

e

Une

xpla

ined

fa

lls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

21%

. C

SS is

res

pons

ible

for

recu

rren

t fal

ls a

nd

sync

ope

in 2

1% o

f pa

tient

s re

ferr

ed to

a

med

ical

out

patie

nt

clin

ic.

¥

3

Ken

ny

1991

68

130

77,

rang

e 67

-89

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, re

tros

pect

ive

Ref

erre

d fo

r un

expl

aine

d fa

lls

and

sync

ope

Supi

ne C

SM o

nly

13%

C

SS is

pre

sent

in a

sm

all

num

ber

of p

atie

nts

who

pr

esen

t with

une

xpla

ined

fa

lls, d

izzi

ness

or

sync

ope

¥

2

De

Cas

tro

Lace

rda

2008

71

502

65

[±10

] O

bser

vatio

nal

seri

es,

falls

& s

ynco

pe

clin

ic, c

ross

-se

ctio

nal

Une

xpla

ined

fa

lls in

the

past

12

mon

ths

Supi

ne C

SM o

nly

14%

C

SH w

as p

rese

nt in

larg

e nu

mbe

r of

pat

ient

with

un

expl

aine

d fa

lls

¥

3

Lagr

o 20

13 72

17

5 (w

ith

falls

)

75+

O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Une

xpla

ined

fa

lls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

84%

C

SH w

as c

omm

on in

un

expl

aine

d fa

llers

¥

3

Milt

on

2009

86

1464

78

[±

10]

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Falls

and

sy

ncop

e C

SM L

+R

, sup

ine

&

upri

ght (

70°)

8%

C

SH w

as p

rese

nt in

a

smal

l am

ount

of p

atie

nts

with

une

xpla

ined

falls

¥

2

Palin

g 20

11 90

11

1 (w

ith

falls

)

82,

rang

e 61

-99

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Une

xpla

ined

fa

lls

CSM

L+

R, s

upin

e &

up

righ

t (70

°)

44%

(n=

28 V

D, n

=16

m

ixed

, n=

5 C

I) of

un

expl

aine

d fa

llers

42

% o

f tho

se w

ith

sync

ope

CSS

was

com

mon

in

patie

nts

with

un

expl

aine

d fa

lls,

∞

3

Parr

y 93

77

[±

9],

Obs

erva

tiona

l D

rop

atta

cks

(3

CSM

L+

R, s

upin

e &

40

% (

n=35

CI/m

ixed

, C

SS w

as c

omm

on in

¥

3

TABLE 3 (CONTINUED)


Parr

y 20

05 92

93

77

[±

9]

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Une

xpla

ined

fa

lls (3

or

mor

e dr

op a

ttack

s)

HU

T 40

min

s w

ith

cont

inuo

us

mon

itori

ng.

HU

T in

duce

d hy

pote

nsio

n w

ith o

r w

ithou

t br

adyc

ardi

a/as

ysto

le

and

repr

oduc

tion

of

sym

ptom

s.

3%

VV

S is

not

com

mon

in

thos

e w

ith d

rop

atta

cks

π

3

Raf

anel

li 20

14 97

29

8 75

.3

[±11

.1]

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, re

tros

pect

ive

Une

xpla

ined

fa

lls

HU

T 15

min

s or

lo

nger

with

co

ntin

uous

m

onito

ring

.

36%

V

VS

is c

omm

on in

th

ose

with

un

expl

aine

d fa

lls a

nd

sync

ope

¥

3

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk

. OR

/HR

/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. N

OS,

New

cast

le O

ttaw

a sc

ale.

V

VS,

vas

ovag

al s

ynco

pe. H

UT,

hea

d-up

tilt.

∞

HU

T in

duce

d hy

pote

nsio

n/ b

rady

card

ia w

ith s

ympt

om r

epro

duct

ion

¥ V

ASI

S cl

assi

ficat

ion

used

for

defin

ition

of V

VS

[ref

?]

Π H

UT

indu

ced

hypo

tens

ion/

brad

ycar

dia

with

out s

ympt

om r

epro

duct

ion

++

Ass

ocia

tion

mul

tivar

iabl

y ad

just

ed fo

r po

tent

ial c

onfo

unde

rs, +

uni

vari

able

ass

ocia

tion

or h

ighe

r pr

eval

ence

com

pare

d to

con

trol

gro

up, -

abs

ent a

ssoc

iatio

n or

sim

ilar

prev

alen

ce, !

neg

ativ

e as

soci

atio

n

TABLE 4 (CONTINUED)

Tabl

e 4.

Vas

ovag

al s

ynco

pe a

nd f

alls

Firs

t au

thor

N

Age

, yea

rs

Popu

lati

on, s

etti

ng,

desi

gn

Falls

out

com

e A

sses

smen

t m

etho

d Pr

eval

ence

of

VV

S an

d m

ain

find

ings

C

oncl

usio

n V

VS

* N

OS

Cas

e C

ontr

ol

Ben

chim

ol

2007

36

259

/ 55

50

[±

24],

57

[±

21]

Cas

e-co

ntro

l, fa

lls &

syn

cope

cl

inic

, ret

rosp

ectiv

e

Une

xpla

ined

fa

lls a

nd

sync

ope

HU

T 2x

25 m

ins

sphy

gmom

anom

eter

, O

scill

omet

er..

HU

T po

sitiv

e in

65%

of

case

s, a

nd in

5%

of

cont

rols

.

VV

S is

mor

e co

mm

on

in th

ose

with

une

xpla

ined

falls

an

d sy

ncop

e th

an

cont

rols

∞

+

5

Anp

alah

an

2011

32

21 /

17

80 [

±6]

/ 77

[±5]

C

ase-

cont

rol,

acut

e ho

spita

l, re

tros

pect

ive

Une

xpla

ined

an

d ac

cide

ntal

fa

lls

HU

T 40

min

s w

ith

cont

inuo

us

mon

itori

ng

5% o

f une

xpla

ined

fa

llers

had

VV

S, v

s 0%

of

acc

iden

tal f

alle

rs

VV

S w

as m

ore

com

mon

in

unex

plai

ned

falle

rs

com

pare

d w

ith

acci

dent

al fa

llers

¥ +

5

Seri

es

Allc

ock

20

00 31

12

0 78

, ran

ge

66-9

4 O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

retr

ospe

ctiv

e

Une

xpla

ined

fa

lls a

nd

sync

ope

HU

T 30

min

s w

ith

sphy

gmom

anom

eter

. 3%

V

VS

is n

ot c

omm

on in

th

ose

with

une

xpla

ined

fa

lls a

nd s

ynco

pe

∞

3

Dav

ies

19

96 48

26

79

(SE

8)

Obs

erva

tiona

l se

ries

, em

erge

ncy

depa

rtm

ent,

cros

s-se

ctio

nal

Une

xpla

ined

an

d re

curr

ent

falls

HU

T 30

min

s.

15%

V

VS

was

a c

omm

on

findi

ng in

une

xpla

ined

or

rec

urre

nt fa

llers

∞

3

Dey

19

97 51

35

75

, ran

ge

50-9

5 O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Une

xpla

ined

fa

lls (d

rop

atta

cks)

HU

T w

ith c

ontin

uous

m

onito

ring

. 3%

V

VS

was

not

com

mon

in

thos

e w

ith d

rop

atta

cks

∞

3

Eltr

afi

1999

53

149

66 [

±20

] O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

retr

ospe

ctiv

e

Une

xpla

ined

fa

lls a

nd

sync

ope

HU

T 45

min

s w

ith

cont

inuo

us

mon

itori

ng.

9%

HU

T po

sitiv

e in

9%

of

patie

nts

refe

rred

for

unap

lain

ed fa

lls a

nd

sync

ope

∞

3

Palin

g 20

11 90

11

1 82

, ran

ge

61-9

9 O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Une

xpla

ined

fa

lls

HU

T 15

min

s +

20

min

s 11

%

C

ombi

natio

n of

H

UT/

CSM

pr

ovid

ed a

pos

itive

re

sult

in 6

2% o

f su

bjec

ts

∞

3

Tan

2008

108

302

71 [

±11

] O

bser

vatio

nal

seri

es,

falls

&

sync

ope

clin

ic,

retr

ospe

ctiv

e

Une

xpla

ined

fa

lls a

nd

sync

ope

HU

T 20

min

s (n

o G

TN) +

15m

ins

(GTN

) usi

ng

cont

inuo

us

mon

itori

ng.

46%

VV

S is

com

mon

in

thos

e w

ith u

nexp

lain

ed

falls

and

syn

cope

¥

3

TABLE 4. VASOVAGAL SYNCOPE AND FALLS


2014

62

cros

s-se

ctio

nal

past

12

mon

ths

diag

nosi

s of

H

TN

of n

on-f

alle

rs.

OR

0.9

(0.8

-1.0

), H

TN &

rec

urre

nt

falls

1.0

(0.8

-1.2

)

asso

ciat

ed w

ith fa

lls

Jitap

unku

l 19

98 64

44

80

69 [

±8)

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l A

ny fa

ll in

pa

st 6

mon

ths

SR

28%

of f

alle

rs, 2

5%

of n

on-f

alle

rs.

HTN

m

ultiv

aria

bly

asso

ciat

ed w

ith

falls

, ass

ocia

tion

not r

epor

ted

HTN

was

a r

isk

fact

or fo

r fa

lls in

m

ales

∞

++

5

Kao

20

12 65

36

0 76

(ran

ge

64-9

1)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Rec

urre

nt

and

inju

riou

s fa

lls in

pas

t 12

mon

ths

SR

52%

of f

alle

rs, 5

2%

of n

on fa

llers

OR

0.

8 (0

.5–1

.3)

H

TN w

as n

ot

asso

ciat

ed w

ith fa

lls

∞

- 7

Kar

io

2001

66

266

76 [

±5]

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Any

fall

duri

ng 1

2 m

onth

s FU

Supi

ne,

imm

edia

tely

, 2

min

afte

r st

and.

U

ntre

ated

HTN

: SB

P/D

BP

>14

0/90

mm

Hg,

un

trea

ted

Falls

less

com

mon

in

trea

ted

(17%

) and

un

trea

ted

(20%

) hy

pert

ensi

ve

subj

ects

com

pare

d w

ith n

orm

oten

sive

s (3

4%).

Obj

ectiv

ely

mea

sure

d SB

P (1

0 m

mH

g in

crea

se) &

falls

: R

R 0

.8 (0

.7–0

.9)

HTN

was

ass

ocia

ted

with

a d

ecre

ased

ri

sk o

f fal

ls

¶

! 6

Kle

in

2013

69

3544

70

(ran

ge

60-9

7)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

3 m

onth

s SB

P an

d D

BP

mea

sure

d in

si

tting

pos

ition

w

ith m

ercu

ry

sphy

gmom

anom

eter

. SB

P/D

BP

HTN

>14

0/90

24.8

% o

f fem

ale

falle

rs h

ad S

BP

HTN

14

.1%

of m

ale

falle

rs h

ad S

BP

HTN

12

.7%

of f

emal

es

had

DB

P H

TN

9% o

f mal

es h

ad

DB

P H

TN

DB

P H

TN

wom

en &

falls

O

R 0

.6 (0

.4-0

.9).

DB

P H

TN m

en &

fa

lls O

R 0

.9 (0

.5-

1.5)

. SB

P H

TN

wom

en &

falls

O

R 0

.7 (0

.5-

0.99

). SB

P H

TN

in m

en &

falls

O

R 0

.7 (0

.4-1

.2)

HTN

was

ass

ocia

ted

with

a d

ecre

ased

ri

sk o

f fal

ls in

w

omen

, but

not

in

men

.

¶

! 6

Law

lor

2003

73

4050

71

(9

5%C

I 70

to 7

1)

Coh

ort,

Com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

12

mon

ths

Osc

illom

eter

, 2x

seat

ed, S

BP

>16

0/95

mm

Hg

or r

ecei

ving

tr

eatm

ent f

or

bloo

d pr

essu

re

51.6

% o

f fal

lers

and

50

.6%

of n

on-f

alle

rs

(p 0

.39)

H

TN w

as n

ot

asso

ciat

ed w

ith fa

lls

¶

- 5

Liao

, 20

12 77

11

65

75

[±7)

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l A

ny fa

ll in

pa

st 1

2 m

onth

s

Sphy

g.,

SBP/

DB

P >

130/

85m

mH

g or

use

of

antih

yper

tens

ive

med

icat

ion

60%

falle

rs, 5

0%

non-

falle

rs

H

TN w

as n

o m

ore

prev

alen

t in

falle

rs

than

non

-fal

lers

¶

- 6

TABLE 5 (CONTINUED)

Tabl

e 5.

Hyp

erte

nsio

n an

d fa

lls

Aut

hor,

yea

r N

A

ge,

Yea

rs

Popu

lati

on, s

etti

ng,

desi

gn

Falls

ou

tcom

e A

sses

smen

t m

etho

d M

ain

findi

ngs

and

prev

alen

ce o

f HTN

O

R/R

R/H

R

Con

clus

ion

HTN

*

NO

S

Coh

orts

Ass

anta

chai

20

03 35

10

43

Men

69

[±6]

, w

omen

68

[±

7]

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

6 m

onth

s SR

, med

ical

di

agno

sis

of

HTN

42%

(n=

87) o

f fa

llers

, 25%

(n=

223)

of

non

-fal

lers

OR

1.6

(1.1

-2.3

) H

TN w

as a

ssoc

iate

d w

ith fa

lls

∞

++

3

Ber

glan

d

2003

38

307

81 (r

ange

75

-93)

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e A

ny fa

ll du

ring

12

mon

th F

U

SR, m

edic

al

diag

nosi

s of

H

TN

O

R 1

.8, p

<0.

02

HTN

was

ass

ocia

ted

with

futu

re fa

lls

∞

++

6

Bra

ssin

gton

20

00 40

15

26

Ran

ge

64-9

9 C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l A

ny fa

ll SR

, med

ical

di

agno

sis

of

HTN

54%

of f

alle

rs, 4

4%

of n

on-f

alle

rs

Una

djus

ted

OR

1.

5 (1

.1-1

.9)

HTN

was

un

ivar

iabl

y as

soci

ated

with

falls

∞

+

4

Cha

n 19

97 44

40

1 69

(ran

ge

60-9

0)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

12

mon

ths

Not

giv

en

52.2

% (n

=37

) of

falle

rs a

nd 3

7.9%

(n

=12

6) o

f non

-fa

llers

.

Una

djus

ted

OR

1.

8 (1

.1-3

.0)

HTN

was

un

ivar

iabl

y as

soci

ated

with

falls

+

6

Cha

ng

2010

45

1361

72

[±

5]

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Inju

riou

s fa

lls

in p

ast 1

2 m

onth

s

SR, m

edic

al

diag

nosi

s of

H

TN

49%

of f

alle

rs, 4

3%

of n

on-f

alle

rs

H

TN w

as n

ot

asso

ciat

ed w

ith fa

lls

∞§

- 4

Che

n 20

08 46

58

5 81

[±

5]

Coh

ort,

long

-ter

m

care

, cro

ss-s

ectio

nal

Any

fall

MR

50

.5%

of n

on

falle

rs, 5

6.3%

of

falle

rs, p

=0.

442

H

TN w

as n

ot

asso

ciat

ed w

ith fa

lls

§ -

5

Dam

ian

2013

47

733

83 (9

5%

CI,

83-

84)

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

mon

th

MR

45

% o

f coh

ort,

not

give

n fo

r fa

llers

R

R 1

.0 (0

.6-1

.8)

HTN

was

not

as

soci

ated

with

a

fall

in th

e pa

st

mon

th

§ -

5

Dow

nton

19

91 52

20

3 83

[±

5]

Coh

ort,

Com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

12

mon

ths

Sitti

ng b

lood

pr

essu

re

Mea

n SB

P w

as n

ot

diffe

rent

bet

wee

n gr

oups

M

ean

SBP

was

not

as

soci

ated

with

falls

¶

-

3

Hec

kenb

ach

2014

58

5124

73

C

ohor

t, C

omm

unity

, cr

oss-

sect

iona

l G

P vi

sit f

or

any

fall

GP

MR

44

% o

f fal

lers

, 37%

of

non

-fal

lers

. no

t ass

ocia

ted

afte

r ad

just

men

t H

TN w

as n

ot

asso

ciat

ed w

ith fa

lls

§ -

6

Hun

g 20

13 61

40

1 82

[±

0.2]

C

ohor

t, ac

ute

hosp

ital,

cros

s-se

ctio

nal

Any

fall

in

past

3 y

ears

A

vera

ge S

BP

calc

ulat

ed fr

om

SBP

(2-4

x/da

y)

befo

re d

isch

arge

(fo

r 3

days

).

SBP>

140

mm

Hg:

27

% in

non

-fal

lers

an

d 23

% in

falle

rs.

Med

ical

his

tory

of

HTN

76%

in fa

llers

an

d 79

% in

non

-fa

llers

.

H

TN w

as n

ot

asso

ciat

ed w

ith fa

lls

in th

e pa

st y

ear

¶

- 6

Jans

en

8173

64

[±

10]

Coh

ort,

com

mun

ity,

Any

fall

in

SR, m

edic

al

38%

of f

alle

rs, 3

7%

HTN

& a

ny fa

lls

HTN

was

not

∞

§ -

6

TABLE 5. HYPERTENSION AND FALLS


Tabl

e 6.

Low

blo

od p

ress

ure

and

falls

Fi

rst

auth

or

N

Age

, ye

ars

Popu

lati

on,

sett

ing,

des

ign

Out

com

e of

fal

ls

Ass

essm

ent

met

hod

Mai

n fi

ndin

gs a

nd

prev

alen

ce o

f LB

P O

R/R

R/H

R

Con

clus

ion

LBP

* N

OS

Ber

g 19

97 37

96

72

[±

7],

rang

e 60

-88

Coh

ort,

com

mun

ity,

pros

pect

ive

Falls

du

ring

12

mon

th F

U

Not

sta

ted

Low

SB

P 74

% o

f fal

lers

, 37

% o

f non

-fal

lers

. Low

D

BP

52%

of f

alle

rs, 3

5% o

f no

n-fa

llers

.

Low

SB

P &

rec

urre

nt

falls

OR

4.8

(1.6

-20

.1).

Low

DB

P &

re

curr

ent f

alls

OR

2.0

(0

.7-5

.6)

Low

SB

P w

as

asso

ciat

ed w

ith

recu

rren

t fut

ure

falls

SBP

<14

2 m

mH

g +

+

7

Cam

pbel

l 19

89 43

76

1 70

+

Coh

ort,

com

mun

ity,

pros

pect

ive

Falls

du

ring

12

mon

th F

U

Sphy

gmom

anom

eter

, su

pine

or

stan

ding

11%

in fe

mal

e fa

llers

and

3%

in fe

mal

e no

n-fa

llers

, 7%

in m

ale

falle

rs a

nd 5

%

in m

ale

non-

falle

rs.

Syst

olic

hyp

oten

sion

&

falls

RR

3.3

(1.3

-8.

3) in

wom

en.

Low

sys

tolic

BP

was

ass

ocia

ted

with

futu

re fa

lls

in w

omen

SBP ≤1

10

mm

Hg

++

8

Kar

io

2001

66

266

76

[±5]

C

ohor

t, co

mm

unity

, pr

ospe

ctiv

e

Falls

du

ring

12

mon

th F

U

Sphy

gmom

anom

eter

F

alls

2.8

tim

es m

ore

ofte

n in

low

SB

P th

an h

ighe

r). 1

0 m

mH

g in

crea

se in

sta

ndin

g SB

P re

duce

d fa

lls b

y 22

%

Stan

ding

SB

P le

vel &

fa

lls (R

R 0

.78

for

10

mm

Hg

incr

ease

, p=

0.00

5)

Low

er s

tand

ing

SBP

was

an

inde

pend

ent

pred

icto

r of

fu

ture

falls

. DB

P w

as n

ot r

elat

ed

to fa

lls.

SBP<

140

mm

Hg

++

9

Kle

in

2013

69

354

4 70

, ra

nge

60-9

7

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Sp

hygm

oman

omet

er

Low

SB

P 13

% o

f mal

e fa

llers

, 6%

of m

ale

non-

falle

rs,

Low

SB

P& fa

lls in

m

en O

R 2

.5 (9

5%C

I 1.

1-5.

5), l

ow D

BP

&

falls

OR

1.8

(1.0

-3.1

)

Low

SB

P or

D

BP

was

as

soci

ated

with

fa

lls in

men

in

the

past

3

mon

ths

SBP/

DB

P <

120/

80

mm

Hg

++

7

Law

lor

2003

73

405

0 71

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l

Any

falls

in

the

past

12

mon

ths

Osc

illom

eter

7.

3% in

falle

rs, 7

.6%

in

non-

falle

rs

Lo

w s

tand

ing

BP

was

not

as

soci

ated

with

re

curr

ent f

utur

e fa

lls

SBP/

DB

P ≤1

00/6

0 m

mH

g

- 6

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk

. OR

/HR

/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. N

OS,

New

cast

le O

ttaw

a Sc

ale.

D

BP:

dia

stol

ic b

lood

pre

ssur

e. S

BP:

sys

tolic

blo

od p

ress

ure.

LB

P, d

efin

ition

of l

ow B

P *+

+ A

ssoc

iatio

n m

ultiv

aria

bly

adju

sted

for

pote

ntia

l con

foun

ders

, + u

niva

riab

le a

ssoc

iatio

n or

hig

her

prev

alen

ce c

ompa

red

to c

ontr

ol g

roup

, - a

bsen

t ass

ocia

tion

or s

imila

r pr

eval

ence

TABLE 6. LOW BLOOD PRESSURE AND FALLS

Mau

rer

2005

84

139

88 [

±7)

C

ohor

t, lo

ng-t

erm

ca

re, p

rosp

ectiv

e A

ny fa

ll du

ring

12

mon

th F

U

MR

and

SR

, co

ntin

uous

; SB

P/D

BP

>14

0/90

or

use

of a

nti-

hype

rten

sive

s

55%

of c

ohor

t

OR

2.0

(1.1

–3.7

) Pa

tient

s w

ith H

TN

are

mor

e lik

ely

to

suffe

r fu

ture

falls

∞§¶

+

+

4

Mitc

hell

2013

87

5681

65

+

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in

past

12

mon

ths

SR, m

edic

al

diag

nosi

s of

H

TN

54%

of f

alle

rs, 5

1%

of n

on-f

alle

rs.

Una

djus

ted

OR

1.

1 (0

.97-

1.3)

H

TN is

not

as

soci

ated

with

falls

∞

§ -

5

Prud

ham

19

81 95

23

57

65+

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l A

ny fa

ll in

pa

st 1

2 m

onth

s

MR

, SR

and

pr

evio

us H

TN

23%

of f

alle

rs, 2

2%

of n

on-f

alle

rs

H

TN is

not

as

soci

ated

with

falls

∞

§ -

2

Sibl

ey

2014

105

57

65+

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l A

ny fa

ll in

pa

st 1

2 m

onth

s

SR, m

edic

al

diag

nosi

s of

H

TN

21%

of t

hose

with

H

TN fe

ll, c

ompa

red

to 1

8% o

f peo

ple

with

out H

TN

A c

lust

er

'hyp

erte

nsio

n'

was

ass

ocia

ted

with

falls

, OR

1.2

HTN

is a

ssoc

iate

d w

ith fa

lls

∞

++

5

Won

g 20

14 11

5 48

1 80

[±

4]

Coh

ort,

com

mun

ity,

pros

pect

ive

Any

fall

duri

ng 1

2 m

onth

FU

SR

55%

of f

alle

rs a

nd

62%

of n

on-f

alle

rs.

HTN

& fa

lls

unad

just

ed R

R

0.9

(0.7

–1.0

)

HTN

is n

ot

asso

ciat

ed w

ith fa

lls

∞

- 9

Cas

e co

ntro

l

Her

ndon

19

97 60

46

7 65

+

Cas

e-co

ntro

l, co

mm

unity

, cro

ss-

sect

iona

l

In E

R o

r ad

mitt

ed fo

r fa

lls

SR, m

edic

al

diag

nosi

s of

H

TN

7% o

f res

pond

ents

ha

d H

TN, a

djus

ted

O

R 0

.7 (0

.5-0

.9)

HTN

is a

ssoc

iate

d w

ith a

dec

reas

ed

risk

of i

njur

ious

falls

∞

- 5

Lips

itz

1991

78

70

87 [

±6]

/ 87

[±

5]

Cas

e-co

ntro

l, lo

ng-

term

car

e,

Pros

pect

ive

Any

fall

in

past

6 m

onth

s M

R

41%

of f

alle

rs, 3

9%

of n

on-f

alle

rs

H

TN w

as n

ot

asso

ciat

ed w

ith fa

lls

§ -

5

Kel

ly

2003

67

2278

79

[±

8]

Cas

e-co

ntro

l, co

mm

unity

, re

tros

pect

ive

Inju

riou

s fa

lls

repo

rted

in

ED

MR

and

SR

31

% o

f cas

es a

nd

31%

of c

ontr

ols

Adj

uste

d O

R 0

.9

(0.8

-1.0

) H

TN w

as n

ot

asso

ciat

ed w

ith

inju

riou

s fa

lls

∞§

- 4

Seri

es

M

arec

haux

20

09 82

60

81

[±

8)

Obs

erva

tiona

l se

ries

, em

erge

ncy

depa

rtm

ent,

cros

s-se

ctio

nal

In E

D fo

r fa

lls

MR

73

%

H

TN w

as p

rese

nt in

th

e m

ajor

ity o

f pa

tient

s w

ho

pres

ente

d w

ith a

fall

§

2

Van

N

ieuw

enhu

ize

n 20

10 11

3

639

79 [

±8]

O

bser

vatio

nal

seri

es, e

mer

genc

y de

part

men

t, cr

oss-

sect

iona

l

In E

D fo

r fa

ll SR

34

%

H

TN w

as n

ot h

ighl

y pr

eval

ent i

n pa

tient

s in

the

ED w

ith a

fall

∞

2

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R:

rela

tive

risk

. OR

/HR

/RR

are

adj

uste

d fo

r po

tent

ial c

onfo

unde

rs u

nles

s ot

herw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. N

OS,

New

cast

le O

ttaw

a Sc

ale.

HTN

, hyp

erte

nsio

n. M

R, m

edic

al r

ecor

d. S

R, s

elf-

repo

rt. ∞

, Sel

f-re

port

. §, M

edic

al r

ecor

ds. ¶

, Obj

ectiv

e as

sess

men

t. *+

+ A

ssoc

iatio

n m

ultiv

aria

bly

adju

sted

for

pote

ntia

l con

foun

ders

, + u

niva

riab

le a

ssoc

iatio

n or

hig

her

prev

alen

ce c

ompa

red

to c

ontr

ol g

roup

, - a

bsen

t ass

ocia

tion

or s

imila

r pr

eval

ence

, ! n

egat

ive

asso

ciat

ion

TABLE 5 (CONTINUED)


dise

ase

asso

ciat

ed w

ith

falls

St

enha

gen

2013

107

1763

60

-93

Coh

ort,

com

mun

ity

(hom

e),

pros

pect

ive

Any

fall

ast 6

m

onth

s, a

t 3 a

nd

6 ye

ars

MR

(IC

D

code

s )

Hea

rt d

isea

se in

30%

of

falle

rs, 2

0% o

f non

fa

llers

.

OR

1.4

(1.0

-1.8

). H

eart

dis

ease

w

as a

ssoc

iate

d w

ith fu

ture

falls

∞

++

8

Won

g 20

14 11

5 48

1 80

[±

4]

Coh

ort,

com

mun

ity

(hom

e),

Pros

pect

ive

Any

fall

duri

ng

12 m

onth

FU

SR

M

I in

10%

of f

alle

rs,

9% o

f non

falle

rs. M

I &

falls

una

djus

ted

RR

1.0

(0.7

–1.5

) M

I was

not

as

soci

ated

with

fu

ture

falls

∞

- 9

Cas

e co

ntro

l

Her

ndon

60

467

65+

C

ase-

cont

rol,

com

mun

ity,

cros

s-se

ctio

nal

In E

R o

r ad

mitt

ed fo

r fa

lls

SR

14%

of c

ases

, 12%

of

cont

rols

O

R 1

.2 (0

.8-1

.7)

MI w

as n

ot

asso

ciat

ed w

ith

falls

¥ -

5

Seri

es

A

npal

ahan

20

11 32

38

80

[±

6],

77 [

±5]

O

bser

vatio

nal

seri

es, a

cute

ho

spita

l, cr

oss-

sect

iona

l

In E

D fo

r un

expl

aine

d or

ac

cide

ntal

falls

SR, M

R

Whe

n co

mbi

ned

with

H

TN 7

6%

C

VD

with

HTN

is

com

mon

in

olde

r fa

llers

∞

4

Phill

ips

1999

94

142

83, r

ange

76

-99

Obs

erva

tiona

l se

ries

, em

erge

ncy

depa

rtm

ent,

cros

s-se

ctio

nal

In E

R o

r ad

mitt

ed fo

r fa

lls

or s

ynco

pe

Che

st p

ain,

se

rial

EC

Gs,

ca

rdia

c en

zym

es

10%

Prev

alen

ce o

f ac

ute

MI i

n pa

tient

s ad

mitt

ed w

ith

falls

or

sync

ope

¥

3

van

Nie

uwen

huij

zen

201

0 11

3

639

79 (±

8)

Obs

erva

tiona

l se

ries

, em

erge

ncy

depa

rtm

ent,

cros

s-se

ctio

nal

in E

R fo

r fa

lls

SR, M

R

11%

His

tory

of M

I in

falle

rs

pres

entin

g in

th

e ED

¥

2

Vu

2011

114

44,9

42

med

ian

82 (I

QR

76

-87)

Obs

erva

tiona

l se

ries

, acu

te

hosp

ital,

retr

ospe

ctiv

e

In E

R o

r ad

mitt

ed fo

r fa

lls

MR

(IC

D

code

s )

0.9%

(95%

CI 0

.9-1

.0)

ac

ute

MI i

s no

t co

mm

on in

pa

tient

s ad

mitt

ed fo

r in

juro

us fa

lls

¥

1

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk

.. O

R/H

R/R

R a

re a

djus

ted

unle

ss o

ther

wis

e sp

ecifi

ed.

SD (±

): st

anda

rd d

evia

tion.

IQR

, int

erqu

artil

e ra

nge.

CA

D, c

oron

ary

arte

ry d

isea

se, C

HF,

con

gest

ive

hear

t fai

lure

, CV

D, c

ardi

ovas

cula

r di

seas

e, E

D, e

mer

genc

y de

part

men

t. G

P,

gene

ral p

ract

icio

ner,

HTN

, hyp

erte

nsio

n, IH

D, i

sche

mic

hea

rt d

isea

se, M

I, m

yoca

rdia

l inf

arct

ion.

MR

, med

ical

rec

ord.

WH

O, w

orld

hea

lth o

rgan

izat

ion.

SR

, sel

f rep

ort. ∞

Bot

h M

I/Ang

ina,

¥ A

cute

MI o

nly.

*+

+ A

ssoc

iatio

n m

ultiv

aria

bly

adju

sted

for

pote

ntia

l con

foun

ders

, + u

niva

riab

le a

ssoc

iatio

n or

hig

her

prev

alen

ce c

ompa

red

to c

ontr

ol g

roup

, - a

bsen

t ass

ocia

tion

or s

imila

r pr

eval

ence

.

TABLE 7 (CONTINUED)

Tabl

e 7.

Cor

onar

y ar

tery

dis

ease

(A

ngin

a, is

chem

ic h

eart

dis

ease

and

myo

card

ial i

nfar

ctio

n) a

nd f

alls

Firs

t au

thor

N

A

ge ,

year

s Po

pula

tion

se

ttin

g, d

esig

n O

utco

me

of f

alls

M

etho

d as

sess

men

t M

ain

find

ings

and

pr

eval

ence

of

CA

D

OR

/RR

/HR

C

oncl

usio

n C

AD

*

NO

S

Coh

ort

D

amia

n 20

13 47

73

3 83

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l

Any

fall

in th

e pa

st m

onth

M

R

17%

in c

ohor

t IH

D &

falls

RR

0.6

(0

.3 –

1.2

) IH

D w

as n

ot

asso

ciat

ed w

ith

falls

∞

-

Jans

en

2015

62

8173

64

[±

10],

ra

nge

51-

105

Coh

ort,

com

mun

ity

(hom

e), c

ross

-se

ctio

nal

Any

fall

in th

e pa

st 1

2 m

onth

s SR

A

ngin

a 7.

1% o

f fal

lers

, 5.

1% o

f non

-fal

lers

. MI

4.5%

of f

alle

rs ,

4.6%

of

non

-fal

lers

.

Ang

ina

& fa

lls O

R

1.1

(0.9

-1.4

), &

re

curr

ent f

alls

OR

1.

4 (1

.0 -

1.9)

. M

I & fa

lls O

R 0

.8

(0.6

- 1.

1), &

re

curr

ent f

alls

OR

1.

2 (0

.8-1

.7)

MI i

s no

t as

soci

ated

with

fa

lls, a

ngin

a is

as

soci

ated

with

re

curr

ent f

alls

∞

++

6

Law

lor

73

4050

71

(9

5%C

I 70

to 7

1)

Coh

ort,

Com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in p

ast

12 m

onth

s SR

and

MR

23

% o

f fal

lers

, 14%

of

non-

falle

rs

CA

D &

falls

OR

1.5

(1

.2-2

.0),

CA

D &

re

curr

ent f

alls

OR

2.

1 (1

.5-3

.0)

CA

D w

as

asso

ciat

ed w

ith

falls

∞

++

5

Lee

2009

76

11

,113

55

%: 6

5-75

yea

rs.

45%

: 76+

Coh

ort,

com

mun

ity

(hom

e), c

ross

-se

ctio

nal

Rec

urre

nt fa

lls

in th

e pa

st 1

2 m

onth

s

SR

23%

of p

atie

nts

who

ha

d a

fall

had

CA

D

com

pare

d to

16%

of

the

over

all p

opul

atio

n

C

AD

was

mor

e pr

eval

ent i

n fa

llers

co

mpa

red

to

non

falle

rs

∞

+

6

Mitc

hell

2013

87

5681

65

+

Coh

ort,

com

mun

ity

(hom

e), c

ross

-se

ctio

nal

Any

fall

in th

e pa

st 1

2 m

onth

s SR

H

eart

dis

ease

/ang

ina

30%

of f

alle

rs, 2

4% o

f no

n fa

llers

, poo

r ci

rcul

atio

n in

le

gs/p

erip

hera

l vas

cula

r di

seas

e 28

.1%

of

falle

rs, 1

7.4%

of n

on-

falle

rs.

Cir

cula

tory

sys

tem

di

seas

e &

falls

: OR

1.

4 (1

.2–1

.6)

Cir

cula

tory

di

seas

e w

as

asso

ciat

ed w

ith

falls

∞

++

5

Raf

iq

2014

98

135,

433

75 [

±8]

, ra

nge

65-

104

Coh

ort,

com

mun

ity,

pros

pect

ive

GP

visi

t for

any

fa

ll M

R

IHD

15%

, CA

D 5

%, M

I 4%

. IH

D &

falls

O

R 1

.2 (1

.1-1

.2)

IHD

was

in

depe

nden

tly

asso

ciat

ed w

ith

falls

; CH

F,

CA

D a

nd M

I w

ere

not

∞

++

6

Sibl

ey

2014

105

16,3

57

65+

C

ohor

t, co

mm

unity

, cr

oss-

sect

iona

l

Any

fall

in th

e pa

st 1

2 m

onth

s SR

24

% o

f tho

se w

ith

hear

t dis

ease

fell,

co

mpa

red

to 1

9% o

f th

ose

with

out h

eart

OR

1.3

, p 0

.06

Clu

ster

‘hea

rt

dise

ase’

was

no

t si

gnifi

cant

ly

∞

- 4

TABLE 7. CORONARY ARTERY DISEASE (ANGINA, ISCHEMIC HEART DISEASE AND MYOCARDIAL INFARCTION) AND FALLS


Tabl

e 9.

Pos

tpra

ndia

l hyp

oten

sion

(PP

H)

and

falls

Fi

rst

auth

or

N

Age

, ye

ars

Popu

lati

on,

Sett

ing,

Des

ign

Out

com

e of

fal

ls

Ass

essm

ent

met

hod

Mai

n fi

ndin

gs a

nd

prev

alen

ce o

f PP

H

OR

/RR

/HR

C

oncl

usio

n *

NO

S

Coh

ort

A

rono

w

1997

34

499

80 [

±9]

C

ohor

t, lo

ng-

term

car

e,

pros

pect

ive

Any

fall

duri

ng 2

0 m

onth

FU

Bas

elin

e B

P be

fore

lunc

h an

d at

15,

30,

45,

60,

75

and

120

min

utes

afte

r lu

nch.

Res

iden

t in

sitti

ng

posi

tion

for

at le

ast 2

m

inut

es b

efor

e m

easu

ring

.

mea

n m

axim

al

decr

ease

in fa

llers

20

[±

5]m

mH

g, in

no

n-fa

llers

12

[±4]

mm

Hg.

RR

1.2

(1.2

- 1

.2)

PPH

is a

ssoc

iate

d w

ith fu

ture

falls

+

+

6

Le C

oute

ur

2003

74

179

83 [

±7]

C

ohor

t, co

mm

unity

(r

esid

entia

l fa

cilit

y),

cros

s-se

ctio

nal

Any

fall

in

the

past

12

mon

ths

Post

pran

dial

BP

mea

sure

men

ts a

t 60

min

af

ter

the

mea

l in

both

su

pine

and

upr

ight

po

sist

ion

38%

of s

ubje

cts

had

PPH

. PP

H &

falls

OR

1.0

(0

.6–1

.9),

& r

ecur

rent

fa

lls O

R 0

.9 (0

.4–

1.9)

. SB

P <

=11

5 m

m H

g af

ter

a m

eal &

falls

O

R 3

.7 (1

.3–1

1.1)

PPH

was

not

as

soci

ated

with

fa

lls o

r re

curr

ent

falls

, but

SB

P po

stpr

andi

al d

rop

belo

w 1

15 m

mH

g w

as

- 3

Cas

e co

ntro

l

Puis

ieux

20

00 96

45

81

[±

9] /

79 [

±7]

C

ase-

cont

rol,

acut

e ho

spita

l, cr

oss-

sect

iona

l

Adm

itted

fo

r an

y fa

ll 24

hou

r. R

ecor

ding

s ev

ery

15 m

inut

es d

urin

g th

e da

y, e

very

30

min

utes

du

ring

the

nigh

t.

PPH

27%

in th

e sy

ncop

e gr

oup,

18

% in

the

fall

grou

p, 9

% in

the

cont

rol g

roup

.

PP

H is

com

mon

in

patie

nts

adm

itted

fo

r fa

lls a

nd

sync

ope

+

5

Scho

on

2013

104

105

/ 25

79

[±

7] /

74 [

±4]

C

ase-

cont

rol,

falls

& s

ynco

pe

clin

ic,

cros

s-se

ctio

nal

Any

fall

and

sync

ope

10 m

inut

es o

f res

t, st

anda

rdis

ed fl

uid

mea

l co

nsum

ed w

ithin

10

min

s (2

92 c

alor

ies)

. HR

and

BP

cont

inuo

usly

mea

sure

d un

til 7

5 m

inut

es a

fter

the

mea

l.

53%

of c

ases

, 14

% o

f con

trol

s

PPH

is m

ore

com

mon

in th

ose

refe

rred

for

falls

th

an c

ases

with

out

falls

+

6

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk

. OR

/HR

/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. N

OS,

New

cast

le-O

ttaw

a-Sc

ale

scor

e *+

+ A

ssoc

iatio

n m

ultiv

aria

bly

adju

sted

for

pote

ntia

l con

foun

ders

, + u

niva

riab

le a

ssoc

iatio

n or

hig

her

prev

alen

ce c

ompa

red

to c

ontr

ol g

roup

, - a

bsen

t ass

ocia

tion

or s

imila

r pr

eval

ence

.

TABLE 9. POSTPRANDIAL HYPOTENSION (PPH) AND FALLS

Tabl

e 8.

Gen

eral

car

diov

ascu

lar

dise

ase

and

falls

Firs

t aut

hor

N

A

ge,

year

s Po

pula

tion,

set

ting,

de

sign

, O

utco

me

of fa

lls

Ass

essm

ent

met

hod

Mai

n fin

ding

s an

d pr

eval

ence

of C

VD

O

R/RR

/HR

C

oncl

usio

n *

NO

S

Coh

ort

Ala

mgi

r 30

20

15

5996

65

+ C

ohor

t, co

mm

unity

(h

ome)

, cro

ss-

sect

iona

l

Any

fall

in th

e pa

st 3

mon

ths

SR o

f CV

D

Not

giv

en

CV

D &

falls

R

R 1

.1 (0

.6-

1.8)

CV

D w

as n

ot a

ssoc

iate

d w

ith fa

lls

-

6

Bra

ssin

gton

20

00 40

15

26

64-9

9 C

ohor

t, co

mm

unity

(h

ome)

, cro

ss-

sect

iona

l

Any

fall

SR o

f CV

D

30%

of f

alle

rs, 2

2%

of n

on-f

alle

rs.

Una

djus

ted

OR

1.5

(1

.1-2

.0)

CV

D is

uni

vari

atel

y as

soci

ated

with

falls

+

4

Che

n 20

08 46

58

5 81

[±5

] C

ohor

t, lo

ng-t

erm

ca

re, c

ross

-sec

tiona

l A

ny fa

ll in

the

past

6 m

onth

s M

R o

f CV

D

CV

D 5

.2%

in n

on-

falle

rs, 1

2.5%

in

falle

rs

n/s

CV

D w

as n

ot a

ssoc

iate

d w

ith fa

lls

- 4

Hec

kenb

ach

2014

58

5124

73

C

ohor

t, co

mm

unity

(h

ome)

, cro

ss-

sect

iona

l

GP

visi

tfor

any

fall

MR

(GP,

ICD

co

de o

f dis

ease

s of

ar

teri

es/a

rter

iole

s/c

apill

arie

s)

30%

of f

alle

rs, 1

8%

of n

on-f

alle

rs.

OR

1.5

(1

.2-1

.9).

Art

eria

l dis

ease

was

as

soci

ated

with

falls

++

5

Kao

20

12 65

36

0 76

(r

ange

64

-91)

Coh

ort,

com

mun

ity

(hom

e), c

ross

-se

ctio

nal

Rec

urre

nt o

r In

juri

ous

falls

in

the

past

12

mon

ths

SR o

f CV

D

37%

of f

alle

rs a

nd

26%

of n

on fa

llers

. O

R 1

.5

(0.9

-2.6

) C

VD

was

not

ass

ocia

ted

with

falls

-

6

Lee

2006

75

4000

72

[±5

] C

ohor

t, co

mm

unity

(h

ome)

, cro

ss-

sect

iona

l

Any

fall

in th

e pa

st 1

2 m

onth

s SR

of h

eart

di

seas

e To

tal p

reva

lenc

e 17

%

OR

1.6

(1

.4-2

.0)

Hea

rt d

isea

se w

as

asso

ciat

ed w

ith s

ingl

e an

d re

curr

ent f

alls

++

7

Prud

ham

19

81 95

23

57

65+

Coh

ort,

com

mun

ity

(hom

e), c

ross

-se

ctio

nal

Any

fall

in th

e pa

st 1

2 m

onth

s SR

, M

R o

f CV

D

CV

D 2

1% o

f fal

lers

vs

. 16%

of n

on fa

llers

(p

<0.0

5)

C

VD

is m

ore

prev

alen

t in

falle

rs th

an n

on-f

alle

rs in

th

e co

mm

unity

+ 2

Cas

e co

ntro

l

K

elly

67

2278

79

[±8

] C

ase-

cont

rol,

com

mun

ity,

retr

ospe

ctiv

e

Inju

riou

s fa

lls

repo

rted

in E

D

SR ,

MR

of C

VD

25

% o

f cas

es, 1

9% o

f co

ntro

ls

OR

1.1

(0

.95-

1.2)

C

VD

was

not

ass

ocia

ted

with

falls

-

4

Seri

es

Smeb

ye

2014

106

111

82 [

±7]

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Ref

erre

d fo

r an

y fa

ll M

R o

f CV

D

52%

CV

D is

com

mon

in o

lder

fa

llers

3

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk.

OR

/HR

/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. N

OS,

New

cast

le O

ttaw

a Sc

ale.

CV

D: c

ardi

ovas

cula

r di

seas

e, G

P: g

ener

al p

ract

icio

ner.

(C)H

F: (c

onge

stiv

e) h

eart

failu

re.

*++

Ass

ocia

tion

mul

tivar

iabl

y ad

just

ed fo

r po

tent

ial c

onfo

unde

rs, +

uni

vari

able

ass

ocia

tion

or h

ighe

r pr

eval

ence

com

pare

d to

con

trol

gro

up, -

abs

ent a

ssoc

iatio

n or

sim

ilar

prev

alen

ce, !

neg

ativ

e as

soci

atio

n

TABLE 8. GENERAL CARDIOVASCULAR DISEASE AND FALLS


66-9

4 sy

ncop

e cl

inic

, re

tros

pect

ive

fa

lls a

nd

sync

ope

obse

rved

in s

ubje

cts

with

une

xpla

ined

fa

lls

Arm

stro

ng

2003

33

15

73,

rang

e 61

-89

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, re

tros

pect

ive

Ref

erre

d fo

r un

expl

aine

d fa

lls a

nd

sync

ope

ILR

(u

p to

3 y

ears

) 27

%

C

ardi

ac a

rrhy

thm

ia

was

freq

uent

ly

obse

rved

in s

ubje

cts

with

une

xpla

ined

fa

lls a

nd s

ynco

pe

with

no

othe

r at

trib

utab

le d

iagn

osis

fo

r th

eir

fall

Π

2

Dav

ies

1996

48

200

79

(SE8

) O

bser

vatio

nal

seri

es,

emer

genc

y de

part

men

t, cr

oss-

sect

iona

l

In E

D fo

r un

expl

aine

d an

d re

curr

ent

falls

12-l

ead

ECG

an

d/or

am

bula

tory

he

art r

ate

mon

itori

ng

8%

A

rrhy

thm

ia w

as

com

mon

in

unex

plai

ned

falle

rs

Π

3

Mid

ttun

20

11 85

20

7 83

, ra

nge

58–9

5

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, re

tros

pect

ive

Ref

erre

d fo

r un

expl

aine

d fa

lls

Exte

rnal

Loo

p R

ecor

der

(7 d

ays)

16

%

C

ardi

ac a

rrhy

thm

ia

was

not

freq

uent

ly

obse

rved

in s

ubje

cts

with

une

xpla

ined

fa

lls

∞

1

Parr

y 20

05 92

93

77

[±

9],

rang

e 55

-92

Obs

erva

tiona

l se

ries

, fal

ls &

sy

ncop

e cl

inic

, cr

oss-

sect

iona

l

Une

xpla

ined

fa

lls, (

3 or

m

ore

drop

at

tack

s) in

the

past

6 m

onth

s

12-l

ead

ECG

and

H

olte

r m

onito

ring

18

% a

rrhy

thm

ia. 6

%

sign

ifica

nt a

rrhy

thm

ia

C

ardi

ac a

rrhy

thm

ia

is a

freq

uent

find

ing

in s

ubje

cts

with

un

expl

aine

d fa

lls

µ,∞

3

Smeb

ye

2014

106

111

82

[±7]

O

bser

vatio

nal

seri

es, f

alls

&

sync

ope

clin

ic,

cros

s-se

ctio

nal

Ref

erre

d fo

r an

y fa

ll 12

-lea

d EC

G

AF

8%

Atr

iove

ntri

cula

r bl

ock,

gra

de I

6%

Bra

nch

bloc

k 2%

(n

=2/

106)

A

rrhy

thm

ias

wer

e co

mm

on in

old

er

falle

rs

∞

3

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk

. OR

/HR

/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

. SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. S

E: s

tand

ard

erro

r. N

OS,

New

cast

le-O

ttaw

a-Sc

ale.

AF:

atr

ial f

ibri

llatio

n.

ECG

: ele

ctro

card

iogr

am. I

LR, i

nter

nal l

oop

reco

rder

. ¥

Ven

tric

ular

/ Sup

erve

ntri

cula

r ar

rhyt

hmia

s. ∞

Bra

dyca

rdia

/hea

rt b

lock

onl

y. Π

Any

arr

hyth

mia

. µ

atr

ial f

ibri

llatio

n.

*++

Ass

ocia

tion

mul

tivar

iabl

y ad

just

ed fo

r po

tent

ial c

onfo

unde

rs, +

uni

vari

able

ass

ocia

tion

or h

ighe

r pr

eval

ence

com

pare

d to

con

trol

gro

up, -

abs

ent a

ssoc

iatio

n or

sim

ilar

prev

alen

ce, !

neg

ativ

e as

soci

atio

n

TABLE 10 (CONTINUED)

Tabl

e 10

. Car

diac

arr

hyth

mia

s an

d fa

lls

Firs

t au

thor

N

A

ge,

year

s Po

pula

tion

, Se

ttin

g, D

esig

n O

utco

me

of

falls

A

sses

smen

t m

etho

d M

ain

findi

ngs

and

prev

alen

ce o

f CA

O

R/R

R/H

R

Con

clus

ion

CA

*

NO

S

Coh

ort

Dam

ian

2013

47

733

83

Coh

ort,

Com

mun

ity,

Cro

ss-s

ectio

nal

Any

fall

in th

e pa

st m

onth

M

edic

al c

hart

, in

terv

iew

with

ph

ysic

ian

Arr

hyth

mia

s in

22.

3%

of fa

llers

A

rrhy

thm

ias

RR

3.4

(1

.8-6

.3)

Med

ical

his

tory

of

arrh

ythm

ia w

as

asso

ciat

ed w

ith a

fall

in th

e pa

st m

onth

Π

++

6

Hun

g 20

13 61

40

1 82

[±

0.2]

C

ohor

t, ac

ute

hosp

ital,

Cro

ss-

sect

iona

l

Any

fall

in th

e pa

st 3

yea

rs

12-l

ead

ECG

, Te

lem

etry

, M

edic

al c

hart

hi

stor

y

AF

20%

of f

alle

rs,

11%

of n

on-f

alle

rs, p

0.

029

AF

& fa

lls 2

.0 (1

.1-

3.6)

A

F w

as

inde

pend

ently

as

soci

ated

with

hi

stor

y of

falls

.

µ +

+

5

Jans

en

2015

63

4886

62

[±

8]

Coh

ort,

Com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in th

e pa

st 1

2 m

onth

s EC

G

AF

3.6%

in fa

llers

, 2.

1% in

non

-fal

lers

A

F &

any

fall

OR

1.4

(0

.9-2

.2).

A

ge 6

5-74

: OR

2.0

(1

.0-4

.1)

AF

is a

ssoc

iate

d w

ith

any

fall

in th

e pa

st

year

in th

ose

aged

65

-74,

but

not

in th

e ov

eral

l age

gro

up

µ +

+

6

Cas

e C

ontr

ol

Dav

ison

20

05 50

12

8 77

[±

6]

Cas

e-co

ntro

l, em

erge

ncy

depa

rtm

ent,

cros

s-se

ctio

nal

Rec

urre

nt fa

lls

in th

e pa

st 1

2 m

onth

s

24-h

our

ambu

lato

ry E

CG

re

cord

er.

≥1 E

CG

abn

orm

. w

ere

iden

tifie

d in

49

% o

f fal

lers

and

41

% o

f con

trol

s. N

o ca

usat

ive

arrh

ythm

ias

wer

e id

entif

ied.

Any

EC

G

abno

rmal

ity &

falls

: R

R 1

.2 (0

.9–1

.6).

No

caus

ativ

e ar

rhyt

hmia

s id

entif

ied

in

recu

rren

t fal

lers

co

mpa

red

to c

ontr

ols

with

out a

his

tory

of

falls

.

Π

- 8

Ros

ado

1989

101

51

86

Cas

e-co

ntro

l, lo

ng-t

erm

car

e an

d co

mm

unity

, cr

oss-

sect

iona

l

Any

fall

in p

ast

7 da

ys

Hol

ter

mon

itori

ng

82%

ven

tric

ular

ar

rhyt

hmia

s in

bot

h gr

oups

, 100

%

supr

aven

tric

ular

ar

rhyt

hmia

s in

bot

h gr

oups

.

C

ardi

ac a

rrhy

thm

ia

was

not

mor

e pr

eval

ent i

n th

ose

who

had

falls

¥ -

8

Sand

ers

20

12 10

3 21

1 82

[±

9]

Cas

e-co

ntro

l, em

erge

ncy

de

part

men

t, re

tros

pect

ive

In E

R fo

r ac

cide

ntal

and

no

n-ac

cide

ntal

fa

lls

12-l

ead

ECG

, m

edic

al h

isto

ry

(cha

rt r

evie

w)

26%

of n

on-

acci

dent

al fa

llers

had

a

med

ical

his

tory

of

AF,

com

pare

d to

15%

of

thos

e w

ith

acci

dent

al fa

lls

His

tory

of A

F &

non

ac

cide

ntal

falls

OR

1.

2 [1

.0-2

.7]

com

pare

d to

non

-ac

cide

ntal

falls

. O

bjec

tifie

d A

F no

t as

soci

ated

with

falls

AF

is a

ssoc

iate

d w

ith

non-

acci

dent

al

(une

xpla

ined

) fal

ls

com

pare

d to

ac

cide

ntal

falls

µ +

+

5

Seri

es

Allc

ock

2000

31

120

78,

rang

e O

bser

vatio

nal

seri

es, f

alls

&

Ref

rred

for

unex

plai

ned

12-l

ead

ECG

and

H

olte

r m

onito

ring

<

1%

C

ardi

ac a

rrhy

thm

ia

was

not

freq

uent

ly

Π

3

TABLE 10. CARDIAC ARRHYTHMIAS AND FALLS


Tabl

e 12

. Str

uctu

ral c

ardi

ovas

cula

r ab

norm

alit

ies

and

falls

Fi

rst

auth

or

N

Age

, ye

ars

Popu

lati

on,

sett

ing,

des

ign

Falls

ou

tcom

e Ty

pe o

f ab

norm

alit

y A

sses

smen

t m

etho

d an

d de

fini

tion

of

abno

rmal

ity

Mai

n fi

ndin

gs a

nd p

reva

lenc

e of

ab

norm

alit

y an

d m

ain

find

ings

C

oncl

usio

n *

NO

S

Scho

on

2013

104

105

79 [

±7]

/ 7

4 [±

4]

Cas

e-co

ntro

l, fa

lls &

sy

ncop

e cl

inic

, cro

ss-

sect

iona

l

Any

fall

or

sync

ope

lead

ing

to

refe

rral

Hea

d tu

rnin

g in

duce

d hy

pote

nsio

n

10 m

in. a

ctiv

e st

and,

co

ntin

uous

BP.

Thr

ee h

ead

mov

emen

ts (r

otat

ion

righ

t, le

ft an

d hy

pere

xten

sion

). SB

P ca

lcul

ated

as

mea

n of

thre

e be

ats

with

low

est S

BP

duri

ng

the

HTT

. HTT

def

ined

as

a dr

op in

SB

P of

≥20

mm

Hg.

39%

of c

ases

had

HTI

H,

com

pare

d to

44%

of c

ontr

ols.

H

TIH

is n

ot

diffe

rent

bet

wee

n th

ose

pres

entin

g w

ith fa

lls a

nd

sync

ope

com

pare

d to

he

alth

y co

ntro

ls

- 6

Van

der

V

elde

20

07 11

1

215

77.4

[±

6.

0]

Coh

ort,

geri

atri

c ou

tpat

ient

cl

inic

, pr

ospe

ctiv

e

Any

fall

duri

ng 3

m

onth

FU

, m

onth

ly

cale

ndar

s

Stru

ctur

al

card

iac

abno

rmal

ities

Echo

card

iogr

aphy

. Aor

tic

valv

e st

enos

is, a

ortic

val

ve

regu

rgita

ion,

mitr

al v

alve

re

gurg

itatio

n, tr

icus

pid

valv

e re

gurg

itatio

n, p

ulm

onar

y va

lve

regu

rgita

tion,

pu

lmon

ary

hype

rten

sion

, LV

hy

pert

roph

y (s

eptu

m

>12

mm

), LV

EF <

40%

AV

S 7%

falle

rs, 1

0% n

on-f

alle

rs.

AV

R 2

9% o

f fal

lers

, 24%

non

-fa

llers

. M

VR

. 43%

of f

alle

rs, 2

9% n

on-

falle

rs, H

R 1

.7 (1

.0–2

.9).

TVR

67

% fa

llers

, 37%

non

-fal

lers

, HR

2.

4 (1

.3–4

.4).

PVR

. 47%

falle

rs,

29%

non

-fal

lers

, HR

1.7

(1.0

–3.

0). P

H 2

9% fa

llers

, 19%

non

-fa

llers

, HR

1.3

5 (1

.1–1

.7).

LVH

36

% fa

llers

, 33%

non

-fal

lers

, HR

1.

8 (0

.9–3

.6).

Mitr

al, t

ricu

spid

an

d pu

lmon

ary

valv

e re

gurg

itatio

n an

d pu

lmon

ary

hype

rten

sion

w

ere

asso

ciat

ed

with

futu

re fa

lls

++

4

Won

g 20

14 11

5 53

1 80

[±

4]

Coh

ort,

com

mun

ity,

pros

pect

ive.

Any

fall

duri

ng 1

2 m

onth

FU

, m

onth

ly

cale

ndar

s

Art

eria

l st

iffne

ss

Car

otid

–fem

oral

PW

V

mea

sure

d su

pine

usi

ng a

se

mi-

auto

mat

ed p

ulse

wav

e an

alys

is s

yste

m. H

igh

PWV

w

as ta

ken

as th

e to

p qu

intil

e (>

13 m

/s)

Puls

e w

ave

velo

city

11.

5 [2

.6]

m/s

in fa

llers

and

11.

0 [2

.2]

m/s

in

non

-fal

lers

(RR

1.0

5 (1

.01–

1.09

)). T

op q

uint

ile o

f PW

V &

fa

lls R

R 1

.37

(1.0

6–1.

78),

adju

sted

for

age,

gen

der

and

othe

r co

nfou

ndin

g fa

ctor

s

Art

eria

l stif

fnes

s is

an

inde

pend

ent

pred

icto

r of

fu

ture

falls

++

9

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR

: odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: r

elat

ive

risk

. OR

/HR

/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: i

nter

quar

tile

rang

e. N

OS,

New

cast

le O

ttaw

a Sc

ale.

V

S, a

ortic

val

ve s

teno

sis.

AV

R, a

ortic

val

ve r

egur

gita

tion.

MV

R, m

itral

val

ve r

egur

gita

tion.

TV

R, t

ricu

spid

val

ve r

egur

gita

tion.

PV

R, p

ulm

onar

y va

lve

regu

rgita

tion.

PH

, pu

lmon

ary

hype

rten

sion

. LV

H, l

eft v

entr

icul

ar h

yper

tens

ion.

*+

+ A

ssoc

iatio

n m

ultiv

aria

bly

adju

sted

for

pote

ntia

l con

foun

ders

, + u

niva

riab

le a

ssoc

iatio

n or

hig

her

prev

alen

ce c

ompa

red

to c

ontr

ol g

roup

, - a

bsen

t ass

ocia

tion

or s

imila

r pr

eval

ence

, ! n

egat

ive

asso

ciat

ion

TABLE 12. STRUCTURAL CARDIOVASCULAR ABNORMALITIES AND FALLSTa

ble

11. H

eart

failu

re a

nd fa

lls

Firs

t aut

hor

N

Age

, ye

ars

Popu

latio

n,

sett

ing,

des

ign

Out

com

e of

falls

A

sses

smen

t met

hod

Mai

n fin

ding

s an

d pr

eval

ence

of O

H

OR/

RR/H

R C

oncl

usio

n C

HF

* N

OS

Coh

orts

Dam

ian

2013

47

733

83

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in th

e pa

st m

onth

M

edic

al c

hart,

in

terv

iew

with

ph

ysic

ian,

20%

in c

ohor

t RR

2.2

(1.2

- 4.0

) H

F w

as

asso

ciat

ed w

ith a

fa

ll in

the

past

m

onth

++

6

Hec

kenb

ach 20

14 58

5124

73

C

ohor

t, co

mm

unity

, re

trosp

ectiv

e

GP

visi

t for

any

fa

ll M

edic

al c

hart,

IC

D-c

odes

GP

19%

of f

alle

rs, 9

%

of n

on-fa

llers

. O

R 1.

7 (1

.3-2

.3)

HF

was

as

soci

ated

with

pr

evio

us fa

lls

++

5

Jans

en

2015

62

8173

64

[±

10]

Coh

ort,

com

mun

ity,

cros

s-se

ctio

nal

Any

fall

in th

e pa

st 1

2 m

onth

s Se

lf re

porte

d do

ctor

-dia

gnos

ed

1.6%

of f

alle

rs,

0.9%

of n

on-fa

llers

H

F &

falls

OR

1.4

(1.1

-1.7

) H

F &

recu

rren

t fal

ls

OR

1.5

(1.0

-2.1

)

HF

was

as

soci

ated

with

fa

lls a

nd re

curr

ent

falls

++

6

Rafiq

20

14 98

13

5,4

33

75

[±8]

C

ohor

t, co

mm

unity

, re

trosp

ectiv

e

GP

visi

t for

any

fa

ll M

edic

al c

hart,

GP

char

ts,

4% in

who

le

coho

rt N

ot g

iven

H

F w

as n

ot

asso

ciat

ed w

ith

falls

∞

- 6

Sten

hage

n 20

13 10

7 17

63

Rang

e 60

-93

Coh

ort,

com

mun

ity,

pros

pect

ive

Any

falls

in th

e pa

st 6

mon

ths,

at

3 an

d 6

year

s

Med

ical

cha

rt,

ICD

-10

ex

amin

atio

n by

a

phys

icia

n

11%

of f

alle

rs a

nd

4% o

f non

-falle

rs.

OR

1.9

(1.2

-3.0

) H

F w

as

asso

ciat

ed w

ith

futu

re fa

lls

¥ ++

8

Seri

es

Vu

2011

114

44,9

42

82

(IQR

76-8

7)

Obs

erva

tiona

l se

ries,

acu

te

hosp

ital,

retro

spec

tive

In E

R or

adm

itted

fo

r fal

ls

Med

ical

cha

rt, IC

D

code

s 3%

n/

a H

F is

not

co

mm

on in

pa

tient

s ad

mitt

ed

for i

njur

ious

falls

1

N/A

: Not

app

licab

le. 9

5% C

I: 95

% c

onfid

ence

inte

rval

. OR:

odd

s ra

tio. H

R: h

azar

d ra

tio. R

R: re

lativ

e ris

k. O

R/H

R/RR

are

adj

uste

d un

less

oth

erw

ise

spec

ified

SD

(±):

stan

dard

dev

iatio

n. IQ

R: in

terq

uarti

le ra

nge.

NO

S, N

ewca

stle

Otta

wa

Scal

e. (C

)HF:

(con

gest

ive)

hea

rt fa

ilure

. ∞ N

HS

read

crit

eria

for C

HF.

¥. N

YHA

cla

ss II

-IV s

ympt

oms

*++

Ass

ocia

tion

mul

tivar

iabl

y ad

just

ed fo

r pot

entia

l con

foun

ders

, + u

niva

riabl

e as

soci

atio

n or

hig

her p

reva

lenc

e co

mpa

red

to c

ontr

ol g

roup

, - a

bsen

t ass

ocia

tion

or s

imila

r pr

eval

ence

TABLE 11. HEART FAILURE AND FALLS


APPENDIX S1. SEARCH STRATEGY

Key search terms were ‘falls’, ‘aged’ and ‘cardiovascular’. Search terms for falls included: falling, stumbling, slipping or tripping. Search terms for ‘aged’ included: aging, frail elderly, old, senior, geriatric and postmenopausal women. Search terms for ‘cardiovascular’ included: cardiovascular, circulatory or heart diseases, hypertension, blood pressure, arrhythmia, sinus node disease, heart conduction abnormality, atrial fibrillation, bradycardia, heart valve disease, cardiomyopathy, myocardial ischemia or infarction, heart failure, carotid sinus syndrome, orthostatic or postural hypotension, postprandial hypotension, vasovagal and neurocardiogenic syncope.

APPENDIX S2. ACTUAL SEARCHES FOR MEDLINE AND EMBASE

Medline in process & other non-indexed materials, 2014-11-10, OvidSP (2703 hits)

1. accidental falls/2. Geriatric assessment/ OR aging/ OR frail elderly/ OR exp aged/ OR

middle aged/3. 1 and 24. ((fall? OR fell OR falling OR fallen OR faller OR stumble? OR stum-

bling OR stumbles OR slip OR slips OR slipping OR slipped OR trip OR tripped) adj3 (old OR older OR senior OR elder OR elderly OR aged OR geriatric* OR middle-age? OR geriatric OR frailty OR Ageing OR elders OR Mci OR postmenopausal women OR Geriatric assessment OR aging)).ab,kw,ti

5. 3 or 4 [population]6. exp cardiovascular diseases/ or exp hypertension/ or hypotension/

OR exp cardiac arrhythmias/ OR heart diseases/ or cardiac output, low/ or cardiomegaly/ or cardiomyopathies/ or heart failure/ or heart valve diseases/ or myocardial ischemia/ or ventricular dysfunction/ or ventricular outflow obstruction/

7. (cardiovascular disease? or hypertension or hypotension or circulato-ry disease?).ab,kw,ti

8. blood pressure/ or myocardial ischemia/ or prehypertension/9. (blood pressure or systolic pressure or diastolic pressure).ab,kw,ti10. (((cardiac OR cardiovascular OR heart) adj3 (disorder? or disease? or

abnormalit* or failure or dysfunction*)) OR irregular heartbeat OR Sinus node disease OR Atrial fibrillation OR Bradycardia OR valve

disease* OR (valv* adj3 (insuffic* OR incompet* or stenos* or disease? or regurgitation)) OR cardiomyopath* OR Myocardial ischemia OR Myocardial infarction OR carotid sinus OR orthostasis OR orthostatic hypotension OR postural hypotension OR postprandial hypotension OR vasovagal syncope OR Neurocardiogenic syncope OR arrhythmia or ventricular dysfunction).ab,kw,ti

11. or/6-10 [cardiovascular diseases and -parameters]12. 5 and 1113. 11 and (fall? OR fell OR falling OR fallen OR faller OR stumble? OR

stumbling OR stumbles OR slip OR slips OR slipping OR slipped OR trip OR tripped).ab,kw,ti

14. (older adult? or elderly).ab,kw,ti.15. 13 and 1416. 12 or 15

Embase 1947 to Present, 2014-11-10, OvidSp (3833 hits)1. falling/2. Geriatric assessment/ OR aging/ OR frail elderly/ OR exp aged/ OR

middle aged/3. 1 and 24. ((fall? OR fell OR falling OR fallen OR faller OR stumble? OR stum-

bling OR stumbles OR slip OR slips OR slipping OR slipped OR trip OR tripped) adj3 (old OR older OR senior OR elder OR elderly OR aged OR geriatric* OR middle-age? OR geriatric OR frailty OR Ageing OR elders OR Mci OR postmenopausal women OR Geriatric assessment OR aging)).ab,kw,ti

5. 3 or 4 [population]6. cardiovascular disease/ or exp hypertension/ OR exp heart arr-

hythmias/ or ecg abnormality/ or exp heart arrhytmia/ or exp heart failure/ or exp ischemic heart disease/ or exp myocardial disease/ or exp valvular heart disease/ or exp coronary artery disease/

7. (cardiovascular disease? or hypertension or circulatory disease?).ab,kw,ti8. blood pressure/9. (blood pressure or systolic pressure or diastolic pressure).ab,kw,ti10. (((cardiac OR cardiovascular OR heart) adj3 (disorder? or disease? or

abnormalit* or failure or dysfunction*)) OR irregular heartbeat OR Si-nus node disease OR Atrial fibrillation OR Bradycardia OR valve disease* OR (valv* adj3 (insuffic* OR incompet* or stenos* or disease? or regurgitation)) OR cardiomyopath* OR Myocardial ische-mia OR Myocardial infarction OR carotid sinus OR orthostasis OR orthostatic hypotension OR postural hypotension OR postprandial


hypotension OR vasovagal syncope OR Neurocardiogenic syncope OR arrhythmia or ventricular dysfunction).ab,kw,ti

11. or/6-10 [cardiovascular diseases and -parameters]12. 5 and 1113. 11 and (fall? OR fell OR falling OR fallen OR faller OR stumble? OR

stumbling OR stumbles OR slip OR slips OR slipping OR slipped OR trip OR tripped).ab,kw,ti

14. (older adult? or elderly).ab,kw,ti.15. 13 and 1416. 12 or 15

APPENDIX S3. QUALITY ASSESSMENT

Quality of included studies was assessed by the same reviewers. Because of the variety of nonrandomized study designs included, the Newcastle-Ottawa Scale (NOS) was used to evaluate risk of bias in the case control-led and cohort studies [1]. The scale was adjusted to allow for appropri-ate quality assessment of falls. As prospective reporting of falls through calendars or diaries is considered the gold standard for falls reporting, studies using this method were allotted two stars. All other types of falls reporting were allotted one star. A score of 0-3 was considered low qua-lity, 4-6 intermediate and 7 or above high qualityCohort studies could be allotted a maximum of eleven stars and case con-trol studies could be allotted a maximum of nine stars. As observational series were also included in our review, the NOS for case-control studies was used, omitting the items on comparability and selection and ascer-tainment of controls, allowing a maximum of three stars for these studies.

QUALITY REVIEW FOR- CASE-CONTROL STUDIES OR OBSERVATIONAL SERIES

SelectionIs the case definition adequate?

Requires some independent validation (e.g. >1 person/record/time/pro-cess to extract information, or reference to primary record source such as medical/hospital records).• Yes, with independent validation *• Yes, with record linkage (e.g. ICD codes in database) or self-report• No description

Representativeness of the casesAll eligible cases with outcome of interest over a defined period of time, all cases in a defined catchment area, all cases in a defined hospital or clinic, group of hospitals, health maintenance organisation, or an appro-priate sample of those cases (e.g. random sample)• Consecutive or obviously representative series of cases *• Not satisfying requirements or not stated.

Selection of Controls (n/a for obs series)This item assesses whether the control series used in the study is derived from the same population as the cases and essentially would have been cases had the outcome been present.• community controls * (i.e. same community as cases and would be

cases if had outcome)• Hospital controls, within same community as cases (i.e. not another

city) but from a hospitalised population• No description

Definition of controls (n/a for obs series)If cases are first occurrence of outcome, then it must explicitly state that controls have no history of this outcome. If cases have new (not necessa-rily first) occurrence of outcome, then controls with previous occurrences of outcome of interest should not be excluded.• no history of disease (endpoint) *• no mention of history of outcome• N/A

ComparabilityComparability of cases and controls on the basis of the design or analysis (n/a for obs series)Either cases and controls must be matched in the design and/or confoun-ders must be adjusted for in the analysis. Statements of no differences between groups or that differences were not statistically significant are not sufficient for establishing comparability. Note: If the odds ratio for the exposure of interest is adjusted for the confounders listed, then the groups will be considered to be comparable on each variable used in the adjustment.• Controlled for age and/or gender *• Controlled for other factors *• no desciption


Exposure Ascertainment of exposure (risk factor)

• secure record (cardiovascular assessment) *• structured interview where blind to case/control status *• interview not blinded to case/control status• written self report or medical record only• no description

Same method of ascertainment for cases and controls (n/a for obs series)• yes *• no

Non-response rate (n/a for obs series)• same rate for both groups *• non respondents described• rate different and no designation• no description

QUALITY REVIEW FOR COHORT STUDIES

SelectionRepresentativeness of the exposed cohort

• truly representative of the average older persons in the community *• somewhat representative of the average older persons in the

community *• selected group of users eg volunteers• no description of the derivation of the cohort

Selection of the non exposed cohort• drawn from the same community as the exposed cohort *• drawn from a different source• no description of the derivation of the non exposed cohort

Ascertainment of exposure (cohort)• Some form of independent validation (e.g. cardiovascular assessment) *• structured interview *• written self report or medical record only• no description

Demonstration that outcome of interest was not present at start of studyyes *no

ComparabilityComparability of cohorts on the basis of the design or analysisEither exposed and non-exposed individuals must be matched in the de-sign and/or confounders must be adjusted for in the analysis. Statements of no differences between groups or that differences were not statistically significant are not sufficient for establishing comparability. Note: If the relative risk for the exposure of interest is adjusted for the confounders listed, then the groups will be considered to be comparable on each vari-able used in the adjustment.• Controlled for age and/or gender *• Controlled for other factors *• No description

OutcomeAssessment of outcome• Prospective self-report through fall calenders **• Incident report (e.g. in nursing homes) *• Medical record (e.g. patient with fall-related injury in ED) *• Retrospective self report• No description

Was follow-up long enough for outcomes to occur (N/A for cross-sectional studies)?• yes (six months or more) *• no

Adequacy of follow up of cohorts (N/A for cross-sectional studies)• complete follow up - all subjects accounted for *• subjects lost to follow up unlikely to introduce bias - small number lost *• subjects lost to follow up likely to introduce bias• No description

Reference1. Wells G, Shea B, O’connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analy-ses, 2000.


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23. van der Velde N, Stricker BHC, Pols HAP, van der Cam-men TJM. Risk of falls after wit-hdrawal of fall-risk-increasing drugs: a prospective cohort study. Br J Clin Pharmacol. 2007;63(2):232-7.

24. van der Velde N, van den Meiracker AH, Pols HA, Stricker BH, van der Cammen TJ. Wit-hdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J Am Geriatr Soc. 55. United States2007. p. 734-9.

25. Moya A, Sutton R, Am-mirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30(21):2631-71.

26. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:Cd007146.

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