Q&A for Falls and Syncope Session, BGS Autumn Meeting 2020

Dr Oly Todd is a registrar at Bradford Teaching Hospitals NHS Foundation Trust. He is currently undertaking a PhD research study at the University of Leeds, funded for by the Dunhill Medical Trust investigating the association of blood pressure in older people with frailty. He spoke at the BGS Autumn Meeting 2020, this conference is now available on-demand here.  

The falls and syncope session at the BGS Autumn Meeting 2020 was a quick-fire session looking at some of the key issues arising in the management of patients who fall: management of hypertension & orthostatic hypotension, carotid sinus syndrome, rehabilitation, fear of falling and lastly a debate regarding the target blood pressures that we should aim for in our older adults.

We had some fascinating questions in the chat box which we want to share with you as they provide great learning for us all.

Panel:

• Lara Mitchell (Chair, Glasgow)
• Oly Todd (Bradford)
• James Frith (Newcastle)
• John Davidson (Newcastle)
• Edward Alcorn (Manchester)
• Helena Dolphin (Dublin)
• Nigel Beckett (London)

Talk 1: Can frailty help inform the balance of benefit and harm from antihypertensive treatment in older adults -  Oly Todd

Alice Ong: The classical conundrum of hypertension with orthostatic hypotension, in particular supine hypertension with systolic of 190 and standing BP of 160....

Wilson Lim: How do you balance your treatment in patients with severe supine hypertension who still have significant symptomatic orthostatic hypotension?

John Davison: Thanks Alice. My practice with this group is to individualise the approach based on their symptoms. If symptomatic and experiencing falls and thus impacting on quality of life, I err towards running higher supine BP after a shared decision-making process with the patient and ensuring all other secondary prevention therapies are in place.

James Frith: Hi Alice. First principle is shared decision making. A 24 hour BP is useful to gauge how severe the supine hypertension is. Non-drug therapies are useful here. They work and are safe, but avoid bolus water drinking before bedtime. Another trick would be to have a carbohydrate snack before bedtime for a 'therapeutic post-prandial hypotension'. Don't use fludrocortisone as it is long acting. I prefer pyridostigmine and midodrine in this situation. Also, some positive impacts of desmopressin if there is significant nocturia.

David McGhee: I imagine even more postural hypotension is being missed with the advent of telephone consultations during Covid-19.....

James Frith: Hi David, yes probably. I am currently doing a small study to see how safe and reliable it is for older people to measure their own postural BP at home.

Alice Ong:  It is actually surprising how many people have access to a BP monitor. I ask the next of kin to help them get a supine and standing 1min and 3min BP reading.

Katrina Davies: In general practice we are now measuring all patients with their own BP to reduce footfall. Technique is important. There needs to be adequate supine rest (5 to 6 minutes), the first standing BP should be measured ideally within 30-60 seconds (this time point has the greatest clinical relevance and can be achieved with standard monitors) and then again at minute 2 and minute 3, with the reporting of symptoms.

Lara Mitchell: These two blogs re: virtual assessments are really useful...

• Falling for virtual assessments: Advice and resources for virtual falls risk assessments - Part 1
• Falling for virtual assessments: Advice and resources for virtual falls risk assessments - Part 2

Katrina Davies: Quality Outcomes Framework dictates that GPs should try to get BP under 150/90 for over 80yr olds - it does not specify frailty level. Should this be challenged? - we know 160-170 systolic is a better target for patients at risk of falls.

Oly Todd: Hi Katrina - thanks for this great question. I did not find evidence in my work using Welsh data to support a change in current UK Guideline targets. Low BP was associated with higher falls in all frailty groups. These findings may relate to limitations of my methods. However other big data studies by Ravindrarajah et al (PMID 28432148) and Masoli et al (PMID 32133525), albeit in association with different outcomes, have also not clearly demonstrated a higher BP 'sweet point' with frailty. I think rather than look at the frailty index (which combines 36 risk factors), it may be better to look at what are the specific predictors of falling at low BP in people with treated hypertension, in routine data. Observational data will not give us a definite answer on this and a trial is necessary. One is underway in France in nursing home residents (RETREAT_FRAIL).

Alice Ong: Katrina, I think the guidelines do say target the standing BP and I tend to adjust depending on symptoms of orthostatic hypotension. I find it a bit tricky when they are not that frail with lots of cardiovascular risk and actually complain of headaches with higher BPs, but yet have orthostatic hypotension which is symptomatic....

Oly Todd: Yes Alice – there are older people for whom the risk of falls is greater who may need a less interventionist approach – as mentioned above. However, for people at low risk of falls, and high cardiovascular risk, there may be evidence that BP-lowering treatment can reduce orthostatic hypotension, (PMID 32909814) but it comes with several caveats – orthostatic hypotension was not measured in the first minute, postural BPs were measured in a sitting not supine position, and falls and syncope were not measured as outcomes.

Marc Osterdahl: Hi Oly, Thank you for a really interesting talk. From your qualitative work - did you look to see if there was a difference in the sharing of decision making between different frailty groups?

Oly Todd: Thanks Marc for this interesting question - I only involved people with moderate/severe frailty in my qualitative study. But I recently presented the qualitative findings to a Public and Patient involvement (PPI) panel which was made up of people of similar age to the interviewees. The panel by comparison was very robust and much more involved in their own hypertension management, and they were also from a different social class etc. It would be interesting to look and compare by frailty status, but overall the sense was that frailty did not categorise a group for whom a particular set of outcomes was more or less relevant - they were very heterogeneous – and what each person valued related more to their own individual circumstances than something that could be collectively defined as ‘a frailty core outcome set’.

Talk 2: Orthostatic hypotension: an update -  James Frith

Lisa Ramsawak: How much was the bolus, how many times was it given and over what period of time?

Connie Snape: James, and did you find older adults were able to drink that much? Our older adult inpatients would really struggle with that much fluid within 15 minutes

Samina Khwaja: Is there a particular time at which the bolus drinking should take place?

Wilson Lim: How do you go about advising on bolus water drinking to your patients with orthostatic hypotension?

James Frith: As always, there is a lot of interest in bolus water drinking. Most studies, including mine, which focused on older people with orthostatic hypotension, used 500 ml of room temperature tap water, consumed within 15 minutes. There are always concerns from clinicians and patients that they will not be able to do this. But our study showed that it was easier than anticipated and well-tolerated. I usually recommend people do this twice a day, on waking and before lunch to prevent post-prandial hypotension. The pressor effects last for around 90 minutes. I also use common sense; if someone is smaller, I recommend a smaller volume. See Acceptability of non-drug therapies in older people with orthostatic hypotension: a qualitative study and The efficacy of nonpharmacologic intervention for orthostatic hypotension associated with aging.

Punam Sinha: Atomoxetine - is it available on the NHS?

Rajesh Dwivedi: What about caution with use of Atomoxetine in people with known ischemic heart disease, etc?

James Frith: Punam, yes I have used it a couple of times. We use a much smaller dose for people with orthostatic hypotension than is used for attention deficit hyperactivity disorder (ADHD). As the evidence is limited and it is unlicensed for orthostatic hypotension, it should be used with caution, appropriate consent, and possibly limited to specialist centres.

James Frith: Rajesh, yes you definitely need caution in that situation, just as you would with midodrine.

Rajesh Dwivedi: I recently had a patient with severe orthostatic hypotension associated with supine HTN. Tried Midodrine cautiously during the day and used Losartan 25mg at night. Your thoughts?

James Frith: Rajesh, if all non-drug options had been exhausted that is what I would start with, without the evening midodrine dose if possible. I also prefer pyridostigmine (if tolerated) as there is no risk of increasing supine hypertension.

Rowlandson Pratt: Is Losartan the best medication for treating patients with systolic hypertension and orthostatic hypotension?

James Frith: Rowlandson, it is the best of a bad bunch. The evidence supporting it is very limited indeed, but it seems it might be better than glyceryl trinitrate, captopril and amlodipine. But non-drug therapies should be tried first.

Alice Ong: Yes James, I certainly find amlodipine too potent an antihypertensive....

James Frith: It also does not reduce nocturnal diuresis if given at night time. Losartan should be used at night time as it seems to reduce nocturnal diuresis (but only if absolutely necessary).

Alice Ong: Think there is scope for another trial...

Parul Shah: Where can I find guidance on using pyridostigmine for OH, how to start and what dose etc.?

James Frith: Parul, try the European Academy of Neurology. I start with 30mg twice daily. I rarely get it up to 60mg three times a day due to gastrointestinal side effects.

FURTHER RESOURCES

• Lara Mitchell: See this patient information leaflet for orthostatic hypotension.
• James Frith: See this patient education animation on orthostatic hypotension

Talk 3: Is carotid sinus massage (CSM) still relevant in unexplained falls?  - John Davison

Tahir Masud: Is the diagnosis of cardio-inhibitory carotid sinus syndrome (CSS) still an asystole of 3 seconds? There was talk it may be increased to 6 seconds?

James Frith: Hi Tash, yes you can diagnose it with 3 seconds of asystole, but only pace if it is longer than 6 seconds (current recommendation).

John Davison: Hi Tash. Currently cardio-inhibition is still defined as 3 seconds as this is the definition used in the intervention studies. However the consensus is shifting towards 6 seconds with reproduced syncope. In my experience, patients are not syncopal with a short cardio-inhibition of 3 seconds during carotid sinus massage . The positive carotid sinus massage with syncope invariably has > 6 seconds pause.

Atef Michael: Do you need cardiopulmonary resuscitation (CPR) equipment available before carotid sinus massage (CSM) ?

John Davison: Yes Atef. There is case report evidence of other arrhythmias being precipitated, notably ventricular tachycardia, whereby having CPR equipment is relevant. In our experience in Newcastle Falls and Syncope Service we have never needed it.

James Frith: Atef I believe I have come across a European document that recommends having access to resuscitation facilities in syncope clinics.

Mark Kasozimusoke: Brilliant exposition of evidence. For patients with a convincing history and no significant comorbidities, should we request a focused Echo in the Emergency Department/Acute Medical Unit then just do CSM in the department with the patient connected to monitoring? Maybe this could then be recorded and referred on rapidly?

James Frith: Mark, John will probably have a better answer than me. But you would need the equipment for beat-to-beat monitoring and a tilt-table as 30% of cases are only positive in the upright position. There is also some brand new Italian data suggesting that we should proceed to standard tilt-test straight after CSM if it is negative to save time and increase diagnostic yield. And don't forget you need appropriate consenting mechanisms in place.

John Davison: Mark, unless the electrocardiograph (ECG) is abnormal, or there is an abnormal cardiac examination, echocardiography rarely adds useful information in syncope evaluation, so I do not request this routinely. CSM in an Emergency department/Acute Medical Unit would allow you to determine cardio-inhibition but you will miss the third of patients with a cardioinhibitory response if you do not have access to beat-to-beat BP monitoring. I would generally recommend CSM is undertaken by someone who is familiar with the technique as inter-operator variability is high.

Mark Kasozimusoke: Thank you very much John. Our Physician friends put so many Echo requests in and I never understand why.

John Davison: Yes - that's my experience too, that Echo depts are overwhelmed with unnecessary requests. Its role as a test in syncope should be in the context of identified rhythm disturbance on ECG, history of ischaemic heart disease or ischaemic symptoms, signs or symptoms of heart failure, ECG or clinical evidence of left ventricular hypertrophy / cardiomyopathy, clinical evidence of valvular heart disease, specifically AoS.

James Frith: I suppose the old reg flag of Echo if syncope occurs during exercise. But in reality, it always turns out to be vasovagal syncope not outflow obstruction (should still do it though).

TALK 4: Patient Outcomes From a General Inpatient Rehabilitation Ward. Does Frailty or Reason For Admission Make a Difference to Patient Outcome? Edward Alcorn

Connie Snape: What outcome measures were used for mobility?

Edward Alcorn: Mainly based on what mobility aids they needed/ assistance needed.

Connie Snape: How many rehabilitation sessions were provided? Was this across a 7 day period? And were the amount of sessions provided the same for all 4 groups? Did you look at the refusal to engage in rehab?

Edward Alcorn: Aimed for 2 sessions a day, 5 days a week, same for all 4 groups.

Connie Snape: Not a standardised outcome measure? I just wonder about the subjective effect on this?

Edward Alcorn: Given it was a retrospective study we can use the information which had already been recorded in the medical and therapy notes. I agree that if doing the study prospectively it would be beneficial to use more objective outcome measures.

Connie Snape: Thanks - and did you capture how often the patient engaged in these sessions? I just wonder if one of those groups engaged a little more in rehab than others?

Edward Alcorn: Think that’s a good point about patient engagement, not something I have data on from this study.

Matthew Bailey: Interesting rehab talk... I’m finding that resources for physio input on rehab wards are becoming increasingly limited. 1 physio plus 1 physio assistant are often only offered per ward of 30 patients. This gives an average of 3-4 x 15 min physio treatments/week...is this what others are experiencing?

David McGhee: Yes. We lack all members of the multi-disciplinary team (MDT).

Claire O'Connell: I think it will vary across the country. I previously worked in a community rehab unit, 1-2 physios for 30 patients + 4 patients in a separate location. Most patients would not have 3-4 physio-led sessions per week due to increased amount of involvement in d/c planning etc.

Matthew Bailey: Thanks all for replies...I’m thinking we need a different approach to rehab and I am thinking quality improvement project (QIP) in this zone as I’m experiencing a lack of return to baseline/quick turnarounds with reliance on delayed community rehab...maybe fighting against a struggling increasingly frail population. But I can’t help thinking that poor rehab outcomes may also be due to resources and overall lack of rehab input.

Claire O'Connell: I think the key is patients should start rehab on admission to hospital, not when they are medically optimised and then referred for a rehabilitation bed. Need to focus on increasing activity levels within the hospital setting to avoid risks of deconditioning/ becoming institutionalized. Hard to rehabilitate patients who have had everything done for them in an acute setting.

Connie Snape: Agreed - I also think we are missing a trick with rehabilitating these patients in the 'pre-frail' stage.

Matthew Bailey: Agree with what you say...physiotherapy/ occupational therapy rehab is happening from day 1. We triage patients to rehab wards on day 2 if the rapid response team feels they need inpatient rehab over community referral to reduce ward moves. It's then on inpatient rehab ward that resources I think limit progress. If we can’t improve this then maybe the only other solution is working harder on "prefrail" as some else also mentioned.

TALK 5: Fear of Falling in Community Dwelling Ambulatory Older Patients: Associations with Physiological Falls Risk, Cognition and Mood Disorders - Helena Dolphin, Tallaght hospital

Anil Kumar: What are your views on hip protectors for fallers?

Helena Dolphin: Hi Anil, thank you for this question. As the Cochrane review from 2014 suggests, they probably do work but older people don't like wearing them so acceptance is low. Also slightly higher risk of pelvic fractures, reducing hip fractures. I do not tend to prescribe them.

Jen Smith: For the fear of falling study - is there any action you can take to help this group overcome their fear? Can they go through an exercise programme for example?

Helena Dolphin: Excellent question, thank you. Fear of falling seems to be a multifactorial problem. A Cochrane review again from 2014 found that exercise programmes such as balance training, strength and resistance or Tai Chi work to reduce fear of falling just for the duration of the time of the exercise programme and don’t seem to hold out longer than that, and also unfortunately don't actually reduce falls. There's a suggestion that it could actually be a presentation of Generalised Anxiety Disorder (GAD) in older adults as there is a cohort of older people very fearful of falling who have not actually fallen. No evidence that I know of though of an anti-anxiety, e.g. mindfulness or cognitive behavioural therapy (CBT)-based intervention, being efficacious.