I've Fallen and I Can't Get Up
This phrase, popularized in a television commercial and made part of our lexicon by glib pundits, belies a horrifying problem in our geriatric community. Falls in the elderly are no joking matter since they frequently result in serious and potentially life-threatening or life-altering injuries. When taking a history in fall victims, clinicians are careful to discern whether or not there was loss of consciousness before the fall since this is assumed to be the sine qua non of the diagnosis of conduction disease. In this issue of The American Journal of Geriatric Cardiology, Seifer and Kenny challenge this concept by hypothesizing that falls occur in some of our elderly patients because of conduction system disease even without a cohesive history of loss of consciousness. They examined this problem by performing a retrospective, case-control study, and found a higher number of falls in patients who had received a cardiac pacemaker compared with an age- and gender- (but not cardiac disease) matched population. Because of a small sample size, the difference in the number of falls did not reach statistical significance. There was a high interpatient variability in the number of falls, and the interviews were not blinded. We also do not know if pacemaker insertion impacted fall incidence; interviews were carried out only a month postimplant.
As the authors correctly point out, the study's methodology is far from optimal. In addition to the design issues, we do not have electrocardiographic (ECG) recordings at the time of the events. As noted in the article, our ability to monitor patients has been improved substantially with the advent of implantable loop recorders. New systems will permit continuous and supervised ambulatory ECG recordings for periods of days or weeks. This capability would have a major advantage in the present context since a recorded cardiac event or patient-activated emergency signal would allow a trained technician to summon help if necessary.
If Seifer and Kenny are correct, clinicians will need to reorient their approach to elderly fallers. In obtaining a history, interviewers will have to remain open to the possibility that a "fall" may be caused by a malignant bradycardia complicated by poor memory or confusion about the initiating factors. A much more detailed arrhythmia assessment, including extended ECG monitoring or even invasive electrophysiologic testing, might be indicated especially if there is evidence on the ECG of conduction system disease. Given the health care implications, and the need to prevent dangerous and recurrent falls in our elderly patients, properly designed, prospective trials are critically needed.
This phrase, popularized in a television commercial and made part of our lexicon by glib pundits, belies a horrifying problem in our geriatric community. Falls in the elderly are no joking matter since they frequently result in serious and potentially life-threatening or life-altering injuries. When taking a history in fall victims, clinicians are careful to discern whether or not there was loss of consciousness before the fall since this is assumed to be the sine qua non of the diagnosis of conduction disease. In this issue of The American Journal of Geriatric Cardiology, Seifer and Kenny challenge this concept by hypothesizing that falls occur in some of our elderly patients because of conduction system disease even without a cohesive history of loss of consciousness. They examined this problem by performing a retrospective, case-control study, and found a higher number of falls in patients who had received a cardiac pacemaker compared with an age- and gender- (but not cardiac disease) matched population. Because of a small sample size, the difference in the number of falls did not reach statistical significance. There was a high interpatient variability in the number of falls, and the interviews were not blinded. We also do not know if pacemaker insertion impacted fall incidence; interviews were carried out only a month postimplant.
As the authors correctly point out, the study's methodology is far from optimal. In addition to the design issues, we do not have electrocardiographic (ECG) recordings at the time of the events. As noted in the article, our ability to monitor patients has been improved substantially with the advent of implantable loop recorders. New systems will permit continuous and supervised ambulatory ECG recordings for periods of days or weeks. This capability would have a major advantage in the present context since a recorded cardiac event or patient-activated emergency signal would allow a trained technician to summon help if necessary.
If Seifer and Kenny are correct, clinicians will need to reorient their approach to elderly fallers. In obtaining a history, interviewers will have to remain open to the possibility that a "fall" may be caused by a malignant bradycardia complicated by poor memory or confusion about the initiating factors. A much more detailed arrhythmia assessment, including extended ECG monitoring or even invasive electrophysiologic testing, might be indicated especially if there is evidence on the ECG of conduction system disease. Given the health care implications, and the need to prevent dangerous and recurrent falls in our elderly patients, properly designed, prospective trials are critically needed.
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