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Introduction
Accidents represent the fifth cause of death in the general population, 66% is due to falls, of this total, 75% occur in patients over 65 years; with an incidence of 0.2-1.6 falls/person per year, with an approximate average of 0.7 falls/year. Having as main consequences fractures, immobility, pressure ulcers and even death. There is a causal relationship between the number of falls and increased mortality in the elderly1,2. The falls syndrome is defined as precipitation at a lower level, suddenly, involuntarily and unexpectedly with or without secondary injuries confirmed by the patient or a witness3,4. This condition is recognized worldwide as one of the main health problems in the elderly, because it has great consequences since it increases morbidity in the elderly and causes disability and death5. The study of the elderly with falls syndrome identifies extrinsic factors (environmental) and intrinsic factors (patient) such as alterations in balance and gait, immobility, cognitive impairment, visual and auditory alterations, musculoskeletal, polypharmacy, endocrine, neurological, gastrointestinal, genitourinary and cardiovascular pathology6,7. Cardiovascular pathology involves a large number of diseases that can increase the risk of falls and are highly prevalent in the elderly, such as arrhythmias (atrial fibrillation, AF), postural hypotensive syncope (PHS), thyroid disorders, dyslipidemia, previous acute myocardial infarction (AMI), history of stroke, systemic arterial hypertension (SAH), heart failure (HF), Diabetes Mellitus 2 (DM2) and the treatment of cardiovascular diseases; which lead to an increase in the risk of falls. The elderly who have at least 4 of these risk factors have a 60% greater risk of falling than the general population8.
In recent years, frailty has shown the impact it has on the cardiovascular health of the elderly, increasing the risk of adverse cardiovascular outcomes, as well as being related to the decrease in gait velocity, sarcopenia, and dynapenia9. Frailty is currently considered a cardiovascular disease by different cardiology societies worldwide10. Few studies have attempted to clarify the role of cardiovascular diseases as a risk for falls in the elderly, some have shown that the presence of a heart murmur has an OR with falls of 1.39, Syncope with 1.71, arrhythmia 1.30; Cardiovascular multimorbidity is a risk factor for the elderly to fall, estimating an OR of 2.07 (95 CI 1.18 - 3.64, p <0.05)11. It has been found an important association with falls related to HF and AF, postulating that the mechanism by which falls occur is due to a phenomenon of low cerebral perfusion, leading to chronic brain injury at the sites associated with stability and gait by neurodegeneration, besides of having a clear association between stroke and cognitive impairment12. Regarding the presence of AF and falls, a positive association has been demonstrated, with a prevalence of between 15% and 46%13. There is very little evidence regarding the impact of interventions in cardiovascular pathologies to reduce the number of falls in the elderly, a Cochrane review aimed at assessing the reduction of falls in those subjects with PHS undergoing bicameral pacemaker implantation showed that does not reduce the risk of falls14.
Material and methods
Population
We studied ambulatory patients from the Geriatrics Service of the ISSSTE León Regional Hospital, Guanajuato, Mexico, between March 2018 until June 2019, the protocol was authorized by the hospitals local ethics committee. Patients with a diagnosis of falls syndrome were taken into account (precipitation at a lower level of shape sudden, involuntary and unsuspected, with or without injuries)15 and a comprehensive geriatric assessment was performed, identifying those patients with cardiovascular diseases that included DM2, SAH, PHS, Hypothyroidism, history of AMI, Dyslipidemia, AF and HF previous stroke and frailty, the diagnosis of the diseases was made through direct interrogation, clinical history, FRAIL fragility criteria were taken into account16 (self-report of fatigue, able to climb 1 floor of stairs, walk 1 block, more than 5 diseases, weight loss greater than 5% in the last 6 months); those who had more than 3 items were considered fragile and those that did not have any criteria were considered robust. Inclusion, exclusion and elimination criteria are shown in supplementary data.
Statements of Ethics
The study was approved by the local ethics committee of the institute (ISSSTE). The approval number in the national platform is 716.2018 the study is based on the Declaration of Helsinki´s declaration (Fortaleza version, 2013).
The researcher explained, in a coloquial language, all the risks and benefits to the patients who decided to participate in the study. Likewise, the different procedures performed in the project were discussed. The study is regulated by the Nuremberg Code and the participants voluntarily signed an informed consent letter after they received the explanation and prior to the inclusion of the study; the signature was obtained by any of the investigators participating in this research. The aim of this study is to obtain useful results that can benefit society, by proposing an effective and cheap strategy to reduce the incidence of falls in the geriatric population.
Statistic analysis
The study was a descriptive, analytical and cross-sectional study. Two groups were considered, patients who fell and those who did not fall. For the descriptive analysis, measures of central tendency (mean, mode and median) were used. For the inferential analysis, the variables (DM2, SAH, PHS, Hypothyroidism, history of AMI, Dyslipidemia, AF, HF, previous Stroke and Frailty) were dichotomized into qualitative variables and considered as affirmative or negative. In the case of frailty, we considered the fragile patients as well as the robust ones. Chi-Square X2 test or Fishers exact test was used for the association analysis and prediction analysis was also performed using linear regression. For statistical significance, a value of p <0.05 was used. Statistical analysis was performed using SPSS software (SPSS version 23, IBM, Inc. Chicago, IL, USA).
Results
Demographic characteristics
A total of 669 patients were included, the average age of the patients who fell was 81 (+6.9) years, in the group of non-falls 80 (+7.3) years, total women 440 (219 vs 221), men 229 (119 vs 110) (Table 1).
Table 1 Demographic and Cardiovascular Diseases
| Characteristics (N) | Falls (n = 338) | No Falls (n = 331) | Total (n = 669) | p Value* |
|---|---|---|---|---|
| Age, (±) | 81( ± 6.9) | 80 (± 7.3) | 81 (± 7.1) | £ 0.05 |
| Gender | ||||
| Female, N (%) | 219 (65) | 221 (67) | 440 (66%) | 1.23 |
| Male, N (%) | 119 (35) | 110 (33) | 229 (34%) | 1.55 |
| Cardiovascular Diseases | ||||
| Frailty, N (%) | ||||
| Fragile | 313 (92) | 280 (84) | 593 (88) | 0.05 |
| Robust | 25 (8) | 51(16) | 76 (12) | 0.05 |
| DM2, N (%) | 136 (40) | 132 (40) | 268 (40) | 0.98 |
| SAH, N (%) | 245 (72) | 242 (73) | 487 (73) | 0.85 |
| Stroke, N(%) | 52 (16) | 63 (19) | 115 (17) | 0.26 |
| AMI, N (%) | 53 (16) | 50 (15) | 103 (15) | 0.34 |
| AF, N (%) | 26 (8) | 18 (5) | 44 (7) | 0.24 |
| Dyslipidemia, N (%) | 19 (6) | 199 (60) | 218 (33) | 0.01 |
| PHS, N (%) | 53 (16) | 47 (14) | 100 (15) | 0.28 |
| Hipothyroidism, N (%) | 49 (15) | 66 (20) | 115 (17.1) | <0.05 |
| HF, N (%) | 55 (16) | 55 (17) | 110 (16) | 0.76 |
DM2: Type 2 Diabetes Mellitus; AH:arterial hypertension; AMI: acute myocardial infarction; AF: atrial fibrillation; HF: heart failure; PHS: postural hypotension syncope.
*p Value ≤ 0.05.
Frequency of cardiovascular diseases
From the total of 669 participants, 593 were considered Fragile patients (88.4%) (219 falls vs 221 No falls), 76 patients were considered Robust (11.6%) (25 vs 51), 268 patients had DM2, (39.9%) (136 vs 132), 487 patients had SAH (72.6%) (245 vs 242), those with a history of Stroke were 115 patients (17.1%) (52 vs 63), AMI, 103 patients (15.4 %) (53 vs. 50), AF 44 patients (6.6%) (26 vs. 18), Dyslipidemia 54 patients (8%) (19 vs. 199), PHS 100 patients (14.9%) (53 vs. 47), Hypothyroidism 115 patients (17.1 %) (49 vs 66) and 110 HF patients (16.4%) (55 vs 55).
The results are shown in Table 1.
Association analysis
When performing the association, frailty had statistical significance with an increased risk for an OR of 1.65 (95% IC, 1.37-3.77), (p = 0.01), HF (p = 0.05) OR 1.02, (95% IC, 0.68 - 1.54), Dyslipidemia (p = 0.01) OR 0.46, (95% IC 0.28 0.90), SAH (p 0.85), T2DM (p = 0.98), AMI (p = 0.34), Stroke (p = 0.26), FA (p = 0.24), Hypothyroidism (p = 0.62), SC (p = 0.28), (Table 2) (Figure 1).
Table 2 Association between cardiovascular diseases and falls
| Variable | Falls | Odds Ratio (IC 95%) | P* | |
|---|---|---|---|---|
| Falls | No | |||
| Frailty | 313 | 280 | 1.65 (1.37 - 3.77) | 0.01 |
| SAH | 245 | 242 | 0.96 (0.68 - 1.32) | 0.85 |
| DM2 | 135 | 132 | 0.99 (0.73 - 1.36) | 0.98 |
| AMI | 53 | 50 | 1.04 (0.68 - 1.58) | 0.34 |
| Stroke | 52 | 62 | 0.79 (0.52 - 1.18) | 0.26 |
| AF | 26 | 18 | 1.44 (0.77 - 2.68) | 0.24 |
| Hipothyroidism | 49 | 66 | 0.68 (0.45 - 1.02) | 0.62 |
| Dyslipidemia | 19 | 199 | 0.46 (0.28 0.90) | 0.01 |
| PHS | 53 | 47 | 1.12 (0.73 1.72) | 0.28 |
| HF | 55 | 55 | 1.02 (0.68 1.54) | 0.05 |
DM2: Type 2 Diabetes Mellitus; AH:arterial hypertension; AMI: acute myocardial infarction; AF: atrial fibrillation; HF: heart failure; PHS: postural hypotension syncope; NS: non significance.
*Chi-Square Test.
Binary logistic regression analysis
When performing the logistic regression analysis by entering the variables (Fragility, AH, DM2, AMI, Stroke, AF, Hypothyroidism, Dyslipidemia and HF), it shows a probability of falling of 57% (Table 3).
Table 3 Linear Regression Model. Showing that cardiovascular diseases increases the risk of falls by up to 57%
| Variable | B | Standar Error | Wald | p* | Exp (B) | 95% IC para Exp (B) | |
|---|---|---|---|---|---|---|---|
| Inferior | Superior | ||||||
| Frailty | .92 | .27 | 11.44 | <.05 | 2.50 | 1.47 | 3.77 |
| DM2 | -.09 | .17 | .28 | .59 | .91 | .64 | 1.27 |
| SAH | -.08 | .19 | .18 | .66 | .92 | .63 | 1.32 |
| AMI | .11 | .23 | .21 | .64 | 1.11 | .70 | 1.77 |
| Stroke | -.32 | .21 | 2.34 | .12 | .72 | .47 | 1.09 |
| AF | .44 | .33 | 1.72 | .19 | 1.55 | .80 | 3.01 |
| Hypothiroidism | -.34 | .22 | 2.51 | .11 | .70 | .45 | 1.08 |
| Dyslipidemia | -.71 | .30 | 5.28 | <.05 | .49 | .26 | .89 |
| HF | .05 | .23 | .05 | .81 | 1.05 | .67 | 1.54 |
| PHS | .114 | .23 | .26 | .60 | 1.12 | .72 | 1.73 |
| Constant | .749 | 1.2 | .38 | .57 | 2.11 | ||
*p value < 0.05.
The risk of falls by up to 57%.
DM2: Type 2 Diabetes Mellitus; AH:arterial hypertension; AMI: acute myocardial infarction; AF: atrial fibrillation; HF: heart failure; PHS: postural hypotension syncope; NS: non significance.
Discussion
Our results show that cardiovascular diseases, when individually analyzed, are not associated with falls in the elderly, except for frailty; however, falls and cardiovascular pathology in the geriatric population are highly prevalent. Individually, they cause high morbidity and mortality in the geriatric population, so seeking an association between them, taking into account that cardiovascular diseases could be associated with a greater risk of falls is interesting and important. Our study aimed to find an association between falls and major cardiovascular diseases, in order to guide a policy of improvement in prevention, care and rehabilitation and, at the same time, reduce the risk of falling; In our analysis, we found that several of the variables did not obtain the expected statistical significance value (SAH, T2DM, PHS, AF, Hypothyroidism, Dyslipidemia, HF); however, the presence of fragility grants a risk of falling of 1.65 times more compared to the non-fragile patient. This is interesting, since the frailty model analyzed and considered as a cardiovascular risk factor (due to the intense inflammatory load and its association with endothelial damage and dysfunction) is overwhelming. The presence of frailty has been observed in 20% of patients over 65 years of age undergoing cardiac catheterization and in 27% of those over 70, increasing mortality by myocardial infarction up to five times17. According to projections, in 2040, the number of vascular surgeries in patients 65-84 years will increase by 101% due to the presence of frailty18. Frailty indicators are associated with increased risk of falls, but not blood pressure and / or anti hypertensive treatment19.
There is important evidence from multiple and large observational studies that indicate that the presence of cardiovascular disease is a risk factor for frailty and that fragile patients are likely to develop cardiovascular disease to a greater extent than non-fragile ones; this observation is not surprising because inflammation, insulin resistance and coagulation disorders have been identified as cardinal factors in the pathophysiology of frailty20,21,22. Thus, cardiovascular diseases and frailty can be seen as diseases that arise from similar mechanisms, both accelerate their clinical course by vicious cycles that amplify inflammation, insulin resistance and other mechanisms that are not well known but contribute synergistically into the causation of major disease23,24.
Accordingly, regardless of age and other risk factors, the presence of frailty in patients with cardiovascular disease burden, double the risk of death25. Some studies have shown that there is a relationship between the fragile phenotype and the risk of falling, and they have also found that the fragile patient is at greater risk of falling than the robust one26. Even more than those prefragile27. Falls in the elderly are at risk of complications such as fractures, hospitalization and death28. Beyond this, there are studies in the elderly Mexican-American population that have shown that fragility increases the OR of falls by up to 3.2. This elderly population show a high prevalence of fragility and share many characteristics with our study population29. Diagnosis of HF in our study also showed to be associated with falls, and this association possibly relates to what has been commented on fragility but at the present time it is not entirely clear if the fragility itself can contribute to the organic dysfunction and have a causal relationship with HF30. Some studies such as the Health, Aging and Body Composition Study found that in the elderly dwelling community, the presence of fragility increased the risk for incidence HF31. More than half of the patients admitted to the hospital with the diagnosis of HF are fragile32. Frailty and heart failure share inflammation as a factor associated with the development of the disease33.
Despite the poor prognosis of frailty and concomitant HF, it is important to comment that fragility can be reversed, or at least decreased, in subjects with HF; most of the time, treating HF decreases frailty34. There is increasing evidence that the implantation of cardiac resynchronizers in elderly patients over 80 years improves their quality of life and a 6-minute walk test, a finding that emphasizes that age by itself, is an inadequate prognostic tool35,36,37.
Another important aspect in the assessment of falls in elderly patients with high cardiovascular morbidity is the fact that, as a complementary part of the treatment, they need anticoagulation (AF, HF, AMI). This is a topic of debate in fragile patients with high risk of falls; therefore, the identification and treatment of the different pathologies would improve the prognosis of the patients and could yield identification of candidates for the use of anticoagulation38,39,40. As part of the statistical analysis, we carried out a logistic regression analysis, to characterize the risk profile of falls; this prediction model shows us that the elderly with cardiovascular pathology has a 57% risk of falls.
Another interesting finding in the study is that the presence of cholesterol above the cutoff value of 200 mg/dL, the upper limit of reference range in our study, shows a protective factor of 54% and this is coincident with the results reported in the Honolulu Heart Study and others, where low cholesterol values have shown a higher risk of morbidity and mortality in the elderly patients, compared to those who maintained normal to high cholesterol levels, taking into account that our patients also had a higher burden of disease41,42,43.
Among the limitations of our study, all the patients included were ambulatory and we didn´t take into account patients in the emergency department or those hospitalized; another limitation is that the study only included patients of the Geriatrics service who are, by definition, patients with high risk of falls as well as with high comorbidity and multimorbidity, which makes them more susceptible to fall. We believe that a study that includes in the analysis patients who arrive at the emergency services as well as those hospitalized with the presence of cardiovascular disease and falls could provide more data and identify potential associations with other cardiovascular diseases. The presence of cardiovascular morbidity is highly prevalent in geriatric patients, and it is necessary to emphasize the importance of considering fragility as a risk factor for falls in the elderly patients; and that interventions aimed at reducing the risk to fall will have a positive impact on the quality of life of geriatric patients.
