Falls and fall related injury in older people with chronic liver disease

Abstract

Introduction Alongside an ageing population with an increasing prevalence of chronic liver disease (CLD) is an improved survival rate for younger people with CLD who are surviving into older age. Older people often have different, more complex health service needs for which geriatric services exist. However, the rapidly expanding older CLD population may have specific needs or outgrow specialty specific services. Falls are more common with increasing age in the general population and represent a substantial burden for individuals, families, society and the economy. People with CLD have multiple theoretical risk factors for falling, generating the hypothesis that falls and fall related injury will be common in older people with CLD. However, in order for services to adapt to the changing demographic evidence is required; firstly for an evidence-based management approach for falls intervention and prevention studies and secondly to support setting up of services. Methods In Phase 1, self-complete data collection tools were mailed to existing, comprehensive databases of extant cases with primary biliary cirrhosis (PBC), primary sclerosing cholangitis and post-liver transplant (post-LT). The same tools were completed by patients with non-alcoholic fatty liver disease and alcoholic liver disease in the clinic. The tools provided data to define falls and fall related injury prevalence in an older (>65 years) and a younger CLD cohort. An existing database of older, healthy community-dwelling adults was used as a control group. In Phase 2, multidisciplinary falls assessments were performed in a group of people with CLD to explore possible modifiable fall associations in order to inform future intervention/prevention studies. Finally, potential barriers to multifactorial intervention were explored. Results Falls are common in older people with CLD with almost 50% having had a fall in the previous year, significantly more so than age- and sex- matched community controls. Falling was unrelated to liver disease but was independently associated with orthostatic dizziness, lower limb strength and fear of falling. Falls were most common in older people with PBC (58%) and least common in ALD (18%). Fall prevalence post-LT is similar to other CLDs and significantly greater than in community controls; it is associated with orthostatic dizziness and the nadir blood pressure on standing up. Transplantation appears to have no effect on falling. Several barriers to intervention exist, confidence to exercise, understanding the benefits of physical activity, fatigue and FOF which was independently associated with levels of physical activity. Conclusion As falls are very common in older people with CLD and represent a substantial problem on an individual and societal level, current services will need to adapt. Several fall associations have been identified, each of which is modifiable and provides evidence for future intervention studies and services. In the general population orthostatic dizziness is amenable to conservative measures and lower limb strength and fear of falling can be improved through physiotherapy. If future studies revealed these to be effective intervention methods a multidisciplinary team consisting of a physician, nurse and physiotherapist would be required.