- Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Harwood RH et al. 2004. Paper read at the BGS autumn meeting, Harrogate.
Summary: First eye cataract surgery reduces the number of recurrent falls and associated fractures and improves visual function and general health status.
Editor's comment: This is encouraging. Although vision assessment and referral is successful in reducing falls when part of a multifactorial intervention, up until now there has been no evidence that correcting vision as a single intervention can reduce fall rates.
- The effect of balance training on postural stability in Parkinson's disease: a pilot study. Whitney JC et al. 2004. Poster presentation at the BGS autumn meeting Harrogate.
Summary : 12 patients (mean age 69) with PD were randomised to either balance training or seated exercises. After 10 weeks the balance training group compared with controls showed significant reductions in the number of steps taken to turn 180 degrees and postural sway (eyes closed on foam).
Editor's comment: After a few years of the illness falls become a major problem for people with PD and have a significant impact on quality of life. Strength and balance exercises are known to improve balance and reduce falls in older people but this is the first study to demonstrate improved balance in people with PD.
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Benign paroxysmal positional vertigo - a curable cause of dizziness. Lawson J et al. 2004. Poster presentation at the BGS autumn meeting Harrogate.
Summary: 31 patients with BPPV were initially referred to a falls and syncope service (FSS) compared with 28 referred to the ENT department. The FSS patients were older ( mean age 69 v 55), the dizzy symptoms had been present longer (mean 19 months v 11) and 16% (v 0%) had more than one type of dizziness. FSS patients were more likely to have cerebro or cardiovascular co-morbidity (13% v 4%) and were taking more medications (3.2 v 1.7). 83% of the FSS patients were cured with intervention compared to 86% if referred to ENT.
Editor's comment: In older people dizziness is more likely to be multifactorial. BPPV is an important remedial cause (it has a prevalence of 9% in the older population) and should be routinely looked for using the Hallpike test.
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Osteoporosis: change in recommended treatment.
Data from the WHI trial suggests that the risks of HRT outweigh the benefits and HRT is no longer recommended for long term use in the prevention of osteoporosis. It does however remain an option for women with osteoporosis who have troublesome menopausal symptoms.
In summary the trial showed:
- 1/3 reduction in hip fracture
- 24% reduction in total fracture
- 37% reduction in colorectal cancer
- 26% increase in breast cancer
- 22% increase in total cardiovascular disease
- 41% increase in strokes
- x2 increased risk of venous thromboembolism.
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Writing Group for the Women's Health Initiative Investigators 2002. Risks and Benefits of estrogen plus progestin in healthy postmenopausal women:principal results from the Women's Health Initiative randomised controlled trial. JAMA 288(3); 321-33
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Atypical antipsychotic medications and risk of falls in residents of aged care facilities. Hien le T.T. et al. 2005 J Am Geriatr Soc; 53: 1290-5
Summary This was a prospective cohort study in Sydney with 1-month follow-up and accidental falls as the outcome. 55% of subjects used at least one type of psychotropic and 14% used an antipsychotic. 11% of subjects had at least one fall during follow up. After adjustment the hazard ratios for falls were 1.35 (95% CI=0.87-2.09) for typical antipsychotics, 1.32 (95% CI=0.57-3.06) for risperidone and 1.74 (95% CI= 1.04-2.90) for olanzapine. Antidepressants were also associated with falls with a hazard ratio of 1.45 (95% CI=1.09-1.93).
Editor’s comment Although the atypicals have fewer extrapyramidal side effects they are not associated with fewer falls than the older antipsychotics. The widespread use of antipsychotic drugs to control behaviour disturbances in residents who do not have schizophrenia (about 80% of nursing home antipsychotic prescriptions) is a continuing concern. There is other evidence from Sydney that between 1998 and 2003 antipsychotic medication use in nursing homes has not declined but there has been a major switch to atypicals. Use of anxiolytics and hypnotics has declined but more residents are taking antidepressants.
- A randomized controlled trial of tai chi for the prevention of falls: the central Sydney tai chi trial. Voukelatos A. et al. 2007 J Am Geriatr Soc; 55: 1185-91
Summary This was a 16 week study on 702 relatively healthy community-living people of weekly tai chi classes with a waiting list control group. Falls were less frequent in the tai chi group. The hazard ratio after 16 weeks was 0.72 (95% CI=0.51-1.01, P=.06) and after 24 weeks it was 0.67 (95% CI=0.49-0.93, P=.02).
Editor’s comment Enthusiasm for tai chi has waxed and waned since the original study in Atlanta by Wolf but the evidence that it reduces falls in community-dwelling older adults is now fairly convincing: whether with a weekly session, as with this trial, or with a three-times-per-week, 6-month programme (Li F. 2005). In frailer subjects tai chi can reduce fear of falling (Sattin R. 2005) and there is evidence from other trials that it can improve mental well-being in older people, although probably not more than other exercise programmes. Much depends on whether participants find the tai chi sessions enjoyable and will therefore attend regularly and the skill and experience of the teacher who can pace the class appropriately for the frailer members.
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UK hip fracture audit.
Summary Six standards have been proposed in a best practice guideline TheBlue Book on the Care o fPatients with Fragility Fractures, published in September 2007 by the British Orthopaedic Association and the British Geriatrics Society.
One of the standards is that all patients presenting with a fragility fracture are assessed for antiresorptive treatment to prevent future osteoporotic fractures. The report points out that there are 75,000 hip fractures annually in the UK and that between a half and two-thirds of these patients have had a previous fracture .The opportunity to prevent hip fractures is being missed. Less than 5% of women with a fracture have a DXA scan and less than 10% are given drugs to reduce their risk of further fractures. The Blue Book is available at http://www.boa.ac.uk/site/showpublications.aspx?ID=59
Editor’s comment This is an audit that all Falls teams should be involved in. The main point is that one fracture predicts another. This is particularly true in men. Men with a fragility fracture following a fall are 3.5 (RR 3.47, 95% CI=2.68-4.48) times more likely to suffer another than men who have never had a fracture. The relative risk of a second fracture for women is 1.97 (95% CI=1.70-2.25). The absolute risk of subsequent fracture is similar for men and women and persists for up to 10 years (Center J. 2007).
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Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Tang B.M. et al. 2007 Lancet; 370: 632-4.
Summary This was a meta-analysis of all RCTs in which calcium or calcium in combination with vitamin D were used to prevent fracture and osteoporotic bone loss. 29 RCTs (n=63,897) were identified. Where fracture was the outcome treatment was associated with a 12% risk reduction in fractures of all types. Where bone mineral density was the outcome treatment was associated with a reduced rate of bone loss at the hip of 0.54% and 1.19% in the spine. High compliance rates produced significantly greater reduction in fracture risk and treatment effect was greater with doses of at least 1200 mg calcium and 800iu of vitamin D.
Editor’s comment The risk reduction and the conclusions are similar to the 2005 Cochrane review. The evidence of benefit of combined calcium and vitamin D (evidence for Vitamin D on its own is still unclear although in this study there was a significant difference between the effects of different vitamin D doses) for older people living in institutions is now pretty strong, provided that compliance is good and the doses are adequate. For fitter, older people living in their own homes the benefit is less certain.
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Vascular events in healthy older women receiving calcium supplementation: randomized controlled trial. Bolland M.J. et al. 2008 BMJ 336; 262-6
Summary This was a secondary analysis focusing on adverse events in a RCT looking at the effect of calcium supplements on myocardial infarct, stroke and sudden death in healthy menopausal women. MI was more commonly reported in the calcium group, as was the composite end point of MI, stroke or sudden death. The paper was accompanied by a ‘What this study adds’ comment that: Healthy older women randomized to calcium supplementation showed increased rates of myocardial infarction. This effect could outweigh any benefits on bone from calcium supplementation.
Editor’s comment The paper has been extensively criticized on the grounds that the primary end point was not clear, there were differences between the groups in the number of smokers and previous vascular events and confounding factors such as NSAID and analgesic use were not controlled for. Furthermore the statement that calcium supplementation increased the rate of MI was incorrect and based on non- significant findings. Most patients at risk of fractures are given calcium and vitamin D supplements, not calcium alone, so this practice should not change on the basis of this paper.
- What do patients think of Falls Clinics? RCP falls patient survey 2008
A Royal College of Physicians survey of patients who had attended a falls clinic found that they were not always sure of the purpose of the clinic and how it related to them. As a result many patients did not continue with their exercises. Psychologists have noted that calling it a “falls clinic” is negative and off -putting ('falls happen to old people, not me!') and suggest that it would be better to stress the positive aspects of improving balance and independence. Letters of invitation asking patients to attend falls clinics/services should reflect GPs' support and include details explaining why the invitation has been sent and describe what benefits patients may get from attending the service. Clinics should individualise rehabilitation programmes and focus on the patient's goal.
- Effectiveness of falls clinics: an evaluation of outcomes and client adherence to recommended interventions. Hill KD et al. 2008 JAGS 56:600-8.
Summary This study was carried out in 13 outpatient falls clinics in Australia. The patients were high risk with 78% having fallen in the previous six months. An average of 7.6 risk factors/patient were identified. 61% of patients returned for a six month assessment and at this time there was a 50% reduction in falls rate, multiple falls and fall injuries. The average adherence to the clinic’s recommendations was 74%.
Editor’s comments This is an impressive ‘real world’ result and highlights the multi-factorial nature of falls and the importance of good clinic organisation in ensuring adherence to the management programme. Very different from the recent report from the National Institute for Health Research (UK) which threw doubt on the effectiveness of falls clinics finding that they only reduced recurrent falls by 10%. The report found a lack of consistency between clinics and variations in organisation, staff skill mix and patient management. Staff in these clinics need to look critically at what they are doing and ensure that they are closely following NICE guidelines.
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Interventions for preventing falls in older people living in the community. Gillespie LD et al. 2009 Cochrane Database Syst Rev Apr 15:(2) CD0007146
Summary This is a review of 111 trials and confirmed that group and individual exercise programmes are effective. Assessment and multi-factorial interventions reduce the rate but not the risk of falling. Overall vitamin D does not reduce falls but may do so in people with lower vitamin D levels. Overall home safety interventions do not reduce falls but are effective in patients with severe visual impairment and in others at high risk. Anti-slip shoes reduce falls in icy conditions. Gradual withdrawal of psychomotor drugs reduces the rate but not the risk of falling. Pacemakers reduce the rate of falls in patients with carotid sinus hypersensitivity. First cataract surgery reduces the rate of falls.
Editor’s comments An invaluable guide to evidence based practice. There are no surprises but it does show that interventions need to targeted thoughtfully at high risk patients.
