Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
cane the dogs
- milind m deshpande (21 March 2004)
-
Climbing can help elderly in preventing fall
- Zhikun Zhang (22 March 2004)
-
Visual impairment can be a factor in falls
- Susan L Blakeney (22 March 2004)
-
A proper assessment of risks and benefits of stopping psychotopic medication if needed in individual cases
- Lathika P Weerasena (25 March 2004)
-
Vitamin D can help prevent falls in the elderly
- Peter J Lewis (25 March 2004)
-
Exercise Interventions in Frequent Fallers –evidence emerges faster than guidelines?
- Dawn A Skelton, Chris Todd, Susie Dinan, Steve Iliffe, Bob Laventure, and Tahir Masud (29 March 2004)
-
JAMA meta-analysis finds vitamin D supplements help prevent falls
- Peter J Lewis (4 May 2004)
-
Elderly fall in the hospital
- Angela I Castillo, Susan L Blakeney (2 February 2008)
|
|
|||
|
milind m deshpande, consultant orthosurgeon hubli,india,580031
Send response to journal:
|
sir, There is no doubt about the cane which helps prevent falls in the senior citizens but i would also add an interesting mechanism by which the cane works in india.Stray dogs often follow or run along the early morning brisk walkers,thus frightening them and invite falls among the elderly causing disastrous fractures.Hence many carry canes to cane the dogs rather than to support their gait. Competing interests: None declared |
|||
|
|
|||
|
Zhikun Zhang, Co-Director in CDC in Tangshan,PRC CDC in Tangshan,PRC,063000
Send response to journal:
|
Sir: Falls in the elderly in China is a very common complication in social life, considering the high prevalence of stroke in this country. To prevent this serious problem, social workers from general hospitals have done many work that has proved to be effective. One of the interventions is to organize the retired (aged from 50 or more) to participate in pastime activities, including climbing moderate steps in small hill; this activity really fullfilled their life and improved their health. Though it needs a more strict design to prove its effect, we cannot neglect its positive effects in a psychological and social sense. Zhikun Zhang Competing interests: None declared |
|||
|
|
|||
|
Susan L Blakeney, Optometric Adviser College of Optometrists, 42 Craven Street, London WC2N 5NG
Send response to journal:
|
We welcome the recognition that the causes of falls are often multifactorial and we would like to highlight the fact that vision can often be a contributing factor. The College of Optometrists and the British Geriatrics Society have jointly published a document highlighting the link between vision and falls. Two of the recommendations are that all people undergoing a falls assessment should be screened for visual impairment and those people found to have visual impairment should have a full eye examination by an optometrist. The document can be found at http://www.college-optometrists.org/professional/NSFfalls.pdf Competing interests: None declared |
|||
|
|
|||
|
Lathika P Weerasena, Associate Specialist in Old Age Psychiatry Queen Elizabeth Psychiatric Hospital, B15 2QZ
Send response to journal:
|
A proper assessment of risks and benefits of stopping psychotropic medication if needed in individual cases. We read with interest the recent editorial 1 in the BMJ, which addressed the issue of the prevention of falls amongst elderly people. We welcome the increased interest in this important public health issue but would like to comment on one intervention that the author highlighted. Mention is made of the finding in the Cochrane Review 2 of the efficacy of the gradual withdrawal of psychotropic medication. We are in no doubt that addressing this issue is important and that in many cases psychotropics are over-prescribed in elderly people, and reducing or stopping them can produce significant benefits. However recently we have come across patients of ours in whom psychotropic medication has been stopped because of concerns that these may contribute to the risk of falls. The cessation of medication has lead to a recurrence of the underlying problem for which the psychotropic was prescribed in the first place. This may of course be one reason that patients who reduce their psychotropic drugs return to their original pattern of drug taking. As in all clinical situations, heed must be taken of both the benefits and risks of any intervention and we would just remind all doctors of the need to take this into account when trying to stop psychotropic medication in the elderly. Dr Lathika Weerasena, Associate Specialist in Old Age Psychiatry, Queen Elizabeth Psychiatric Hospital Dr Gabra Hanna, Specialist Registrar in Old Age Psychiatry, Queen Elizabeth Psychiatric Hospital Dr Christopher Vassilas, Consultant in Old Age Psychiatry, Queen Elizabeth Psychiatric Hospital References 1 Gillespie L, Preventing falls in the elderly. BMJ 2004;328:653-654. 2 Gillespie L D, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst. Rev 2003; 4:CD000340 Competing interests: None declared |
|||
|
|
|||
|
Peter J Lewis, integrative physcician 15 South Steyne, Manly, NSW 2095, Australia
Send response to journal:
|
EDITOR - I was surprised that no mention of the role of vitamin D in preventing falls in elderly people was made in the editorial by Gillespie (1), or in the papers by Haines et al (2) and Chang et al (3). Vitamin D deficiency is a common and neglected problem, and the elderly are particularly at risk. Hypovitaminosis D is associated with muscle weakness (4) and increased body sway (5), and has been shown to be an independent predictor of incident falls (6). Several randomised clinical trials have shown a reduction in falls in elderly people with vitamin D supplementation. In one recently published study, a group of Swiss researchers reported that those subjects who received vitamin D (1 mcg of alfacalcidiol) who consumed more than 512 mg of calcium a day were 55% less likely to fall than those given a placebo (7). By comparison, participants in the targeted falls prevention programme described by Haines et al (2), experienced 30% fewer falls than those in the control group; Chang et al, in their review (3), found the most effective intervention to be a multifactorial falls assessment and management programme, which reduced the risk of falls by 18%. Annual measurement of serum 25-hydroxyvitamin D (25(OH)D) is a reasonable approach to monitoring for vitamin D deficiency (8). Although published lower reference values are generally in the range 40-50 nmol/L, Veith argues for a lower limit of 100 nmol/L (9) and there is certainly a well established body of evidence that suggests that a level of at least 80 nmol/L is required for optimal bone health and prevention of many chronic diseases. The [British] National Diet & Nutrition Survey (10) found that the mean 25(OH)D level for men was 48.3 nmol/L and for women 49.6 nmol/L; 57% of men and 54% of women had a 25(OH)D level of less than 50 nmol/L; 91% of men and 88% of women had 25(OH)D levels less than 80 nmol/L; 98% of men and 97% of women had 25(OH)D levels less than 100 nmol/L. This suggests that the majority of British adults have suboptimal 25OHD levels. To ensure that 25(OH)D levels exceed 100 nmol/L, a total vitamin D supply of 4,000 IU (100 mcg) of is required (9). Although vitamin D is potentially toxic, published cases of vitamin D toxicity with hypercalcaemia all involve intake of >/= 40,000 IU (1,000 mcg)/day (9). Whilst additional research may be needed, vitamin D supplementation is a simple, safe and inexpensive intervention that may help prevent falls in elderly persons, which deserves much more emphasis. Indeed, a BMJ editorial in 1998 concluded that the evidence for routine vitamin D supplementation in the elderly is compelling (12). Dr Peter J Lewis, integrative physician 15 South Steyne, Manly, NSW 2095, Australia drlewis@yourhealth.com.au Competing interests: None. 1. Gillespie L. Preventing falls in the elderly. BMJ 2004;328:653-4. 2. Haines PT, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomized controlled trial. BMJ 2004;328:676-9. 3. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ et al. Interventions for the prevention of fall in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004;328:680-3. 4. Vitamin D deficiency, muscle function, and falls in elderly people. Janssen HC, Samson MM, Verhaar HJ. Am J Clin Nutr 2002;76(6):1454- 5. 5. Pfeifer M et al. Vitamin D status, trunk muscle strength, body sway, falls, and fractures among 237 postmenopausal women with osteoporosis. Exp Clin Endocrinol Diabetes 2001;109(2):87-92. 6. Flicker F et al. Serum vitamin D and falls in older women in residential care in Australia. J Am Ger Soc 2003;51(11):1533-1538. 7. Dukas L et al. Alfacalcidiol reduces the number of fallers in a community-dwelling elderly population with a minimum calcium intake of more than 500 mg daily. J Am Ger Soc 2004; 52(2):230-236. 8. Holick MF. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr 2004;79:362-371. 9. Veith R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr 1999;69:482-56. 10. Rushton D, Hoare J, Henderson L, Gregory J.The National Diet & Nutrition Survey: adults aged 19 to 64 years. Volume 4: Nutritional status (anthropometry and blood analytes), blood pressure and physical activity The Stationary Office, London, 2004. 11. Heaney RP. Lessons for nutritional science from vitamin D. Am J Clin Nutr 1999;69:825-6. 12. Compston JE. Vitamin D deficiency: time for action. BMJ 1998:317:1466-7. Competing interests: None declared |
|||
|
|
|||
|
Dawn A Skelton, Co-ordinator of Prevention of Falls Network Europe University of Manchester, M13 9PL, Chris Todd, Susie Dinan, Steve Iliffe, Bob Laventure, and Tahir Masud
Send response to journal:
|
There remains considerable debate about the type of exercise interventions which are effective amongst people at high risk of falls, as the editorial (BMJ Vol 328) by Gillespie suggests. Recent guidelines (1, 2) highlight exercise interventions to improve balance and strength as part of a multi-factorial intervention, but argue that there is no strong evidence to support group exercise-only interventions in community dwelling people at high risk of falls. The recently published draft of the NICE guidelines (2) rightly concludes that there is little evidence of the effectiveness of untargeted exercise interventions, whilst noting the trial by Day et al. (3). Day et al’s randomized factorial trial showed that group based exercise was the most potent single intervention, but that falls were further reduced with the addition of home hazard management or reduced vision management. However, the emerging evidence from more recent trials in community dwelling over 70s selected as via a standardized risk assessment (4) and frailer older adults in sheltered housing (5) is more encouraging. The review by Chang et al (6), included one of these trials (3) and showed multi-factorial intervention trials to be the most effective at reducing risk of falls (pooled Relative Risk (RR) 0.82) but that exercise only programmes also show benefit (pooled RR 0.86). This, read with the editorial, presents a mixed message to implementers. Barnett et al’s (4) RCT of 163 community dwelling people aged over 65 years identified as at risk of falling using a standardized assessment screen by their general practitioner or hospital-based physiotherapist showed that within the 12-month trial period, the rate of falls in the intervention group was 40% lower than that of the control group (IRR=0.60, 95% CI 0.36–0.99). In Lord et al’s trial (5), 551 people aged 62 to 95 living in self- and intermediate-care retirement villages (where the risk of falls is greater than those living in the community) were cluster randomised into a weight-bearing group exercise (GE), a control arm attending flexibility and relaxation classes or no group activity. After adjusting for age and sex, there were 22% fewer falls during the trial in the GE group than in the control groups and 31% fewer falls in the 173 subjects who had fallen in the past year. In Skelton et al’s RCT (7), community dwelling frequent fallers (who had fallen at least 3 times in the previous year), undertaking group balance and strength exercises (supplemented by home based exercises) for 9 months, had half the risk of falls (RR 0.53) compared to the control group after the intervention. It seems that the "mix" of type of activities, intensity, duration and frequency of the balance and strength exercises is very important, as is the expertise and qualifications of the instructor to provide the most effective way to improve balance and allow the older person the ability to correct a trip and reduce their chances of an injurious fall. Clearly, the issue to be addressed is how to put the evidence into practice, but there are specific recommendations available for policy makers and clinicians (8). The emerging evidence suggests that both individualized targeted intervention as well as specific balance and muscle strengthening group exercise programmes, with additional home based exercise, are likely to reduce falls risk in older community dwelling people, both with and without a history of falls. In falls prevention the evidence base is changing faster than guideline developers can assess it, with the risk that any guidelines may rapidly become obsolescent. References: (1) American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guidelines for the prevention of falls in older persons. J Am Geriatr Soc 2001; 49; 664 -672. (2) NICE Guidelines on Falls Prevention – www.nice.org.uk (3) Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. Brit Med J 2002; 325: 128-132 (4) Barnett A, Smith B, Lord S, Williams, M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomized controlled trial. Age and Ageing 2003; 32: 407-414 (5) Lord SR, Castell S, Corcoran J, Dayhew J, Matters B, Shan A, Williams P. The effect of group exercise on physical functioning and falls in frail older people living in retirement villages: a randomized, controlled trial. J Am Geriatr Soc. 2003;51:1685-92 (6) Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Brit Med J 2004; 328: 680-7. (7) Skelton DA. Balance Exercise in Falls Prevention – FaME into Practice. A report to the Exploratory Workshop on Interventions for Falls Prevention, Brussels, European Commission, 2001. (8)World Health Organisation Health Evidence Network. Skelton D, Todd C. What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? How should interventions to prevent falls be implemented? . http://www.euro.who.int/eprise/main/WHO/Progs/HEN/Syntheses/20030820_1 Dr Dawn Skelton - Coordinator of ProFaNE – Prevention of Falls Network Europe, School of Nursing, Midwifery and Health Visiting, University of Manchester, UK. Professor Chris Todd- Director of ProFaNE – School of Nursing, Midwifery and Health Visiting, University of Manchester, UK. Susie Dinan – Royal Free and University College Medical School and Royal Free Hospital NHS Trust, London, UK. Dr Steve Iliffe – Centre for Ageing Population Studies, Royal Free and University College Medical School, London, UK. Bob Laventure – British Heart Foundation National Centre for Physical Activity and Health, Loughborough University, UK. Dr Tahir Masud - Consultant Physician, Nottingham City Hospital NHS Trust, Nottingham, UK and Secretary of IS-PAPOFF (International Society of Physical Activity for the Prevention of Osteoporosis, Falls and Fractures). Competing interests: None declared |
|||
|
|
|||
|
Peter J Lewis, integrative physician 15 South Steyne, Manly, NSW 2095, Australia
Send response to journal:
|
EDITOR - Further to my rapid response of 25 March 2004, a meta- analysis (based on 5 double-blind randomised, controlled trials) published in the April 28 2004 Journal of the American Medical Association found that taking vitamin D supplements reduces the risk of falls in elderly people by 22% (1). The authors conclude that 'given the...high morbidity, mortality, and economic cost of falls, our results are sufficiently compelling to consider vitamin D supplementation for elderly individuals'. Dr Peter J Lewis, integrative physician, 15 South Steyne, Manly, NSW 2095, Australia 1.Bischoff-Ferrari HA et al. Effect of Vitamin D on Falls: A Meta- analysis. JAMA 2004;291:1999-2006. Competing interests: None declared |
|||
|
|
|||
|
Angela I Castillo, PGY1 North Central Bronx Hospital. Bronx. NY. 10467, Susan L Blakeney
Send response to journal:
|
Is it necesary to preform a complete skeletal survey in an elderly who fell in the hospital ?
Competing interests: None declared |
|||