- Email: [email protected]
Prevention of falls in elderly people
Prevention of falls in elderly people Sir—Jacqueline Close and co-workers (Jan 9, p 93)1 show that an interdisciplinary approach to elderly patients with falls effectively decreased the number of further falls and limited functional impairment. The intervention included appropriate modification of drug therapy, through direct contact with the general practitioner. Of 110 individuals in whom a primary attributable cause was identified, drugs were found to have resulted in the fall in two patients. However, the researchers provide no information about the basis, nature, and success of the intervention. Cumming2 has shown specific classes of drugs, such as psychotropic and antihypertensive agents, are a preventable factor that contribute to the risk of falls. In a randomised casecontrol study—the Geriatric Rehabilitation And Pharmacotherapeutic Intervention Trial (GRAPHIT)—we investigated the long-term adherence to an intervention performed by a panel of two experienced clinical pharmacologists and one senior physician of internal medicine. Patients with falls admitted for treatment of hip fracture were included consecutively and we recorded demographic, medical, and medication data. During the patients’ hospital stay, the intervention was done randomly and the requirement of hypnotics/ sedatives, such as long-acting benzodiazepines, antihypertensive agents, or both was reassessed. Inappropriate or unnecessary drugs were discontinued, the drug dosage readjusted, and in patients with insomnia preference was given to nondrug therapy. At discharge, patients and their practitioners were informed about the background of the changes in drug therapy. 6 months later at a follow-up visit in patients’ homes, we assessed the acceptance of the intervention by the patient and the practitioner. Drug-induced orthostatic hypotension was diagnosed by repeated measurements of blood pressure in the sitting posture and an additional 24 h blood pressure monitoring. We defined the upper cut-off for hypotension as 120 mm Hg for systolic and 70 mm Hg for diastolic blood pressure.3 149 patients (120 women, mean age 79·5 [SD 10·6] years) were included in our study, of whom 67 were randomly allocated to the intervention group. Surprisingly, only in nine patients (age 83·0 [9·2] years) a drug intervention was needed. In none of these cases did
928
the patients’ physician comply with our therapeutic recommendations, although they were adequately informed. Withdrawal (n=2) and switch (n=2) from long-acting benzodiazepines were not followed, in four patients changes in antihypertensives were neglected and in one patient the stopped neuroleptic was reinstituted.* There was no difference in compliance between patients who lived in the community or in nursing homes. Cognitive impairment was an unlikely explanation for the non-compliance because the mean of Folstein’s minimental state examination score (total range from 0 to 30) was 24·0 (3·3). We conclude that general practitioners are frequently unaware that drugs, such as long-acting benzodiazepine, increase the risk of falls among elderly patients. Close and colleagues do not mention an outcome of their pharmacotherapeutic intervention. In a randomised clinical trial in the longterm care setting, Rubenstein and colleagues4 found that suggestions for drug modification decreased the risk of falls in 33 of 76 participants. They also reported a fairly high rate of compliance (67%) by the physicians with recommendations by the research team for medication changes. Postgraduate medical education in clinical geriatrics is needed. Prevention programmes to decrease the injurious falls among elderly people are not sufficient. Butler and colleagues’ study 5 to improve general practitioners’ management of depression in the elderly indicates that teaching programmes (postgraduate training course) can significantly improve knowledge on therapeutic management with psychoactive drugs. This work has been supported by the Robert Bosch Foundation, Stuttgart, Germany. The study protocol was approved by the local ethics committee. *Full details are available from the authors, on request.
*Matthias Schwab, Frank Röder, Klaus Mörike, Klaus-Peter Thon, Ulrich Klotz *Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, D-70376 Stuttgart, Germany; and Departments of Geriatric Rehabilitation and General, Abdominal and Traumatic Surgery, Robert Bosch Hospital, Stuttgart 1
2
3
Close J, Elis M, Hooper R, et al. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999; 353: 93–97. Cumming RG. Epidemiology of medicationrelated falls and fractures in the elderly. Drug Aging 1998; 12: 43–53. Passare G, Guo Z, Winblad B, Fastbom J. Drug use and low blood pressure in the elderly. A study of data from Kungsholmen project. Clin Drug Invest 1998; 15: 497–506.
4
Rubenstein LZ, Robbins AS, Josephson KR, et al. The value of assessing falls in an elderly population. A randomised clinical trial. Ann Intern Med 1990; 113: 308–16. 5 Butler R, Collins E, Katona C, Orrell M. Does a teaching programme improve general practitioners’ management of depression in the elderly? J Affect Disord 1997; 46: 303–08.
Sir—The report by Jacqueline Close and colleagues1 prompts me to describe our “pilot” falls clinic. In 1994–95, we ran a falls clinic staffed by a physician, nurse, occupational therapist, and physiotherapist. We offered an appointment within 2 weeks to patients older than 75 years who presented with a fall but did not require admission. The patients underwent a full assessment with the occupational therapist with respect to the activities of daily living, social situation, and community support. The physiotherapist focused on musculoskeletal and neurological assessment, the physician took a detailed history of the fall, noted the medication taken, and examined the patient. Investigations included full blood count, 24 h electrocardiography, tests of autonomic function, and blood pressure monitoring. Further assessment or treatment could be arranged from the clinic. After 12 months, of 140 patients offered an appointment, 70 attended the clinic. In 50% of patients, no cause of the fall was found, 35% required further input from occupational therapist or physiotherapist, and 15% were further investigated. Of the 13 patients who reattended accident and emergency, only one had attended the clinic. The response to this clinic from general practitioners and social services was favourable and it was expected that more patients would be seen if referrals were accepted from a wider source. A meta-analysis indicated that only multiple risk intervention reduced the number of falls in the elderly.2 Despite this evidence base, we were unable to obtain funding to continue the clinic or to undertake a local randomised controlled trial. However, our health authority was prepared to fund, at a cost of £55 000 per year, an exercise programme for about 20 unselected, elderly people in a local general practice, with a view to prevent falls in the community. We hope the PROFET trial1 will provide the “evidence base” necessary to warrant the £25 000 per year we requested to support our clinic. Susan Ell Care of the Elderly Department, The Queen Elizabeth Hospital, King’s Lynn & Wysbech Hospitals National Health Service Trust, King’s Lynn, Norfolk PE30 4ET, UK
THE LANCET • Vol 353 • March 13, 1999
928
the patients’ physician comply with our therapeutic recommendations, although they were adequately informed. Withdrawal (n=2) and switch (n=2) from long-acting benzodiazepines were not followed, in four patients changes in antihypertensives were neglected and in one patient the stopped neuroleptic was reinstituted.* There was no difference in compliance between patients who lived in the community or in nursing homes. Cognitive impairment was an unlikely explanation for the non-compliance because the mean of Folstein’s minimental state examination score (total range from 0 to 30) was 24·0 (3·3). We conclude that general practitioners are frequently unaware that drugs, such as long-acting benzodiazepine, increase the risk of falls among elderly patients. Close and colleagues do not mention an outcome of their pharmacotherapeutic intervention. In a randomised clinical trial in the longterm care setting, Rubenstein and colleagues4 found that suggestions for drug modification decreased the risk of falls in 33 of 76 participants. They also reported a fairly high rate of compliance (67%) by the physicians with recommendations by the research team for medication changes. Postgraduate medical education in clinical geriatrics is needed. Prevention programmes to decrease the injurious falls among elderly people are not sufficient. Butler and colleagues’ study 5 to improve general practitioners’ management of depression in the elderly indicates that teaching programmes (postgraduate training course) can significantly improve knowledge on therapeutic management with psychoactive drugs. This work has been supported by the Robert Bosch Foundation, Stuttgart, Germany. The study protocol was approved by the local ethics committee. *Full details are available from the authors, on request.
*Matthias Schwab, Frank Röder, Klaus Mörike, Klaus-Peter Thon, Ulrich Klotz *Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology, D-70376 Stuttgart, Germany; and Departments of Geriatric Rehabilitation and General, Abdominal and Traumatic Surgery, Robert Bosch Hospital, Stuttgart 1
2
3
Close J, Elis M, Hooper R, et al. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet 1999; 353: 93–97. Cumming RG. Epidemiology of medicationrelated falls and fractures in the elderly. Drug Aging 1998; 12: 43–53. Passare G, Guo Z, Winblad B, Fastbom J. Drug use and low blood pressure in the elderly. A study of data from Kungsholmen project. Clin Drug Invest 1998; 15: 497–506.
4
Rubenstein LZ, Robbins AS, Josephson KR, et al. The value of assessing falls in an elderly population. A randomised clinical trial. Ann Intern Med 1990; 113: 308–16. 5 Butler R, Collins E, Katona C, Orrell M. Does a teaching programme improve general practitioners’ management of depression in the elderly? J Affect Disord 1997; 46: 303–08.
Sir—The report by Jacqueline Close and colleagues1 prompts me to describe our “pilot” falls clinic. In 1994–95, we ran a falls clinic staffed by a physician, nurse, occupational therapist, and physiotherapist. We offered an appointment within 2 weeks to patients older than 75 years who presented with a fall but did not require admission. The patients underwent a full assessment with the occupational therapist with respect to the activities of daily living, social situation, and community support. The physiotherapist focused on musculoskeletal and neurological assessment, the physician took a detailed history of the fall, noted the medication taken, and examined the patient. Investigations included full blood count, 24 h electrocardiography, tests of autonomic function, and blood pressure monitoring. Further assessment or treatment could be arranged from the clinic. After 12 months, of 140 patients offered an appointment, 70 attended the clinic. In 50% of patients, no cause of the fall was found, 35% required further input from occupational therapist or physiotherapist, and 15% were further investigated. Of the 13 patients who reattended accident and emergency, only one had attended the clinic. The response to this clinic from general practitioners and social services was favourable and it was expected that more patients would be seen if referrals were accepted from a wider source. A meta-analysis indicated that only multiple risk intervention reduced the number of falls in the elderly.2 Despite this evidence base, we were unable to obtain funding to continue the clinic or to undertake a local randomised controlled trial. However, our health authority was prepared to fund, at a cost of £55 000 per year, an exercise programme for about 20 unselected, elderly people in a local general practice, with a view to prevent falls in the community. We hope the PROFET trial1 will provide the “evidence base” necessary to warrant the £25 000 per year we requested to support our clinic. Susan Ell Care of the Elderly Department, The Queen Elizabeth Hospital, King’s Lynn & Wysbech Hospitals National Health Service Trust, King’s Lynn, Norfolk PE30 4ET, UK
THE LANCET • Vol 353 • March 13, 1999