Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Long live Medispeak!
- Alan N Conner (10 January 2003)
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Fracture risk against fall risk
- Matthew Thomas, Longfleet Road, Poole BH15 2JB (17 January 2003)
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Two too different calls for falls
- Giovanni Gambassi, Giovanni Gambassi, Claudio Pedone, Graziano Onder, Roberto Bernabei (25 January 2003)
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Preventing Falls in Cognitively Impaired Older People
- Rebecca S Walton, Phil Mackie, and Peter Donnelly. (25 February 2003)
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Alan N Conner, retired orthopaedic surgeon Royal Hospital for Sick Children, Glasgow. G3 8SJ
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Sir I assume that the paper "Mutifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randamised controlled trial" was about the prevention of falls in the elderly. You are encouraging bold, concise letters. I would make a similar plea for bold and concise titles to published articles. Competing interests: None declared |
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Matthew Thomas, Consultant Physician Poole Hospital NHS Trust,, Longfleet Road, Poole BH15 2JB
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Editor Shaw et al (1) question whether resources should be targeted at the cognitively normal in order to reduce falls in the elderly. The adjacent paper by Meyer et al (2) points out that hip protectors have good compliance and may help prevent fractures in Nursing Home residents (the majority of Shaw’s study group). The attention to fracture risk and not just fall risk is vital in demented patients in residential care (fracture neck of femur mortality at 1yr is twice that of the cognitively normal patient (3) with figures of 70% at1 yr quoted (4)). I suggest that resources should continue to be directed at all elderly patients be directed but it should be targeted at fracture risk and not just fall risk. 1. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial Fiona E Shaw, John Bond, David A Richardson, Pamela Dawson, I Nicholas Steen, Ian G McKeith, and Rose Anne Kenny BMJ 2003; 326: 73. 2. Effect on hip fractures of increased use of hip protectors in nursing homes: cluster randomised controlled trial Gabriele Meyer, Andrea Warnke, R Bender, and I Mühlhauser BMJ 2003; 326: 76. 3. Outcome after hemi-arthroplasty for displaced intracapsular femoral neck fracture related to mental state. Injury. 2000 Jun;31(5):327-31. 4. Effect of mental state on mortality after hemiarthroplasty for fracture of the femoral neck. A retrospective study of 543 patients. Eur J Surg. 1994 Apr;160(4):203-8. Competing interests: None declared |
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Giovanni Gambassi, Associate Professor of Medicine Università Cattolica, 00168 Rome, Italy, Giovanni Gambassi, Claudio Pedone, Graziano Onder, Roberto Bernabei
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The issue over intervening to reduce the risk of falling in older people with cognitive impairment is now even. In the present article including 90% of people with a definitive diagnosis of dementia and an average MMSE score of 13(range 6-18)the multifactorial intervention failed to modify the primary outcome and any of the prespecified secondary outcomes.(1) However, a recent article by Jensen et al.(2)came to different conclusions. In a population of older individuals (mean age 84 years)living in residential care facilities in Sweden, with an average MMSE score of 18 (range 0-30), an interdisciplinary and multifactorial prevention program targeting residents, staff, and the environment greatly (over 50%) reduced falls and fractures. Strikingly, this study showed a prolonged and even increasing efficacy of the intervention during follow- up that the authors ascribe to the development of a positive process among those involved. Additional studies are warranted to shed more light on this issue. In fact, despite some differences between the two studies are grossly evident, they might not account for by the opposite results. Could it just be a matter of how severe is the cognitive impairment? 1. Shaw FE, et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ 2003;326:73 2. Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in residential care facilities. A cluster randomized trial. Ann Intern Med 2002;136:733-41 Competing interests: None declared |
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Rebecca S Walton, Specialist Registrar in Public Health Lothian NHS Board, Deaconess House, 148 Pleasance, Edinburgh. EH8 9RS, Phil Mackie, and Peter Donnelly.
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EDITOR, In their paper examining the effectiveness of multifactorial intervention to prevent falls in older people with cognitive impairment Shaw et al have identified an important research question that they investigated in a well-conducted study. However, we remain concerned about the validity of their conclusions. The size of effect that the authors require in order to demonstrate improvement is in our opinion, unreasonably high. The authors cited two papers that were used in their power calculation, both of which demonstrated a 30% reduction in the proportion of patients who fell. However the populations studied were fundamentally different from those included in Shaw’s analysis because they specifically excluded patients with cognitive impairment. Intuitively one might expect this type of multifactorial intervention to be less effective for people with cognitive impairment. We suggest that although the study did not detect a difference between the intervention group and the controls, a far larger study would be required to detect a smaller but still important improvement in primary outcome. We therefore took the opportunity to recalculate the sample size required to demonstrate effectiveness. We estimate that 780 subjects would need to be included in order that there is sufficient power to demonstrate whether the intervention results in at least a 10% reduction in the proportion of people falling. Similarly 240 subjects would be required to be able to demonstrate a 20% reduction. In Shaw’s paper, unlike other studies, the patients in the control and intervention groups lived in the same care homes. The authors recognise that contamination may have occurred between the two arms of the study and have demonstrated relatively low levels of adherence with intervention in the control group. Perhaps the use of a cluster randomisation approach with the care home as the unit of analysis could have been used in order to reduce the potential impact of bias and contamination. We applaud the attempt to raise the issue of falls prevention in older people with cognitive impairment and value the finding that this intervention may be less effective than for those who are not cognitively impaired. However, we are concerned that the ‘take home message’ of the study could be misinterpreted. The study does not have adequate power to conclude that there is no benefit of multifactorial intervention in this population. Rather, further research is required to determine the level of benefit and economic implications of multifactorial interventions to prevent falls in older people with cognitive impairment. Competing interests: None declared |
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