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Prevention of falls or supervised care in institutionalized elderly?
- Ángel J. Romero Cabrera, Carlos Hernández, Marisela L. Pérez (16 January 2007)
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Clinical medication review preventing falls in care homes
- Arnold G Zermansky, David P Alldred, Duncan R Petty, David K Raynor, Nick Freemantle, Peter Bowie. (17 January 2007)
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Poor positon sense in elderly people
- GEORGE Y CALDWELL (19 March 2007)
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Falls bed height
- Peter J Honey (12 March 2008)
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Ángel J. Romero Cabrera, MD, Assistance Profesor Gustavo Aldereguía Hospital, Cienfuegos, Cuba. PC: 55100, Carlos Hernández, Marisela L. Pérez
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Dear Sir: We have perused the systematic review by Oliver et al (1) in BMJ, and we expect the same results as published. It´s clear that hospitalized elderly and in care homes are different to those in a community setting, where studies have shown the beneficial impact of interventions to prevent falls (2, 3). Some communitary programs report a 30 - 39 % reduction in falls with measures including pharmacological treatment check, postural hypotension control, hearing and vissual loss correction, environmental risk prevention, exercise promotion, foot problems care and calcium rich diet. But another thing happens with the institutionalized elderly because they are, generally, oldest, suffer more chronic diseases, have higher prevalence of frailty and incapacity, higher frequency of geriatric syndromes as inmobility, incontinence, depression, cognitive impairment and polypharmacy, and we can hope that the results from interventions in them have poorer outcomes. We studied falls in 185 older adults residents in an elderly home in Cienfuegos, Cuba, during a year. The annual incidence rate was 55,6 %, the greater number of falls episodies was presented between 3:00 and 11:00 p.m. that includes bath and dinner time. Falls predominated in women and in the 75 - 79 age group. Medical and neurological causes were the main, specially dementia, malnutrition, gait dosorders and hearing and visual loss. Psichopharms were the drugs consumed more commonly by the falling patients. The incidence of fractures and post - fall syndrome was 20,4 % and 29 %,respectively.(Hernández C, Romero AJ. Falls in institutionalized elderly. Causes and consecuences. Cienfuegos, 1997. Unpublished Thesis). Thus, we believe that in the institutionalized elderly the way to become effective falls prevention is supervised care more than other measures like hip protectors or exercise programs. I agree with the editorial writers (4) that careful assessment by doctors of every cases to identify risk factors from falls, avoiding pharmacological iatrogenia, an excellent nursing and caregivers assistance, and a safe institutional environment for elderly must have possitive influence in this important problem, but we can not forget that the main part is leading by the patient functional impairment. Sincerely, Dr. Ángel J. Romero Cabrera References: 1. Oliver D, Connelly JB, Victor CR, Shaw FE, Whithead A, Genc Y, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analysis. BMJ 2007; 334:82-87. 2.Tinetti ME. Prevention falls in elderly persons. N Engl J Med 2003; 348:42-49. 3. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomized clinical trials. BMJ 2004; 328: 680-683. 4. Cameron ID, Kurrle S. Preventing falls in elderly people living in hospitals and care homes. Inconclusive evidence means uncertainly remains. BMJ 2007; 334:53-54. Competing interests: None declared |
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Arnold G Zermansky, Hon Senior Research Fellow Pharmacy Practice and Medicines Management Group, Healthcare Studies, University of Leeds LS2 9JT, David P Alldred, Duncan R Petty, David K Raynor, Nick Freemantle, Peter Bowie.
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The date of submission of any literature survey inevitably excludes studies reported after that date. The summated time lags of both the surveyor (from submission to publication) and reported work (from completion of project to publication) mean that, through no fault of their authors, surveys are considerably out of date long before they are published. We are therefore not critical of Oliver et al in their reporting the lack of evidence for medication review preventing falls (1). They could not have done otherwise. It is, however, important for your readers to know that there is now evidence from our clinical trial that clinical medication review by a pharmacist of care home residents and their treatment is associated with a substantial and statistically significant (p<0.0001) reduction in the number of falls from 1.3 to 0.8 falls per patient in 6 months (secondary outcome) (2). Since very little else has been shown to reduce the high incidence of falls in care home residents, this evidence is of particular value. Our intervention also led to an increase in the number of drug changes per subject (2.4 versus 3.1, P<0.0001), but no difference in the number of GP consultations, cognitive state, activities of daily living or the number or cost of prescribed drugs. The reduction in hospitalisations did not reach statistical significance. REFERENCES 1. Oliver D, Connelly JB, Victor CR, Shaw FE, Whitehead A, Genc Y, et al. Strategies to prevent falls and fractures in in hospitals and care homes and effect of cognitive impairment: systematic review and meta- analysis. BMJ 2007;334:82-85. 2. Zermansky AG, Alldred DP, Petty DR, Raynor DK, Freemantle N, Eastaugh J, et al. Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial Age and Ageing 2006;35(586-591). Competing interests: None declared |
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GEORGE Y CALDWELL, GENERAL PRACTITIONER 31 BALMORAL PARK, #18-33, SINGAPORE 259858
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Position sense is disturbed in elderly people as a result of altered sensation in their peripheral nervous system. Also there may be a deficiency in their 8th Nerve response. This may be as a result of the many medications being given so there would be a malabsorption of certain Vitamins of the B Group. One is aware that anti-convulsants for instance inhibit the absorption of both Calcium and Vitamin B.12. Demyelination of the nerve fibres is usually the outcome. Hence a disordered sense of balance due to a peripheral neuro-patholgy. A review should be made of the many different and competing medications given to older patients and why. Then the administration of Vitamins of the B. Group, particularly B.12, should be given by adequate intramuscular injection, daily then weekly. Folic Acid daily by mouth as an adjunct. Since there is already a malabsorption from the gut then the intramuscular injections are essential. Competing interests: None declared |
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Peter J Honey, Architect Weybridge KT13 8NZ
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Bed height is important in falls from bed. The current standard gives 480 mm as the bed height from floor to top of firm mattress, according to BS8300. Hospital beds are generally higher than this. Naturally, when a patient falls out of bed it may have adverse consequences. For some patients, including those who are stressed & forgetful, they get out of bed on the side to which they are accustomed. If this has rails they try to climb over. They then find the bed height surprisingly different, and a long fall onto hard surface. The Specification and use of beds may benefit from change to allow adequate range of low bed heights for clinical care. Competing interests: None declared |
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