Letters

Guidelines for prevention of falls in people aged over 65

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7285.554 (Published 03 March 2001) Cite this as: BMJ 2001;322:554

Guidelines should state that assessment of vision is important

  1. R R Seemongal-Dass (robindass{at}hotmail.com), specialist registrar,
  2. T E James, consultant,
  3. C E Atherley, specialist registrar
  1. Department of Ophthalmology, St James's University Hospital, Leeds LS9 7TF
  2. Procter and Gamble Pharmaceuticals, Staines, Middlesex TW18 3AZ
  3. Aventis Pharmaceuticals, West Malling, Kent ME19 4AH

    EDITOR—A fall in an older person can have severe personal as well as healthcare implications. Feder et al have given important guidelines for the prevention of falls in people aged over 65.1 Their aim was to translate trial evidence into recommendations to reduce the rate of falls in people aged over 65.

    The methods used to gather information did not seem to include any references to the patients' visual function. There have been several reports linking poor visual function with an increased risk of falls or fractures related to falls.2-4 A recent study by Ivers et al shows that decreased visual function is a risk factor for hip fractures.5

    It would seem logical that people who do not see well are more likely to fall than those who do see well. It is unfortunate, then, that the guidelines given do not contain any references to improving visual function. Poor vision is quite common in elderly people. The causes are varied and include problems related to spectacles (not wearing them, incorrect prescription, scratched lenses, inability to afford them, inappropriate lenses), cataracts, glaucoma, age related macular degeneration, diabetic retinopathy, and other vascular abnormalities.

    We believe that regular visual assessments should be included in the guidelines aimed at the prevention of falls. An ophthalmologist should assess patients with potentially treatable eye disease. Perhaps we should more often consider the risk of falling when we assess our patients with cataracts and other eye disease. Certainly, patients with poor vision from untreatable causes should be provided with low vision aids as appropriate. These patients may also be the ones most likely to benefit from other interventions, as set out by Feder et al.

    Footnotes

    • Competing interests None declared.

    References

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    5. 5.

    Health improvement plans must incorporate falls and osteoporosis strategies

    1. Mark Chakravarty (chakravarty.m{at}pg.com), head of government affairs,
    2. Anna Sörman, head of government and NHS policy
    1. Department of Ophthalmology, St James's University Hospital, Leeds LS9 7TF
    2. Procter and Gamble Pharmaceuticals, Staines, Middlesex TW18 3AZ
    3. Aventis Pharmaceuticals, West Malling, Kent ME19 4AH

      EDITOR—Feder et al address the important issue of minimising the injuries that result from falls by elderly people.1 Falls are the most frequent cause of morbidity and mortality related to injury in elderly people and as such represent a major public health problem. Injuries related to falls will pose even greater challenges to the health service with an ageing population.

      Hip fracture is one of the most costly and debilitating outcomes resulting from a fall but occurs in only 1% of falls.2 It is well known, however, that over 90% of hip fractures are associated with a fall. Clearly, falling is only part of the problem. Fracture is determined not only by the propensity to fall but also by the underlying fragility of the bone. Experts estimate that in people aged over 75 over 90% of hip fractures are attributable to fragile bones due to osteoporosis3; there is simply too little bone in the bone.

      In the NHS at a local level, health improvement plans must integrate falls and osteoporosis strategies. Without the integration of these local initiatives elderly fallers will most probably receive an assessment and intervention after falling but will not be assessed or treated to reduce the risk of fracture should a further fall occur. This was shown recently in a study by Kamel et al, where only 5% of women admitted to a community hospital in the United States over two years left with new drug treatment prescribed to prevent a further fracture.4 Furthermore, patients with osteoporosis may not have their risk of falling investigated and receive only bone strengthening treatment.

      Strategies to reduce fractures, especially of the hip, need to address both falling and bone strength. A review of more than 300 publications related to falls, and interviews with more than 50 healthcare professionals, led to the development of a simple fracture prevention model, which clearly highlights three intervention points for fracture (figure).5

      Interventions that aim to prevent fractures should aim at reducing the risk of falling, strengthening people's bones, and reducing the force of impact of a fall on people's bones. It is to be hoped that the national service framework for older people's services will pick up where Feder et al's work leaves off, by making clear the need to address both osteoporosis and falls in local strategies.

      Competing interests: MC is employed by and has shares in Procter and Gamble. AS is employed by and has shares in Aventis Pharma. Procter and Gamble and Aventis Pharma form the Alliance for Better Bone Health and manufacture and market risedronate sodium (Actonel) for postmenopausal osteoporosis.

      References

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