Fall assessment in older peopleBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d5153 (Published 14 September 2011) Cite this as: BMJ 2011;343:d5153
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Having read with great interest the 3 clinical reviews(1,2,3)assessing elderly people care, we would like to talk about the barriers which stop theoretical ideas leading to practical solutions in France. Our endpoint is to analyze the conditions responsible of this blockage and to see if a better application of theoretical ideas is possible.
French geriatrics, health system and access to medical care are worldly renown (4,5). But how do they correspond to the theoretical principles dealt with in the BMJ?
We interviewed 8 geriatricians and retained three main ideas. The geriatricians worked in the French region of “Poitou-Charentes” which is in the national average for medical demography and population health. We analyzed the theoretical and practical elements of their answers.
Having analyzed this data, we came to the following conclusions.
1) As the proportion of elderly people grows day by day(6,7), one wonders if there will be enough geriatricians in the future. This is one of the reasons why geriatricians insist on the fact that general practitioners will need to take a greater part in older people care because there are many more GPs than geriatricians(8). They ask general practitioners to anticipate as early as possible morbidities linked to physiological ageing and loss of autonomy, medicine interactions and cardiovascular risk factors. A transfer of responsibility is therefore necessary.
2) Secondly, economical considerations are a barrier for taking care of global medical problems in the elderly as the Clinical Reviews recommend. The geriatricians we interviewed insisted on the importance of the Care(9).
They suggest financially promoting the Care acts. As short and numerous consultations lead to health care, prevention is often neglected(10). They suggest that a long dedicated consultation be valorized and that medico-social networks be developed.
Young doctors and interns would find this more attractive as this fits their requests(11) and the specialty would become more attractive for them.
3) Finally, finding that geriatrics would gain from attracting more interns, it would be necessary to rethink geriatricians’ and GPs’ training integrating collaboration with other specialties. This interdisciplinarity would allow the construction of theoretical tools to deal with ageing people issues as GPs encounter them in outpatient clinics.
To conclude, although the French health system has a world-wide reputation, when it comes to geriatrics, access to health care needs to be encouraged especially with the demographic tidal wave on its way. The theoretical recommendations brought forward by our colleagues in the Clinical Reviews need to be assessed which would mean raising a certain number of barriers so that these recommendation come into effect and so that the assessment be constructive.
It is therefore necessary to transfer the competence of these theoretical acts to GPs. The theoretical, global patient care must be valued to entice students to choose this specialty.
From the right to health to the right to health care, won’t our future goal be to apply the theoretical standards of the specialty(12)? A medical assessment cannot, ethically, narrow down to criteria close to the general public’s heart (access to health care), it must take every acts’ efficiency into account.
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Competing interests: No competing interests
We read with interest the clinical review by Close and Lord (1) on fall assessment in the elderly, but are surprised about the methods used and the conclusions drawn by the authors.
First, the authors use a very limited part of the existing evidence that seem to be chosen as it is in line with the authors' pre-defined conclusions. We are astonished about the neglect of the bulk of evidence demonstrating that fall risk assessment and screening is as good as tossing a coin and therefore without clinical relevance and most likely a waste of resources. A proper evidence-based systematic review surely would have led to different conclusions.
The authors acknowledge that useful assessment instruments need to show good predictive and discriminatory characteristics and argue that there are instruments that "have acceptably high accuracy in predicting those who will or will not fall". We wonder how the authors come to their conclusions and where they set the threshold for accuracy. Again a limited part of the evidence is presented to the readers consisting mostly of original validation studies that naturally show higher diagnostic accuracy compared to further replication studies in different populations (2, 3). An own systematic review and a recently conducted HTA report (4) impressively confirmed what had already been acknowledge by Gates et al. (5) for community dwelling elderly and by Oliver for hospitals patients i.e. that it is "time to put [fall risk prediction tools] to bed!" (6).
We seriously challenge the authors' statement that "several approaches" linking assessment and interventions have been shown to be effective. Surely the results of the Cochrane reviews on fall prevention (7, 8) are far from showing a consistent picture. Also, considering the Cochrane reviewers' conclusion that there has to be more research on what might be effective under what circumstances (7), the generalisability of the study results seems disputable. Apart from methodological challenges inherent to the Cochrane reviews, e.g. pooling data in spite of pronounced clinical heterogeneity, most importantly fall assessment and intervention programmes failed to show effectiveness on the most relevant clinical endpoint, i.e. fall-related injuries.
Finally, the authors surprisingly fail to acknowledge the available direct evidence for the absence of effectiveness of fall assessment tools. We have shown in a randomised controlled trial that using a fall risk assessment tool in nursing homes had no effect on falls and fall-related injuries (9).
In conclusion, the authors may be convinced that fall risk assessment is a good thing to do, but have failed to acknowledge the striking evidence for the limited accuracy and the lack of effectiveness of existing tools as well as the weak evidence for multifaceted interventions comprising assessment and interventions.
1. Close J, Lord S. Fall assessment in older people. BMJ 2011;343:d5153.
2. Justice A, Covinsky K, Berlin J. Assessing the generalizability of prognostic information. Annals of Internal Medicine 1999;130:515-24.
3. Koepke S, Meyer G. The Tinetti test - Babylon in geriatric assessment. Z Gerontol Geriatr 2006;39:288-91.
4. Balzer K, Bremer M, Luehmann D, Raspe H. Fall prevention in the elderly: current evidence and challenges for further research. Fourth European Nursing Congress. Older Persons: the Future of Care. Rotterdam, 04.-07.10.2010. J Clin Nurs 2010;19:25-6.
5. Gates S, Smith L, Fisher J, Lamb S. Systematic review of accuracy of screening instruments for predicting fall risk among independently living older adults. J Rehabil Res Dev 2008;45:1105-16.
6. Oliver D. Falls risk-prediction tools for hospital inpatients. Time to put them to bed? Age Ageing 2008;37:248-50.
7. Gillespie L, Robertson M, Gillespie W, Lamb S, Gates S, Cumming R, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2008;2:CD007146.
8. Cameron I, Murray G, Gillespie L, Robertson M, Hill K, Cumming R, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev 2010;1:CD005465.
9. Meyer G, Koepke S, Haastert B, Muehlhauser I. Comparison of a fall risk assessment tool with nurses' judgement alone: a cluster-randomised controlled trial. Age Ageing. 2009;38:417-23.
Competing interests: None declared
We read with interest the clinical review "Fall assessment in older people" by Close and Lord(1). Among the risk factors for falls, some authors have included kidney failure and its relation to defective conversion of calcidiol to calcitriol(2). Vitamin D3 and D2, produced by photo-synthesis in the skin or ingested, are transported to the liver and metabolised to 25-hydroxyvitamin D, the major circulating form. Further hydroxylation occurs in the kidney to form the highly biologically active 1,25-dihydroxyvitamin D. In contrast to the abundant availability of hepatic 25-hydroxylase, the renal capacity for 1 alfa-hydroxylation is limited. Already with a creatinine clearance of less than 65 ml/min it is significantly reduced(3). Impairment of kidney function is very frequent in the elderly and may be overlooked because normal serum creatinine levels in most patients. Perhaps, in these patients D-analogs, preferably alfacalcidol, might be superior in reducing falls in comparison to the plain vitamin D.
In the AAC-Trial(4) ninety patients were included as matched triplets to receive randomly either 1 mcg alfacalcidol daily + 500 mg calcium (group A, n = 30) or 70 mg alendronate weekly + 1,000 mg calcium + 1,000 IU vitamin D daily (group B, n = 30) or 1 mcg alfacalcidol daily + 70 mg alendronate weekly + 500 mg calcium daily (group C, n = 30). This study showed that the combination of alendronate and alfacalcidol was superior in reducing falls in comparison to the combination of alendronate and vitamin D, but not in comparison to alfacalcidol alone. There were 5 new falls with alfacalcidol versus 11 new falls with alendronate+vitamin D versus 4 new falls with alfacalcidol+alendronate.
1. Close JC, Lord SR. Fall assessment in older people. BMJ 2011;343:d5153.
2. Ringe JD, Schacht E. Potential of alfacalcidol for reducing increased risk of falls and fractures. Rheumatol Int. 2009;29:1177-85.
3. Dukas LC, Schacht E, Mazor Z, St?helin HB. A new significant and independent risk factor for falls in elderly men and women: a low creatinine clearance of less than 65 ml/min. Osteoporos Int 2005;16:332-8.
4. Ringe JD, Farahmand P, Schacht E, Rozehnal A. Superiority of a combined treatment of Alendronate and Alfacalcidol compared to the combination of Alendronate and plain vitamin D or Alfacalcidol alone in established postmenopausal or male osteoporosis (AAC-Trial). Rheumatol Int 2007;27:425-34.
Competing interests: None declared
We welcome the article from Close and Lord on falls prevention, as raising awareness of this common, serious and costly condition is important.
However, the evidence for systematic screening for falls risk and intervening on those at high risk is still immature. Screening and intervening may be clinically effective - for example a recent RCT demonstrated a stratum-adjusted incidence rate ratio of 0.86 (95% CI 0.73-1.01), P = 0.08, and 0.73 (95% CI 0.51-1.03), P = 0.07 when adjusted for baseline characteristics in favour of a falls prevention programme for community dwelling older people at high risk of falls (1). However, it does not appear to be cost-effective - from the same study, the estimated Incremental Cost Effectiveness Ratio was ?3,320 per fall averted (2).
It is unlikely that such an exercise is affordable on a widespread scale, especially in a cost-constrained NHS. Recommendations on screening should be more tempered until more robust evidence is available.
1. Conroy S, Masud T, Coupland C, Drummond A, Gladman J, Harwood R, et al. A multicentre RCT of a day hospital falls prevention programme for community dwelling older people. Age Ageing 2010;39(S1):i33.
2. Lisa Irvine, Simon P. Conroy, Tracey Sach, John R. F. Gladman, Rowan H. Harwood, Denise Kendrick, et al. Cost-effectiveness of a day hospital falls prevention programme for screened community-dwelling older people at high risk of falls. Age Ageing 2010;39(6):710-16.
Competing interests: Active researcher in the field
Competing interests: Active researcher in the field