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Clinical Review State of the Art Review

Prevention of falls in older people living in the community

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1419 (Published 28 April 2016) Cite this as: BMJ 2016;353:i1419

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Authors’ responses to BMJ article comments

Dear Dr. Simey and colleagues,
Thank you for the commendation and additional information on this important topic. Yes, “a dose of at least 50 hours of challenging balance and progressive strength training, delivered by trained professionals” is recommended. What we meant was that they specific types and duration of balance, strength and endurance exercises for older adults with varying characteristics and functional capacities still need to be defined. Currently, we use clinical judgement without specific protocols tested for different groups.

Dear Dr. Hai Kiang,
Thank you for acknowledging the relevance of our article and for the insightful comments.

Dear Dr. Seemungal,
We appreciate your very pertinent considerations. Yes, vertigo is a well-known risk for falls (e.g. OR = 1.8, Silvia et al., 2010), and Benign Paroxysmal Positional Vertigo (BPPV) is a cause of balance impairment, which can lead to falls. Whilst symptomatic patients are often seen initially in primary care, diagnostic studies, including the Dix-Hallpike maneuver, and particularly treatment approaches, including the Epley maneuver, are often best performed by specialists in secondary or tertiary care (Maarsingh et al 2010, Annals Journal Club: Causes of Persistent Dizziness in Elderly Patients in Primary Care Ann Fam Med 2010 8:196-205). Currently, systematic screening approach for asymptomatic BPPV in all community-dwelling older adults who experienced falls has not been traditionally included in multifactorial interventions shown to be effective for falls (USPSTF, NICE, Cochrane). Research seeking to optimize the clinical evaluation and management of BPPV in symptomatic and asymptomatic older adults by general practitioners and geriatricians in the context of falls is warranted.

Dear Ms. Goodare,
We were glad to hear you found our article to be “a really thorough treatment of an important subject”. We apologize for the typos. This was a literature review, but we agree that patient views are important to be included in primary studies. In a previous study in long term care facility, we video-recorded residents during transfers (e.g. going from bed to wheelchair), watched the videos with them and asked them what where potential risks for falls during that transfer and what could be done to reduce the risk of falls during that transfer (Vieira et al., 2014). The residents had very insightful information.
Vieira, E. R., O’Rourke, H. M., Hunter, K., & Marck, P. B. (2014). Using video-elicitation to assess risks and potential falls reduction strategies in long term care. Disability and Rehabilitation, 36(10), 855-864.

Dear Dr. Caronni,
Good to hear you found our review to be insightful. Yes, we need to consider pain control in falls prevention.

Dear Dr. Bolland,
We concur that major methodological differences and varying observed results impact in different population subsets constitute a major challenge for evident synthetization and broad inference-making regarding the impact of vitamin D supplementation on fall risk. Investigation of the clinical impact of vitamin D supplementation on health outcomes remains a very fruitful area of research, with novel findings constantly being added to the literature. In our review, we listed important studies that provide major support for current recommendations now in place in support of some level of vitamin D supplementation in the context of falls prevention by important (AGS/BGS, USPSTF, Cochrane), though not all organizations (NICE 2013). Controversy and unanswered questions in the field do remain, and will certainly be further addressed as new evidence becomes available.

Best wishes,
Ed Vieira on behalf of the authors

Competing interests: No competing interests

24 May 2016
Edgar R Vieira
Assistant Professor and Graduate Program Director
Florida International University
11200 SW 8 st, AHC3-430, Miami, FL 33199