Prevention of falls in elderly people

Abstract

Jacqueline Close and co-workers (Jan 9, p 93)1Close J Elis M Hooper R et al.Prevention of falls in the elderly trial (PROFET): a randomised controlled trial..Lancet. 1999; 353: 93-97Summary Full Text Full Text PDF PubMed Scopus (764) Google Scholar show that an interdisciplinary approach to elderly patients with falls effectively decreased the number of further falls and limited functional impairment. The intervention included appropriate modification of drug therapy, through direct contact with the general practitioner. Of 110 individuals in whom a primary attributable cause was identified, drugs were found to have resulted in the fall in two patients. However, the researchers provide no information about the basis, nature, and success of the intervention. Cumming2Cumming RG Epidemiology of medication-related falls and fractures in the elderly..Drug Aging. 1998; 12: 43-53Crossref PubMed Scopus (212) Google Scholar has shown specific classes of drugs, such as psychotropic and antihypertensive agents, are a preventable factor that contribute to the risk of falls. In a randomised case-control study—the Geriatric Rehabilitation And Pharmacotherapeutic Intervention Trial (GRAPHIT)—we investigated the long-term adherence to an intervention performed by a panel of two experienced clinical pharmacologists and one senior physician of internal medicine. Patients with falls admitted for treatment of hip fracture were included consecutively and we recorded demographic, medical, and medication data. During the patients' hospital stay, the intervention was done randomly and the requirement of hypnotics/sedatives, such as long-acting benzodiazepines, antihypertensive agents, or both was reassessed. Inappropriate or unnecessary drugs were discontinued, the drug dosage readjusted, and in patients with insomnia preference was given to non-drug therapy. At discharge, patients and their practitioners were informed about the background of the changes in drug therapy. 6 months later at a follow-up visit in patients' homes, we assessed the acceptance of the intervention by the patient and the practitioner. Drug-induced orthostatic hypotension was diagnosed by repeated measurements of blood pressure in the sitting posture and an additional 24 h blood pressure monitoring. We defined the upper cut-off for hypotension as 120 mm hg for systolic and 70 mm hg for diastolic blood pressure.3Passare G Guo Z Winblad B Fastbom J Drug use and low blood pressure in the elderly. A study of data from Kungsholmen project..Clin Drug Invest. 1998; 15: 497-506Crossref PubMed Scopus (1) Google Scholar 149 patients (120 women, mean age 79·5 [SD 10·6] years) were included in our study, of whom 67 were randomly allocated to the intervention group. Surprisingly, only in nine patients (age 83·0 [9·2] years) a drug intervention was needed. In none of these cases did the patients' physician comply with our therapeutic recommendations, although they were adequately informed. Withdrawal (n=2) and switch (n=2) from long-acting benzodiazepines were not followed, in four patients changes in antihypertensives were neglected and in one patient the stopped neuroleptic was reinstituted.* There was no difference in compliance between patients who lived in the community or in nursing homes. Cognitive impairment was an unlikely explanation for the non-compliance because the mean of Folstein's minimental state examination score (total range from 0 to 30) was 24·0 (3·3). We conclude that general practitioners are frequently unaware that drugs, such as long-acting benzodiazepine, increase the risk of falls among elderly patients. Close and colleagues do not mention an outcome of their pharmacotherapeutic intervention. In a randomised clinical trial in the long-term care setting, Rubenstein and colleagues4Rubenstein LZ Robbins AS Josephson KR et al.The value of assessing falls in an elderly population. A randomised clinical trial..Ann Intern Med. 1990; 113: 308-316Crossref PubMed Scopus (318) Google Scholar found that suggestions for drug modification decreased the risk of falls in 33 of 76 participants. They also reported a fairly high rate of compliance (67%) by the physicians with recommendations by the research team for medication changes. Postgraduate medical education in clinical geriatrics is needed. Prevention programmes to decrease the injurious falls among elderly people are not sufficient. Butler and colleagues' study5Butler R Collins E Katona C Orrell M Does a teaching programme improve general practitioners' management of depression in the elderly?.J Affect Disord. 1997; 46: 303-308Summary Full Text Full Text PDF PubMed Google Scholar to improve general practitioners' management of depression in the elderly indicates that teaching programmes (postgraduate training course) can significantly improve knowledge on therapeutic management with psychoactive drugs. This work has been supported by the Robert Bosch Foundation, Stuttgart, Germany. The study protocol was approved by the local ethics committee. *Full details are available from the authors, on request.