What Falls are to Geriatrics

Dr. Barry Goldlist,
Editor in Chief,
Geriatrics & Aging

After many years of practice in geriatric medicine, I am almost convinced that if any doctor truly grasps all of the issues related to falls and the elderly, she understands everything about geriatrics. This may be an exaggeration--but not as much as one may be inclined to think. The reason for this is twofold: First, many of the geriatric syndromes--confusion, immobility, falls, incontinence, dizziness etc.--share the same risk factors and predisposing factors. Secondly, to understand falls in the elderly, the physician has to understand the factors that make the elderly susceptible to falls. These include changing physiology, environmental and social circumstances, and age-related diseases.

Falls are an important cause of morbidity and mortality in the elderly. Over 50% of all trauma admissions in Ontario are caused by falls (in comparison, motor vehicle accidents account for only 13%). About 40% of trauma admissions (Ontario figures) are comprised of patients over 65, and in this group over 80% of trauma admissions are caused by falls. In my hometown of Toronto, in an average year there will be over 15,000 visits to the emergency department by people who have suffered a fall and who are over the age of 75. Yet despite this, emergency physicians seem to have difficulty with this common cause of injury. The reason is simple: The emergency department is not an ideal place to tease apart the multiple contributing factors that might have resulted in the fall. Emergency physicians are more interested in the acute life-threatening causes or con-sequences of falls. Similarly, for those of us who do consultations on orthopedic wards, there is often little description of the fall that resulted in a fractured hip, let alone a careful delineation of the factors that caused the fall. Although I would agree that this is not really for the orthopedic surgeon to work up, often nobody takes responsibility. Perhaps that is why we see so many patients presenting with a second fractured hip!

What is the solution to this problem? I do not think that we will ever develop the necessary assessment skills, within the emergency department, to satisfactorily handle this type of problem. The process is too time consuming and perhaps contradictory to the way emergency departments have to operate. The obvious solution is to establish accessible clinics in the community. The services offered within such clinics would, by necessity, have to be multidisciplinary, with particularly strong contributions from doctors and physiotherapists. When one considers the cost of a single fractured hip (both in dollars and lost quality of life), it is not hard see that the cost-effectiveness of such assessments would be similar to that of other geriatric interventions.

Of course it would be preferable to prevent such falls in the first place, but is that possible? The first inkling that falls prevention was indeed possible came from Mary Tinetti at Yale University in her article published in the New England Journal of Medicine in 1994. In the past year, there has been further evidence of the positive outcomes of falls prevention measures. Dr. Chris Brymer from the University of Western Ontario summarizes this evidence in his article "From Research to Practice: Three Falls Prevention Trials". Dr. Brymer is quite persuasive, and I think it should now be standard medical practice for primary care physicians to identify elderly patients at risk for falls, and to actively strive to prevent them. There are also related articles on the approach to diagnosis and the management of elderly patients who fall.

Preventive strategies focus on individual patients, and at times can be 'labour intensive' for the practicing physician. It is therefore necessary to determine whether there are any broad-based public health approaches to falls prevention. These types of questions are not always easily answered by randomized clinical trials (not that any randomized trials are easy). However, I think there is very persuasive evidence from epidemiological studies and small interventional studies (Fiatarone's trials measuring the benefits of weight training in the elderly), and the FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) Trials to suggest that increasing the fitness of the elderly through exercise will be beneficial. Improving a patient's fitness is, of course, beyond the ability of a single physician, although please note that this edition does have an article on prescribing exercise for seniors that will at least help us with our individual patients.

We have several other articles of interest in this edition, that cover a broad range of important issues: geographic differences in restraint use, the limitations of provincial health insurance and related risks for those travelling abroad (save this for your next vacation!), innovative programs, and Dr. Matear's column on oral health, among others.

I would also like to take this opportunity to thank our former Associate Editor Dr. Margaret Grant, who is taking up a new position as consultant in geriatric medicine at Credit Valley Hospital in Mississauga, Ontario. Our new Associate Editor is Madhuri Reddy. Madhuri is a specialist in internal medicine who is taking advanced training in geriatric medicine while doing research for her master's degree! I am pleased that she is, nonetheless, available to help us with Geriatrics & Aging.

Enjoy this edition.