Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Jeffrey D. Holmes, MSc(OT), PhD, Assistant Professor, School of Occupational Therapy, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Kevin Wood, BHSc, Research Assistant, Health and Rehabilitation Sciences, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Mary E. Jenkins, BSc(PT), BEd, MD, FRCPC, Associate Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.

Abstract
“Accidents” (specifically falls) are a major contributor to death among older adults (defined as individuals over the age of 65). Falls contribute to ongoing mobility issues, and make it difficult for individuals that have sustained a fall, or who are at significant risk for a fall, to live independently.
Keywords: cognition, falls, dual-task interference

James W. Cooper, RPh, PhD, BCPS, CGP, FASCP, FASHP, Emeritus Professor and Consultant Pharmacist, College of Pharmacy, University of Georgia, Athens, and Assistant Clinical Professor of Family Medicine, Medical College of Georgia, Augusta, GA, USA.
Allison H. Burfield, RN, PhD, Assistant Professor, School of Nursing, College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, USA.

The high incidence of falls among older adults leads to increased health care costs and decrements in functional status. Psychoactive medications consumed by older adults are often implicated in falls. This article briefly reviews the associations between falls and psychoactive medications, with a focus on the long-term care setting, and offers an assessment method and strategies to reduce the risk of certain classes of medications known to contribute to fall risk.
Key words: falls, medications, psychoactive load, interventions, older adults.

Susan B. Jaglal, PhD, Toronto Rehabilitation Institute Chair, Associate Professor, Faculty of Medicine, Department of Physical Therapy, University of Toronto, Toronto, ON.

A wrist fracture is associated with an increased risk of another fracture and should prompt investigation for osteoporosis in both men and women. If the fracture was caused by low trauma (a fall from a standing height or less), a bone density test should be ordered. If the T score is <–1.5, pharmacological treatment with a bisphosphonate and calcium (1,500 mg/d) and vitamin D3 (≥800 IU/d) is recommended. Management should also include balance, posture, and muscle-strengthening exercises and walking, as well as a review of fall-prevention strategies.
Key words: wrist fracture, osteoporosis, diagnosis, treatment, exercise, falls.

Our focus in this issue is Fitness and Falls. The benefit of regular exercise was well established with the MacArthur Foundation’s study of healthy aging in 1998,¹ but the difficulties in implementing its recommendations are twofold: how do we encourage our patients to exercise, and how do we prescribe the right kinds of exercise? These two questions are interconnected and the article “Prescribing Exercise” by Dr. Alison Mudge, Robert Mullins, and Julie Adsett offers some answers. Fractures are common sequelae of falls and one type of fracture is discussed in the article “Vertebral Compression Fractures Among Older Adults” by Dr. Simona Abid and Dr. Alexandra Papaioannou. This article is also the basis for our February CME program. I like to say that there is no such thing as a trivial fall for an older adult. Some falls result in trivial injury, but often that is poor good fortune, and a slightly different angle of fall could result in serious damage. Dr. Susan Jaglal, a noted authority in the area of falls among older adults, addresses this in her article “After the Fall: The ABCs of Fracture Prevention.”

We also have our usual collection of articles on various important areas of geriatric care. Our Cardiovascular Disease column provides an “Update in Endocarditis Prophylaxis” and is written by Dr. Jason Andrade, Dr. Aneez Mohamed, and Dr. Chris Rauscher. The changes are quite significant from previous guidelines. Our Dementia column is on “Recreational Activities to Reduce Behavioural Symptoms in Dementia” by Dr. Ann Kolanowski, Dr. Donna Fick, and Dr. Linda Buettner. This issue’s Drugs and Aging column is part one of two on “Vitamin D Deficiency in Older Adults: Implications for Improving Immune System Health and the Prevention of Chronic Degenerative Disease” by Dr. Aileen Burford-Mason. Our Palliative Care column is entitled ”Prescribing Opioids to Older Adults: A Guide to Choosing and Switching Among Them” by Marc Ginsburg, Dr. Shawna Silver, and Dr. Hershl Berman. Our Men’s Health column is “Sexuality and the Aging Couple Part II: The Aging Man” by Drs. Irwin Kuzmarov and Jerald Bain of our partner organization, the Canadian Society for the Study of the Aging Male.

This issue, the first of the new year, also sees some changes in our pages. We’ve added a new section to each article called Clinical Pearls. These short notes suggest directly implementable changes, practices that clinicians can implement in the office to improve their care of older adults. Also, in our ongoing quest for excellence, we’ve expanded our system of peer review to include not only each issue’s CME article but also all the articles on the issue theme. Starting with this issue, all the Focus articles will undergo the same rigorous peer-review process that readers have come to expect of our CME article.

Enjoy this issue,
Barry Goldlist

1. Rowe JW, Kahn RL. Successful Aging: The MacArthur Foundation Study. New York: Dell Publishing, 1998.

Kristin Casady, MA, Editorial Director, Geriatrics & Aging, Toronto, ON.

Falls are the leading cause of unintentional death among Canadians. According to a report of the Canadian Task Force on Preventive Health Care, falls resulting in serious injury or death are much more frequent among those age 55 and over; 70% of fatal falls occurred among persons 75 years and over. Ninety-five percent of injuries among older adults living in long-term care facilities were due to falls. One percent of falls by individuals aged 65 and over result in hip fracture.¹ Given these statistics, studies examining the efficacy of interventions to prevent falls and/or address the negative sequelae of falls are of significant interest to health care practitioners working with an older adult patient population.

A recent study has analyzed strategies employed in long-term care facilities and hospitals to prevent falls and fractures, as well as the evidence on the effects of cognitive impairment on fall risk.² The authors conducted a systematic review and meta-analysis, using meta-regression to investigate the effects of dementia. Researchers found that some interventions employed in hospitals lead to falls reduction, and that the use of hip protectors in care facilities prevents hip fractures. However, the evidence detected for the use of other single interventions was not significant.

Fall prevention strategies, the authors point out, are often derived from procedures and models suited for the community-dwelling, which do not precisely map on to the needs for fall and injury prevention among transient and institutionalized segments of the population. One particular reason that this is so is that many of those in hospital or long-term care have varying degrees of cognitive impairment. The authors suggest that awareness of the effect of cognitive impairment in incidences of falls should guide the development of best practice in order to avoid the implementation of ineffective prevention strategies.

The range of the 43 studies examined included multifaceted incorporated programs in hospitals and care settings that evaluated a wide range of items from risk factor assessment to medication review to education and exercise programs. The single-intervention programs studied tended to be components represented in the multi-intervention programs.

Among the key findings were that the multifaceted approach programs to prevent falls in hospital yielded the highest benefits, with meta-analysis showing a rate of falls reduction of 18%, but no significant effects on fracture (rate ratio of 0.82 [95% confidence interval 0.68 to 0.997]). Review of 11 studies of the effect of hip protectors showed an overall positive effect of the use of the devices: the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and, the authors asserted, not enough studies on fallers. There was no evidence as to the efficacy of exercise as a single intervention; however, it was a component of successful multifaceted programs. There was no evidence to suggest that removal of physical restraints was efficacious. However, the authors did find two studies in which oral supplementation with calcium and vitamin D reduced rates of falls and fractures in long-term care facilities. Importantly, they found no evidence that effect size of interventions were modified by the prevalence of dementia.

The authors concluded that significant gaps remain in the data yielded by studies of fall reduction interventions. They singled out the need for studies specifically examining programs for the cognitively impaired, the cost-effectiveness of single interventions, and alterations of physical environment, among others, as sources of needed evidence. They surmise that at present health care providers are incurring significant costs by using injury prevention strategies of unproven value.

References

1. Elford RW, for the Canadian Task Force on Preventive Health Care. Prevention of household and recreational injuries in the elderly. Online at http://www.ctfphc.org/ Full_Text/Ch76full.htm
2. Oliver D, Connolly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2006 Dec 8; [Epub ahead of print].

David B. Hogan, MD, FACP, FRCPC, Professor and Brenda Strafford Foundation Chair in Geriatric Medicine, University of Calgary, Calgary, AB.

Dementia is a common condition that places its victims at risk for injury. This article provides an overview of home safety for those with dementia. A conceptual approach to this management challenge is the Home Safety / Injury Model described by Hurley and colleagues. I focus on two common safety concerns: wandering and falls. Unfortunately, most recommendations are based on “common sense” (i.e., what seems reasonable). Whether these approaches actually decrease the likelihood of harm is largely unknown. It is anticipated that future research will lead to evidence-based recommendations.

Key words: dementia, home safety, wandering, falls.

Barbara Liu, MD, FRCPC, Sunnybrook &Women's College Health Sciences Centre and the Kunin-Lunenfeld Applied Research Unit, Baycrest Centre, Toronto, ON.

Falls are a common problem among older patients. Medications in general, and psychotropic drugs in particular, have been shown to increase the risk of falls. The possible mechanisms whereby psychotropic drugs increase this risk include sedation, orthostatic hypotension, arrhythmias, confusion due to anticholinergic effects, and dopaminergic effects on balance and motor control. Several epidemiological studies have identified antidepressant use--both tricyclic and selective serotonin re-uptake inhibitors--as a risk factor for falls. When treating a patient with an antidepressant, efforts should be made to reduce other modifiable risk factors for falls by optimizing intrinsic and extrinsic risk factors for falls.
Key words: falls, antidepressant, hip fracture, tricyclic antidepressant, selective serotonin re-uptake inhibitor.

Heike A. Bischoff, MD, MPH, Robert B. Brigham, Arthritis and Musculoskeletal Diseases Clinical Research Center, Brigham and Women's Hospital and Division on Aging, Harvard Medical School; Boston, MA, USA.

There is increasing evidence that vitamin D supplementation may improve musculoskeletal function and prevent falls in older persons at risk for vitamin D deficiency. One basic concept appears to be the direct effect of vitamin D on muscle strength. Highly specific receptors for 1,25-dihydroxyvitamin D are expressed in human muscle tissue and it has been suggested that these nuclear receptors promote protein synthesis in the presence of 1,25-dihydroxyvitamin D, eventually leading to improved strength.
Key words: vitamin D, muscle strength, function, elderly, falls.

Meghan G. Donaldson, MSc, CIHR Doctoral Scholar, Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC.
Karim M. Khan, MD, PhD, Assistant Professor, Department of Family Practice, Faculty of Medicine, University of British Columbia; consultant in the Osteoporosis Programme at B.C. Women's Hospital and Health Centre; CIHR New Investigator, Vancouver, BC.
Stephen R. Lord, PhD, NHMRC, Principal Research Fellow, The University of New South Wales, Sydney, Australia; Author of "Falls in Older People".

Falls are a major health problem in all Western societies. About 30% of community-dwelling seniors fall annually, and of these, half have recurrent falls. This article focuses on fall prevention in community-dwelling older people. It reviews risk factors for falls, addresses the role of exercise to prevent falls, and outlines management tips for physicians who see patients who fall. There is good evidence that strength and balance training should be prescribed to prevent falls. Also, there are many simple things a physician can do to reduce fall risk, such as medication rationalization and treating fall risk factors in a coordinated manner.
Key words: falls, exercise, balance, resistance training, risk factor modification.

When medical residents rotate through our geriatric service at the University Health Network, we provide a group of seminars on the "Geriatric Giants": confusion, instability and falls, incontinence, geriatric pharmacology and failure to thrive. I have to admit that my personal favourite among the geriatric giants is the topic of falls. I find it to be a perfect paradigm for the clinical practice of geriatric medicine, and thus an excellent tool for teaching the general principles of geriatric care.

What are those principles? I think the first is that any number of problems can result in falls, and that the overwhelming majority of falls in the elderly are not caused by a single factor but by the combination of a multitude of problems. This allows me to demonstrate to the students the various factors that can predispose to falls. These can be intrinsic to the patient (age-related changes or diseases), or external to the patient (environmental factors). The key for the doctor is to determine what factors are operant in a particular patient, and of these, which are modifiable. The next step is to determine which factors can be improved rapidly (e.g., stopping certain medications) and which require long-term strategies (e.g., proximal muscle strengthening). I also emphasize to the residents that there is no such thing as a trivial fall, although some falls only result in trivial injuries. That person's next fall might result in a devastating injury.

The nature of the scientific study of falls in the elderly took an exciting and dramatic turn in the early 1990s, with the article by Mary Tinetti in the New England Journal of Medicine.¹ Her study demonstrated that proper attention to falls risk factors in a primary care setting could actually reduce the number of falls these people would have (absolute risk reduction of 12%, number needed to treat to prevent one fall is 8). This demonstrated clearly that with a comprehensive interdisciplinary approach, complex functional issues in the elderly could be systematically approached and improved.

The new issue in falls prevention is how to reach all those at potential risk. With our rapidly aging population, the individual doctor-patient interaction, while very important, is not enough. The next step in falls prevention is the implementation of community-based programs (e.g., exercise programs) that can have a broader impact. These programs have shown clear efficacy in high quality clinical trials, and we now need to determine if they will be effective when introduced into the community at large.

This issue of Geriatrics & Aging has been designed to provide the tools for primary care physicians to assess the risk factors for falls in their elderly patients, and to allow them to prevent some of these devastating occurrences. Gabriele Meyer, Andrea Warnke and Ingrid Mühlhauser tackle the general topic of fall and fracture prevention in the elderly, and Dr. Fiona E. Shaw addresses the thorny problem of falls in those with dementia. Drs. Nadine Gagnon and Alastair Flint review one of the crippling consequences of falls, namely fear of falling, which dramatically reduces function and quality of life. Dr. Boyd Swinburn and Richard Sager give some practical advice in their article on the promotion of exercise prescriptions for elderly populations. Dr. Margaret Grant provides treatment strategies for one of the most potent risk factors for falls, orthostatic hypotension, while Dr. Karim Khan, et al. present strategies for the optimal delivery of falls prevention programs to the elderly in the community.

Enjoy this issue.

Reference

1. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7.