Gareth R. Jones, PhD, Director, Canadian Centre for Activity and Aging, London, ON.
Jessalynn A.B. Frederick, BHK Honors Co-op, University of Windsor, Windsor, ON.
Canadian Centre for Activity and Aging is affiliated with St. Joseph's Health Care, London and the University of Western Ontario, London, ON.

"Homeboundness" is defined as never or almost never leaving one's home except for emergencies, not going beyond one's door without assistance, or going out of one's home less than once a month, and it is estimated to affect as much as 50% of the population who are 85+ years old.¹ The older homebound adult is more likely to live alone, have mobility limitations, experience incontinence problems, and be considered at high risk for falling and fear of falling, as well as more likely to receive home support services.² Frail seniors living at home are particularly difficult to reach and are at high risk for loss of functional independence and for institutionalization.³

Home exercise is an effective means to prevent falls, to maintain functional independence and to promote rehabilitation following injury or illness.⁴ However, for an older adult faced with mobility challenges and/or other medical problems, attending a traditional community-based exercise program may not be a suitable option.

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.

Fiona E. Shaw, MRCP, PhD, Consultant Physician and Geriatrician, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne, UK.

Older people with dementia are at increased risk of falls and their adverse consequences. Postural instability (impaired gait and balance), medication, environmental hazards and neurocardiovascular instability, in particular orthostatic hypotension, are commonly identified as risk factors for falls in this patient group. It is possible to modify risk factors for falls in older people with dementia. However, to date it has not been possible to demonstrate conclusively that intervention can prevent falls in patients with dementia.
Key words: accidental falls, dementia, cognitive impairment, postural instability, neurocardiovascular instability (syncope).

Margaret Grant, MD, FRCPC, Geriatrician and Medical Director, Geriatric Assessment Unit, Credit Valley Hospital, Mississauga, ON.

This article focuses on the treatment of orthostatic hypotension (OH) in the elderly. OH is a common problem that can affect an elderly person's function and quality of life. A careful history and physical examination must be done to make an accurate diagnosis and to determine the causes of OH. Treatment should focus on the causes of OH. Both nonpharmacological and pharmacological interventions are reviewed.
Key words: orthostatic hypotension, fludrocortisone, midodrine, octreotide, erythropoietin.

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.

Boyd Swinburn, MB, ChB, FRACP, MD, Professor, Centre for Physical Activity and Nutrition, Deakin University, Melbourne, Victoria, Australia.
Richard Sager, BHlthSc (N&D), APD, Public Health Research Fellow, Greater Green Triangle University, Department of Rural Health, Deakin University, Warrnambool, Victoria, Australia.

Regular physical activity in older populations reduces the risks of cardiovascular diseases, diabetes, osteoporosis and falls and also improves mental health. Some programs of written exercise prescriptions by general practitioners have been shown to significantly increase physical activity levels over the medium-term (six to 12 months). Increasing the confidence and skills of general practitioners to prescribe and monitor exercise programs is important. However, the more challenging barriers to the widespread uptake of exercise prescription programs are the structural and economic constraints within general practice, as well as the competing promotion of prescribing pharmaceutical products. Implementation research on overcoming these barriers is urgently needed.
Key words: exercise prescriptions, general practitioner, health gains, training, barriers, health promotion.

Nadine Gagnon, MD, FRCP(C), Research Fellow, Department of Psychiatry, University of Toronto and University Health Network, and Toronto Rehabilitation Institute, Toronto, ON.
Alastair J. Flint, MB, ChB, FRCP(C), FRANZCP, Professor of Psychiatry, University of Toronto, and Head, Geriatric Psychiatry Program, University Health Network, Toronto, ON.

To date, researchers have addressed many aspects of falling. During the past two decades, there has been increasing interest in the phenomenon of fear of falling. This paper summarizes data pertaining to the epidemiology, assessment and management of fear of falling, as well as the relationship of fear of falling to other factors.
Key words: fear of falling, elderly, epidemiology, self-efficacy, activities of daily living.

Gabriele Meyer, Research Fellow, Andrea Warnke, Research Fellow and
Ingrid Mühlhauser, Professor; Unit of Health Sciences and Education,
University of Hamburg, Hamburg, Germany.

Prevention of falls in the elderly is a high priority in many countries. Single component and multifaceted interventions have been extensively studied. However, only two interventions have been shown to reduce injuries or fractures. Hip protectors effectively reduce hip fractures. Home-based exercise programs administered by qualified professionals may reduce falls and fall-related injuries. Most interventions are intensive and require substantial resources. Before considering implementation of a fall prevention program, its practicability, acceptance and cost-effectiveness should be explored.
Key words: accidental falls, prevention, hip fractures, hip protector, protective devices.

Elizabeth Steggles, Occupational Therapist Reg. (ON); Manager, Independence Technologies, Hamilton, ON.

Every-day technologies, such as telephones and remote controls, are an important part of life but are not always user friendly. Too often, devices are designed for people who have good fine motor skills, mobility, hearing, cognition and vision. This article will suggest some simple technologies that may help maintain independence as people age.

Telephones
Ameriphone¹ provides a range of telephones with good access features. Most of the telephones incorporate the following features: large buttons with large numbers and good contrast, amplification of the incoming voice, a ring flasher and a loud ringer.

Some specific models are worth mentioning. The Dialogue XL-50 telephone has the features described above, as well as the ability to increase the sound up to 48 decibels, which is 200 times louder than normal. The Dialogue JV-35 has jumbo buttons with Braille characters, and an electronic voice announces each number as it is dialed. In addition to the general features, the Photo Phone P300 has nine memory locations that may be identified by a photograph of the person whose number is stored. This is very helpful for people who have difficulty remembering or reading numbers. Dialogue CL-40 is a cordless telephone with large back-lit buttons, 100 times amplification and an extra loud ringer.