Falls among older people: relationship to medication use and orthostatic hypotension.

OBJECTIVE: To assess the risk of falls attributable to medication use and orthostatic hypotension. DESIGN: Prospective cohort study. SETTING: Two self-care, apartment-style residential facilities in the Toronto area. PARTICIPANTS: A total of 100 consecutive older volunteers (mean age = 83, range 62-96) who were independent in activities of daily living and able to stand unaided. MEASUREMENTS: Prescription medications used by each subject were documented at baseline. Blood pressure measurements were performed supine, immediately after standing, and after 5 minutes. Subjects reported falls weekly, by postcard, for a period of 1 year; nonreporters were contacted by telephone. RESULTS: Fifty-nine percent of subjects fell at least once during the 1-year follow-up. Antidepressant use was associated with an increase in the risk of experiencing one or more falls (RR = 1.6, P = .02). The use of other drug classes examined, including diuretics and sedative-hypnotics, was not associated with an increased risk of falling. Orthostatic hypotension was not predictive of falls. Surprisingly, there was an increase in the diastolic blood pressure of fallers, after 5 minutes, that was not seen in the nonfallers (3.3 vs -0.2 mm Hg, P = .05). Possible explanations for this previously unreported observation are explored. CONCLUSION: Patients using antidepressants should be followed closely because the risk of falls is increased. Previously reported relationships between benzodiazepines and diuretics and falls are not supported by the present findings. Clinical detection of orthostatic hypotension is unlikely to be useful in predicting future risk of falling.

Report of the Canadian Hypertension Society Consensus Conference: 4. Hypertension in the elderly.

Several knowledge gaps, which made evidence-based guidelines impossible in 1985, have since been filled. There is now unequivocal evidence that treatment of isolated systolic hypertension benefits elderly patients, as does treatment beyond the age of 75 years. Pseudohypertension, although occasionally problematic, is not common and is not a reason to neglect the treatment of elderly patients, including those with isolated systolic hypertension. In general, long-term antihypertensive treatment of the elderly is well tolerated and does not cause important decreases in mental function. Comparative drug studies continue to accumulate; most show no clinically significant general differences between drugs, aside from the somewhat decreased efficacy and tolerability of beta-blockade in elderly patients. As in the young, certain drugs may be preferred in the presence of other conditions--e.g., congestive heart failure or diabetes.

The noisy elderly patient: prevalence, assessment, and response to the antidepressant doxepin.

To measure the prevalence of noisy behavior as a nursing problem, a survey of head nurses was done in a chronic care hospital to identify patients whose vocalizing was frequently disturbing to other patients, staff, or visitors. We found 17 patients among the total of 154. Subsequently, the medical records of 13 surviving subjects were reviewed more exhaustively, and 11 were described as disruptive, usually when they were left alone. Of these "lonely" patients, eight had a previously documented diagnosis of depression. All were demented. Antipsychotic medication had previously been given to all 11 "lonely" patients, but had failed to control their disruptive behavior. Empirically, six patients were treated with doxepin, and in five, all with a history of previous depression, agitation and noisiness diminished. These observations suggest that the prevalence rate of disturbingly noisy behavior among long-term institutionalized elderly patients is about 11% and that the disturbingly noisy patient is often demonstrating depression in conjunction with dementia.

Unnecessary diuretic therapy in the elderly.

The possible beneficial or adverse effects of long-term diuretic use in the elderly were evaluated in 60 males (mean age 80.0 years) and 17 females (mean age 84.3 years). All subjects were found to have no obvious need for diuretics when initially assessed and were not receiving concurrent digoxin therapy. Residents were randomly allocated to placebo or active groups with stratification for prior hypertension or congestive heart failure (CHF) and they were followed for one year in a double-blind design. Mean BP, heart rate and weight at one year were similar to baseline values in both groups. Six active and two placebo subjects developed CHF and two other placebo subjects had a return of BP to hypertensive levels. Serum creatinine, cholesterol, potassium and BUN were significantly improved at one year in the placebo group. Chronic diuretic use did not alter appreciably the occurrence of CHF or hypertension in this elderly population and may not be necessary.

The relationship of postural sway in standing to the incidence of falls in geriatric subjects.

A double-blind study was undertaken to determine the relationship (if one exits) between the extent of postural sway in standing of individual elderly subjects and their frequency of falling. A total of 205 subjects were studied; their average age was 81.8 years. Thirty per cent of the men, and 46% of the women, had one or more falls; the proportion of all subjects with one or more falls was 42%. The average speed of sway was significantly greater (P less than 0.05) for those who fell one or more times in a year than for those who did not fall. In this group of institutionalized elderly, there was no sex-related difference in the mean speed of sway; moreover, no age-related trend was demonstrated by the regression of mean speed upon age for all subjects. The mean speed of sway even for the non-fallers was found to be greater than that measured in a sample of non-institutional elderly subjects studied in the past. Thus, mean speed of postural sway was found to be only of statistical value for determining the risk of falling among these institutionalized elderly. We found postural sway to be an indicator of a tendency to fall, but the difference was less than might have been expected. No trend of increasing postural sway correlating with the increased frequency of falls was found.

Testing your older patient's thyroid function.

Thyroid disease cannot be diagnosed through any single test. Normal aging does affect the values of some test parameters in the elderly. When interpreting laboratory test results in the elderly, careful consideration should be given to gender, concurrent acute or chronic illness, nutritional and mental status, as well as possible recent administration of iodinated radiocontrast media and drug therapy. When these factors have been excluded and preliminary routine thyroid function are abnormal or marginally suspect, the usual standards for younger adults, slightly modified, should suffice for diagnosing both hypo-and hyperthyroidism. Patients with complications may require special measurements of serum FT4 and FT3 levels as well as the TSH and T3 response to TRH. These tests will provide additional supportive diagnostic assistance.

An evaluation of falls, syncope, and dizziness by prolonged ambulatory cardiographic monitoring in a geriatric institutional setting.

Fifty-nine patients living in a geriatric residential setting underwent prolonged ambulatory cardiographic monitoring with the Holter monitor (AHM) as part of an investigation of falls, dizziness, and syncope. In 16 instances, cardiac arrhythmias were a contributing factor; in 12, the diagnostic AHM recordings were associated with unrevealing standard electrocardiographic (ECG) tracings. In 12 patients who had fallen, cardiac arrhythmias played a contributing role, but in only two of these cases was the ECG diagnostic. The value of the AHM for use in managing elderly patients, whose cardiac complaints may be vague, and especially in managing those who have sustained falls, is emphasized.

Reasonable expectations in geriatric rehabilitation.

Rehabilitation and traditional medical treatment have different primary orientations within philosophic, operational and time frameworks. As a result, traditionally trained physicians often do not understand the possible benefits of energetic rehabilitation efforts in the elderly. Accurate assessment includes differentiating the irreversible handicaps of normal aging from the disabilities of remediable disease. Such assessment is the essential prerequisite of effective rehabilitation; together with positive attitudes and continuous reevaluation, the likelihood of a successful outcome is greatly enhanced.

A longitudinal study of falls in an elderly population: I. Incidence and morbidity.

Falls among the elderly, although associated with substantial morbidity and mortality, have not been previously the subject of a longitudinal study. This five-year prospective study of an active ambulatory institutionalized population over 65 years of age, revealed an annual fall rate of 668 incidents per 1000, with a rising frequency in successive age groups after age 75. Forty-five per cent of all subjects suffered at least one fall during the study period. Women had a higher fall rate in all age groups and the severity of their injuries appeared to increase with age. Injuries severe enough to be brought ordinarily to the immediate attention of a physician occurred in 17.5% of falls. Among subjects who ultimately died after suffering many falls, there appeared in some to be a 'clustering' of falls prior to death.

A longitudinal study of falls in an elderly population II. Some circumstances of falling.

Some of the circumstances surrounding 651 falls which occurred in elderly residents of a standard care unit in a home for the aged are described. Falls occurred as frequently at night as during the day-time, and there was no significant variation by day of the week or by season. The great majority occurred inside the home, mainly in the resident's own suite. The subsequent morbidity varied according to the place of occurrence, the percentage of severe injuries being lower in falls occurring in toilets and elevators, and to a lesser extent hallways, compared with those occurring in other inside locations and outside. The commonest activity associated with falling was going to or returning from the toilet. However, one-third of day-time falls occurred when the resident was sitting in a chair. The severity of injury did not vary with associated activity. Possible explanations for these findings are discussed, particularly from the preventive viewpoint.

Serum ionic fluoride: normal range and relationship to age and sex.

We used the Orion fluoride electrode system to determine the normal range of serum ionic fluoride concentrations and to investigate its relationship to sex and age (A). 87 normal men, aged 18-92 years (mean, 46 years), and 49 normal women, age 19-64 years (mean, 38 years), participated in the study. At the 95% confidence limits, males less than 45 years old had a normal range of 0.29 to 1.52 mumol/litre and males greater than or equal to 45 years old 0.29 + 0.0101 (A-45) to 1.52 + 0.0101 (A-45) mumol/litre. Females, however, had a normal range of 0.022A - 0.32 to 0.022A + 1.07 mumol/litre. A group of 51 men 18-44 years old was compared with a group of 36 men 46-92 years old. The mean serum F- of the older group was shown to be significantly greater (P less than 0.01) than that of the younger group. Factors related to serum ionic fluoride values are (a) tea as an important source of dietary F-, (b) the lack of significant variation during daytime hours, and (c) the lack of significant difference in concentration between serum and plsma F-.

Bone loss in primary hyperparathyroidism.

X-ray images of the second metacarpals of 153 hyperparathyroid subjects were measured and an index of cortical bone was derived. Compared with normal standards, the cortical index was above the 50th percentile in only 17.8% of women and 13.6% of men. Comparing the mean index of hyperparathyroid subjects with the normal indices of each 10-year age group, it was found that the differences were highly significant and were the same for all age groups in each sex. In particular, the difference was not greater between older female hyperparathyroid and normal subjects than it was between younger female hyperparathyroid and normal subjects. It appears that bone involvement in the form of excessive cortical thinning is extremely common in hyperparathyroidism and that sex and age do not further influence its incidence or severity.