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`Simple fall' is a forbidden expression on my ward rounds. Falls are common causes of admission of old patients; they are usually complex. The possible causes are legion and important contributory factors are often overlooked.
A new work, Falls in Older People by Lord, Sherrington and Menz1, corrects many misconceptions. Falls are not a non-specific accompaniment of ageing. They are poorly correlated with `dizziness'. Patients may be convinced that they did not lose consciousness when falling, but people with syncope may have retrograde amnesia. The presence of loose rugs in the home is not a predictor of falls: the homes of fallers are no more hazardous than those of non-fallers. Well-meaning therapists may tack down carpets, remove loose mats and relocate furniture. These alterations can annoy the older person (who later may reorder her furnishings in the way she prefers them). The finding that making such apparently sensible modifications to the house causes a reduction in falls outside the house is counterintuitive. Another surprise: there is no direct link between drinking alcohol and falls in old age. Current drinkers have fewer falls than abstainers.
Falls do not occur at random—there is no Poisson distribution. One-third of people over 65 will fall at least once a year. Most falls occur on the flat; falls on the stairs or in the bathroom are relatively rare. Old women tend to fall in the house, old men in the garden. In `care homes', many falls occur on the way to or from the toilet. Only one in a hundred falls results in a hip fracture, but one-fifth cause serious injury. Of those who fall and lie on the floor for hours, half will be dead within six months. Lord and his co-authors carefully analyse the published work on risk factors and prevention. The risk of falls is doubled in dementia. There is also an increased risk with depression; we do not know why. The more drugs an elderly person takes, the greater the risk of falls: the principle of minimal medication is often contravened. Visual impairment is an important risk factor: patients who use eye-drops for glaucoma have a three-fold increased risk of falling; those with cataract are more at risk of breaking a hip. The importance of footwear in the genesis of falls is emphasized: high heels (favoured by many old ladies) reduce stride length, alter toe propulsion and increase lumbar lordosis. Loose slippers can also be a factor in the genesis of falls.
I have nothing but praise for this monograph. The Australian authors—a physiologist, a physiotherapist and a lecturer in foot mechanics and gerontology—recognized that textbooks have dealt with falls superficially and that no-one had methodically analysed and interpreted the published work. They write elegantly and apply academic rigour to the data, highlighting the gaps and uncertainties in our knowledge and generously providing many research ideas for readers to pursue. Each chapter has a succinct summary.
There are over 1000 references, helpful illustrations and very useful tables. We learn about large-scale studies of the effectiveness of multifaceted approaches to falls. There is some evidence for the benefits of specific approaches: after a fifteen-month Tai Chi programme there was a 50% reduction in the risk of falls. The authors make a plea for clarity in the words we use: dizziness can mean many things; drop attacks are not necessarily synonymous with syncope. The list of which risk factors can be modified and which intervention strategies work should be in every geriatric ward and accident and emergency department. Who knows, it might inhibit clinicians from mentioning `simple' falls.