Athanasios Katsarkas, MD, MSc, FRCS(C), Professor of Medicine, McGill University; Director, Dizziness Clinic, Royal Victoria Hospital, Montreal, QC.

Dizziness is a frequent complaint in aging. Although a number of circumstances in everyday life may cause falls and injuries, such events are often due to dizziness induced by pathology. Dizziness as a consequence of more than one organic syndrome is not uncommon in the elderly. In addition, medication may further complicate the clinical picture. Such combinations may pose diagnostic challenges. This paper deals briefly with postural and gaze control in health and disease, how to take the history in dizziness, some peculiarities of the clinical examination, and the most common syndromes of brain stem or inner ear diseases that cause dizziness in general and, more specifically, in aging.
Key words: dizziness, vertigo, falls, vestibular dysfunction, brain stem disease.

Dr. Gabriel Chan, MBBS(HK), FHKAM, MRCP(UK), ABIM, FRCP(C), FRCP(EDIN),
Director of Geriatric Medical Services and Program Medical Director of Long-Term Care, North York General Hospital, Lecturer of Medicine, University of Toronto, Toronto, ON.

Frances Simone, BSc, MHA, Director, Geriatric Ambulatory Care Services, North York General Hospital, Toronto, ON.

The POWER (Promoting Osteoporosis Wellness through Education, Exercise and Resources) program is a collaborative, multi-site initiative designed to empower older adults with osteoporosis to improve their quality of life and prevent falls. POWER consists of a seven-week, culturally sensitive education, exercise and nutrition program developed by North York General Hospital, Baycrest Centre for Geriatric Care, Toronto Public Health and Yee Hong Centre for Geriatric Care. POWER is an effective health promotion model for osteoporosis management and falls prevention that can be replicated in other communities across the country.

Health promotion and disease prevention are very important concepts that support our collective goal for a healthy society. Currently, there is a need to develop models that fully integrate health promotion activities into our 'illness treatment' oriented health system. Without such models, we will face significant challenges as our population ages and our health system attempts to cope with the impact of chronic diseases.

M. Clare Robertson, PhD
Research fellow,
Department of Medical and Surgical Sciences,
University of Otago Medical School,
Dunedin, NZ.

A. John Campbell, MD, FRACP
Professor of Geriatric Medicine,
Department of Medical and Surgical Sciences,
Dean, Faculty of Medicine,
Dunedin, NZ.

Introduction
Falls are a common problem in older people and substantial healthcare resources are required for the treatment of injuries, for rehabilitation and for long-term care after a fall. For the older person and their family or caregivers, a fall can have serious consequences: trauma, pain, impaired function, loss of confidence in carrying out daily activities, loss of independence and autonomy, or even death.

Falls prevention strategies have been based on the multiple risk factors for falls and these are well defined in the literature.¹ There is now good evidence from randomized controlled trials that carefully designed, single or multiple interventions can reduce falls in older people living in the community.² There are fewer reports on the cost effectiveness of these strategies--useful information for making informed decisions on the allocation of scarce healthcare resources.

Figure 1 gives a list of the falls prevention strategies for community living older people that have been tested in randomized, controlled trials.

An Aging Population will Lead to Mounting Fall-Related Health-Care Costs

Brian E. Maki, PhD, PEng
Professor, Department of Surgery and Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

It is well established that falling is a common occurrence in persons aged 65 and older. Among those living independently, 30-60% will fall one or more times each year,^1-3 and the falling rate is even higher among those living in long-term or acute-care institutions.^4,5 Although the degree to which the falling rate among older adults differs from that among younger adults has not been well established, it is clear that falls in older persons are much more likely to result in serious physical and psychosocial consequences. The first part of this two-part article dealt with the fear of falling and other psychosocial correlates of falls, which has tended to be an under appreciated aspect of the problem. The now forthcoming second part, will focus on what has, historically, received the most attention-the physical consequences of falls.

Although the majority of falls do not result in serious physical injury, the societal costs associated with fall-related injuries are immense. Falls are, in fact, the leading cause of fatal injuries among seniors, accounting for twice as many deaths in this population as motor vehicle accidents.

Brian E. Maki, PhD, PEng
Professor, Department of Surgery
and the Institute of Medical Science,
University of Toronto; and Senior Scientist,
Sunnybrook and Women's College Health Sciences Centre

Hip fractures and other physical consequences of falls in older adults have received a great deal of attention, both in the scientific literature and the popular press. It is only recently, however, that the psychosocial consequences of falling, such as fear of falling, have begun to receive due recognition. The injuries due to falls may well prove to be the "tip of the iceberg", with the psychosocial sequelae incurring even greater societal costs.

Murphy and Isaacs¹ first described the "post-fall syndrome" as an extreme fear of falling, characterized by a tendency to stagger, to clutch at objects, and to show hesitancy or alarm when asked to walk without assistance. Some researchers believe that such an anxiety syndrome can be viewed as a classic phobia, and in fact have coined the phrase "ptophobia" to refer to a phobic reaction to standing or walking.² While such a severe reaction may be relatively uncommon, a more moderate fear of falling is very widespread among older adults, with reported prevalence ranging from 20-60%.^3,4 The prevalence increases with age and is reportedly more common among women.4 One should note, however, that a gender-related bias in the willingness to report fear could confound the latter finding.

Psychotropic Drugs and Polypharmacy are Proven Risk Factors for Falls

Tawfic Nessim Abu-Zahra, MSc

Many risk factors have been shown to contribute to falls suffered by the elderly, including the use of sedatives¹ and the concurrent use of several medications.^2-4 Evidence-based conclusions concerning the relationship between drugs and falls provide limited confirmation due to the studies results' variability, inconsistencies in classification schemes of drugs, and because of the small number of subjects participating in most studies.³ Thus, singling out specific agents and recommending guidelines for prescribing to the elderly is difficult. However, some studies have implicated psychotropic or CNS-active drugs, including sedatives, antidepressants and neuroleptics, as being especially high-risk in terms of leading to falls. Hence, special caution should be taken in prescribing these for the elderly.

Leipzig and colleagues reviewed^3,4 all existing literature dealing with the association between drugs and falling in the elderly. Pooled odds ratios that measure the likelihood that a person taking a drug will also experience a fall were calculated for different classes of drugs.

Chris Brymer, MSc, MD, FRCPC
University of Western Ontario,
London, Ontario

Falls are the leading cause of injury admissions to acute care hospitals in Ontario, and are a common cause of admission to an inpatient geriatric assessment unit. Although falls prevention has been an active, ongoing area of geriatric research for many years, the publication of the results of 4 randomized controlled trials in 1999, addressing falls prevention in the outpatient setting, suggests we may be 'turning the corner', going from research to actual practice.

Close et al's January 1999 study published in Lancet, randomized 397 patients, 65 years of age and older, who had presented to an emergency department with a fall and who were provided with either usual care (n=213), or a detailed falls assessment (n=184).¹ Intervention patients underwent a detailed assessment of their visual acuity, balance, cognition, affect, and medication use by a physician in a day hospital setting, and had their functional status and home environment assessed by an occupational therapist. Although the intervention was essentially a 'one-time' assessment, follow-up care was recommended in 84% of cases. During a one-year follow-up period, self-reported falls, recurrent falls, and hospital admission were 61%, 67%, and 39% lower, respectively, in the intervention group by comparison with the usual-care group. Follow-up data was available after one year for approximately 77% of the patients in each group.

Mobility Devices and Good Caregivers Facilitate Recovery and Deter More Falls

Nariman Malik, BSc

Falls in the elderly are a common problem, and often can have serious sequelae. The physical injuries that may be sustained after a fall can lead to hospitalization or even institutionalization. Falls are often considered to be an inevitable consequence of aging; however, they may in fact signal the onset of an illness or an underlying cause of frailty.¹

Falls are a significant cause of disability and death in older persons.² Fractures are a result in 3-5% of cases.³ The most serious fracture in the elderly is the hip fracture, which often requires surgical repair, a procedure which itself is plagued by a high incidence of morbidity and mortality.³ A fall may also lead to immobility which can lead to dehydration, rhabdomyolysis and pressure ulceration. Falls can also often lead to a fear of falling, which may result in withdrawal from usual activities and even social isolation and/or depression which ultimately results in both decreased mobility and a loss of independence.^2,4 Primary care physicians managing elderly patients should be prepared to assess appropriately patients who have fallen, and strive to develop a management plan tailored to meet patients' needs.

Identifying Modifiable Risk Factors in Order to Prevent Future Falls

D'Arcy Little, MD, CCFP
Director of Medical Education and Research
York Community Services, Toronto, ON

Introduction and Epidemiology
Falls are a major health problem for the elderly and have been referred to as one of the "Geriatric Giants."¹ The annual incidence of falls among the community-dwelling elderly is estimated to be 30% among those between 65 and 80 years of age, and 50% among those over 80 years of age.² The annual incidence of falls among elderly nursing home residents is estimated to be 50%, with 40% of residents suffering multiple falls each year.²

Falls are a cause of significant morbidity and mortality in the elderly. Accidents are the 6th leading cause of death in persons over 65, and falls are estimated to be responsible for two-thirds of these deaths.² As a result, falls directly or indirectly cause 12% of deaths within the geriatric population.³ In addition, up to 50% of falls in the elderly give rise to soft-tissue injury, with 5% of these being classified as serious. One percent of falls results in hip fractures, and two-thirds of these patients are unable to return to their pre-fracture functional level. Up to 5% of falls give rise to other varieties of fractures.

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.