Prevention of falls in the elderly.

To prevent falls effectively, one must first understand the underlying reasons. Although environmental factors are sometimes to blame, the fundamental cause is a decline in postural control which is partly age-related and partly due to pathologic changes in the central nervous system. Dizziness is a common complaint among those who fall, and it is often caused by a central or peripheral vestibular disorder. Many patients who complain of dizziness do not have true vertigo but are expressing a fear of falling. Balance exercises can improve postural control and confidence in these patients. Falls are not inevitable in old age and may be prevented by maintenance of health, mobility and confidence, the avoidance of certain drugs, identification of specific problems such as cardiac arrhythmias or postural hypotension, and attention to environmental hazards.

Experience with an incontinence clinic.

In an "incontinence clinic," a study of 309 elderly patients showed the most common causes of incontinence to be: unstable bladder (57 percent), outflow obstruction (13 percent), and atonic bladder (7 percent). Pure stress incontinence was rare (2 percent). One third of the patients improved, one third had to be catheterized, and one third did not improve. An individually designed program of bladder retraining for the patient, coupled with support and instruction for the relatives and for the professional care providers, offered the best chance of success.

Multicentre, double-blind, randomised comparison between lamotrigine and carbamazepine in elderly patients with newly diagnosed epilepsy. The UK Lamotrigine Elderly Study Group.

In a multicentre, double-blind trial 150 elderly patients (mean age 77 years) with newly diagnosed epilepsy were randomised in a 2:1 ratio to treatment with lamotrigine (LTG) or carbamazepine (CBZ). Following a short titration period, the dosage was individualised for each patient while maintaining the blind over the next 24 weeks. The main difference between the groups was the rate of drop-out due to adverse events (LTG 18% versus CBZ 42%). This was in part a consequence of the lower rash rate with LTG (LTG 3%, CBZ 19%; 95% CI 7-25%). LTG-treated patients also complained less frequently of somnolence (LTG 12%, CBZ 29%; 95% CI 4-30%). Although there was no difference between the drugs in time to first seizure, a greater percentage of LTG-treated patients remained seizure-free during the last 16 weeks of treatment (LTG 39%, CBZ 21%; P = 0.027). Overall, more patients continued on treatment with LTG than CBZ (LTG 71%, CBZ 42%; P < 0.001) for the duration of the study. The hazard ratio for withdrawal was 2.4 (95% CI 1.4-4.0) indicating that a patient treated with CBZ was more than twice as likely to come off medication than one taking LTG. In conclusion, LTG can be regarded as an acceptable choice as initial treatment for elderly patients with newly diagnosed epilepsy.

Uncertainties in the pharmacotherapy of Parkinson's disease and how to solve them.

The causative relationship between levodopa and the long-term motor complications of therapy, along with the possibility that levodopa may be toxic to dopaminergic neurones in vivo, has led to a move away from its use in early Parkinson's disease. Alternatives such as amantadine and the anticholinergics suffer from poor efficacy in comparison and a high side effect profile. Selegiline is probably less effective than levodopa and the issue of its safety versus neuroprotective properties remains unresolved. Long-term trials with the old and newer dopamine agonists as monotherapy have shown that as a class they can delay the development of dyskinesia and probably response fluctuations. However, major uncertainties remain about their use as monotherapy in all patients instead of levodopa. No data on their effect on quality of life and health care costs are available. Most of the trials were heavily biased towards younger patients with Parkinson's disease, so little data in the elderly are available. In later disease when patients have already developed motor complications on levodopa, the choice rests between adjuvant therapy with a dopamine agonist, a catechol-O-methyltransferase inhibitor (COMT; e.g. entacapone), and a monoamine oxidase B inhibitor (MAO B; e.g. selegiline). Trials with the former two classes have confirmed that they can reduce 'off' time, reduce levodopa dose, and improve motor impairments and disabilities with acceptable increases in adverse events including dyskinesia. Trials with selegiline as adjuvant therapy were less rigorous but it can allow a reduction in levodopa dose and motor impairments. No studies have compared these three classes of drug as adjuvant therapy so there is no evidence on which to base rational decisions in this type of patient. A large pragmatic trial which includes older patients is needed to clarify which treatment is best for different stages of the disease.

Geriatric medicine in the European Union: future scenarios.

The differences in training and services in geriatric medicine between European Union member countries raise some questions: what is a geriatrician, what is geriatric medicine, what will be the future development of the specialty and how does it interact with other medical specialties? To find answers to these questions, a questionnaire was sent to a selected group of 122 geriatricians. The response rate was 60%. A description has been given of what is a geriatrician and what is geriatric medicine. Based on data from the literature and the answers of the respondents six future scenarios were designed. The six scenarios are: the 'healthy old people', the 'adapted specialties', the 'general practitioner + additional training', the 'co-ordinator geriatrician', the 'community geriatrician' and the 'hospital geriatrician'. The answers of the respondents gave doubts whether general practitioners are able to provide the full range of services for geriatric patients in the community. A small majority of the respondents opted for a division of the specialty into community geriatric medicine and hospital geriatric medicine. Such a division offers good opportunities to raise the quality of medical services and to reduce age-related treatment limitation. It is expected that some aspects of geriatric medicine will be included in the training of other specialties and some GPs will obtain additional training. The collected data can not be considered as a representation of the ideas of the European Union geriatricians. However, they may contribute to the discussion on the national and European level about the future of the specialty.

A comparative study of lormetazepam and chlormethiazole in elderly in-patients.

Sixty-two elderly in-patients suffering from insomnia were studied in a double-blind, double-dummy, placebo-controlled trial. Each group received either lormetazepam 1 mg, chlormethiazole 384 mg or placebo for 7 nights. Both lormetazepam and chlormethiazole significantly increased sleep duration, reduced sleep latency and improved quality of sleep and feelings on awakening. For both drugs, reaction times the next morning were unimpaired and there was no clinical evidence of accumulation after 7 nights continuous dosing. Lormetazepam and chlormethiazole in these doses are effective and safe hypnotics for frail elderly patients.

Simplification of the initiation of bromocriptine in elderly patients with advanced Parkinson's disease.

One hundred and seventy-three parkinsonian patients treated with levodopa entered a randomized multicentre comparison between two introductory schedules for adjuvant bromocriptine. A 2-week placebo run-in was followed by a double-blind 8-week titration phase of bromocriptine up to 15 mg daily, according to the standard seven-step, or a simpler three-step, regimen. They were maintained on this dose for a further 8 weeks and then followed for a further 12 weeks. One hundred and fifty-nine patients completed the placebo run-in period, and 132 completed 16 weeks. No significant differences were found between the standard and simplified regimens for efficacy, side-effects, withdrawals or deaths, nor for any of the clinical or functional assessments. The Webster score improved by 29% and the Cape ADL by 32%. The simpler schedule offers advantages to those elderly parkinsonian patients in whom bromocriptine is added to optimal levodopa dosage.

Vertigo in the elderly.

Half the elderly referrals to a vestibular clinic have, as their principal diagnosis, a central vestibular lesion and a quarter have a peripheral lesion. Many patients also have widespread impairment of postural control so that a precise diagnosis is often difficult. Drugs are rarely of help, except for peripheral vestibular lesions and exercises to improve balance and confidence are often found to be the best approach for vertiginous patients.

Falls in the elderly related to postural imbalance.

Two hundred and forty-three elderly people aged 60 to 96 years were questioned about their falls, and their sway was measured. For comparison sway was also measured in 63 younger subjects. Sway increased with age and was higher in women at all ages. There was no difference in sway between those with no history of falls and those who fell only because of tripping. In both sexes sway was significantly increases in people who fell because of loss of balance and in women whose falls were due to giddiness, drop attacks, turning the head, and rising from bed or a chair. This suggests that there is a physiological decline in postural control with advancing age and also a decline due to disease of the central nervous system.