Alcohol and psychotropic drugs: risk factors for orthostatic hypotension in elderly fallers.

We assess orthostatic hypotension (OH) prevalence in elderly fallers and determine OH-associated risk factors in this patient population. A monocentric prospective study at Lille University Hospital Falls Clinic included 833 consecutive patients who had fallen or were at high risk of falls and who were assessed for the presence of OH. Among 833 patients aged 80.4±7.4 years, OH was found in 199 subjects (23.9% of cases). Multivariate analysis showed that selective serotonin reuptake inhibitors (odds ratio (OR) 2.42, 95% confidence interval (CI): 1.56-3.75), serotonin-norepinephrine reuptake inhibitors (OR 5.37, 95% CI: 1.93-14.97), Parkinsonian syndrome (OR 2.54, 95% CI: 1.54-4.19), excessive alcohol consumption (OR 2.17, 95% CI: 1.32-3.56), meprobamate (OR 2.65, 95% CI: 1.12-6.25) and calcium channel blockers (OR 1.79, 95% CI: 1.16-2.76) were all risk factors for OH. In contrast, angiotensin receptor blockers (OR 0.52, 95% CI: 0.30-0.91) appeared to be protective factors against OH. This study demonstrates that a systematic investigation should be made in all elderly fallers and those at high risk of falls to detect the presence of OH. In OH patients, in addition to the usual predisposing factors, excessive alcohol consumption and psychotropic drug intake-in particular, the intake of serotonergic antidepressants-should be taken into account as potential risk factors.

The Functional Reach Test: strategies, performance and the influence of age.

BACKGROUND: The Functional Reach Test (FRT) is a clinical assessment of the risk of falls in elderly or disabled subjects. However, the FRT is complex (involving the leg, hip and trunk joints) and previous studies have shown that several different strategies can be used to complete the test. OBJECTIVES: To describe the strategies used by healthy, adult subjects when performing the FRT and to assess the influence of age on choice of the strategy. METHOD: This was a pilot study in which 29 non-fallers (18 under-50s and 11 over-75s) were asked to perform the FRT on a force platform in a motion analysis laboratory. A total of 18 reflective markers were placed on the body. The main outcome measures were the FRT score, the centre of pressure (CoP) excursion, and kinetic and kinematic test data. The two age groups were compared using a non-parametric, two-sample Mann-Whitney U test. A cluster analysis of the entire population grouped subjects together according to their functional similarities. RESULTS: The older subjects displayed a smaller CoP anteroposterior displacement (P<0.01), greater backwards displacement of the pelvis (P<0.05) and less trunk rotation during the FRT (P=0.024) than the younger subjects. The cluster analysis split the population into two groups, which differed in terms of age, FRT score, pelvis translation, and CoP displacement. CONCLUSION: Our results suggest that at the moment of trunk flexion, elderly subjects use pelvic translation in order to limit forward displacement of the CoP and prevent forward imbalance.

Fear of falling as seen in the Multidisciplinary falls consultation.

UNLABELLED: Fear of falling may be as debilitating as the fall itself, leading to a restriction in activities and even a loss of autonomy. OBJECTIVES: The main objective was to evaluate the prevalence of the fear of falling among elderly fallers. The secondary objectives were to determine the factors associated with the fear of falling and evaluate the impact of this fear on the activity "getting out of the house". PATIENTS AND METHOD: Prospective study conducted between 1995 and 2006 in which fallers and patients at high risk for falling were seen at baseline by the multidisciplinary falls consultation team (including a geriatrician, a neurologist and a physical medicine and rehabilitation physician) and then, again 6 month later, by the same geriatrician. The fear of falling was evaluated with a yes/no question: "are you afraid of falling?". RESULTS: Out of 635 patients with a mean age of 80.6 years, 502 patients (78%) expressed a fear of falling. Patients with fear of falling were not older than those who did not report this fear, but the former were mostly women (P<0,001), who experienced more falls in the 6 months preceding the consultation (P=0.01), reported more frequently a long period of time spent on the floor after a fall (P<0.001), had more balance disorders (P=0.002) and finally, were using more frequently a walking technical aid (P=0.02). Patients with fear of falling were not going out alone as much as the fearless group (31% vs 53%, P<0.0001). Eighty-two percent of patients in the fearful group admitted to avoiding going out because they were afraid of falling. CONCLUSION: The strong prevalence of the fear of falling observed in this population and its consequences in terms of restricted activities justifies systematically screening for it in fallers or patients at risk for falling.

Impact of different types of walking aids on the physiological energy cost during gait for elderly individuals with several pathologies and dependent on a technical aid for walking.

UNLABELLED: In elderly individuals balance disorders and muscle weakness can lead to prescribing a walker. There are several different models. According to the very poor effort tolerance in this population, the energy cost necessary to operate walking technical aids should be taken into account when making a choice. OBJECTIVE: Compare two types of walker in regards to energy cost produced during gait in weakened elderly individuals. METHOD: Thirty subjects over the age of 65 (six men and 24 women, mean age 81.9 years) were admitted in geriatrics care. They all required a walker and performed the same 10-m course with a fixed walker, then with a model bearing front wheels. The walking speed (S) was computed, heart rate at rest (HRrest) and maximum heart rate (HRmax) were recorded during the test. The physiological cost index (PCI=HRmax-HRrest/S) was calculated. Finally a timed get-up-and-go (TGUG) test was performed with each of these technical aids. RESULTS: With a rollator walker, HRmax was lower (P<0.05) and S higher (P<0.001). It was 2.01 with a fixed walker versus 1.23 with a rollator walker (P<0.01). We found this speed difference during the TGUG test (72.26 sec vs. 82.93 sec, P=0.001). DISCUSSION AND CONCLUSION: There are very little studies on the evaluation of physiological energy cost produced during gait with a walker. The characteristics of our population did not allow us to conduct our test without a technical aid. The use of a fixed walker leads to a major increase in gait PCI, probably due to the required repeated efforts for lifting the walker. This model must be avoided in case of cardiac or respiratory disorders.

[Neurological diseases detected in the Lille Multidisciplinary Falls Consultation]. / Les maladies neurologiques repérées lors de la consultation multidisciplinaire de la chute du CHRU de Lille (France).

BACKGROUND: People with neurological disorders including stroke, dementia, Parkinson's disease, and polyneuropathy are known to have an increased risk of falls. OBJECTIVE: To evaluate the prevalence and nature of neurological risk factors among the patients attending the Multidisciplinary Falls Consultation of the University Hospital of Lille (France), and to analyze the characteristic features of patients termed "neurological fallers" with neurological risk factors. METHODS: The study included 266 consecutive patients who were initially assessed by a geriatrician, a neurologist and a physiatrist, and again, six months later, by the same geriatrician. RESULTS: Two out of three patients had neurological signs that can be regarded as neurological risk factors of falling. These neurological signs had not been diagnosed before the consultation in 85% of cases. The most common conditions were deficit of lower extremity proprioception (59% of patients) and cognitive impairment (43%). The most frequently evoked neurological diseases were dementia (40% of patients), polyneuropathy (17%) and stroke (8%). Compared with other patients, "neurological fallers" were more frequently living in a nursing home, had lower ADL and MMSE scores at baseline, had experienced more falls in the six preceding months, had a lower probability of having a timed Up-and-Go test less than 20 seconds and a single limb stance equal to 5 seconds. In the follow-up, "neurological fallers" reported hospitalizations more often. CONCLUSION: The findings show that a large proportion of old persons presenting at the Multidisciplinary Falls Consultation have unrecognized neurological disorders. Comprehensive neurological examination including an evaluation of cognition is required in every elderly faller.

A specific clinical pattern of camptocormia in Parkinson's disease.

BACKGROUND: Camptocormia, characterised by extreme forward flexion of the thoracolumbar spine and severe stooping in the supine position, seems to be prevalent in Parkinson's disease. OBJECTIVE: The aim of this study was to identify features of parkinsonian camptocormia and to describe the main clinical characteristics of patients with Parkinson's disease who develop the condition. METHODS: An extensive range of clinical, biochemical and imaging data were gathered for 23 patients with Parkinson's disease with camptocormia, notably including magnetic resonance imaging (MRI) of the brain and spine, electromyographic recordings of the paravertebral muscles and muscle biopsies. RESULTS: Camptocormia occurred in severe Parkinson's disease with axial predominance, motor fluctuations and dysautonomic symptoms. The condition was often associated with spondyloarthritic changes and pain. MRI showed paraspinal muscle signal abnormalities in five patients and fatty involution in seven patients. The seven patients had motor unit reductions on the spinal erector electromyogram. The MRI results for the girdle muscles were normal. Cranial MRI showed signal abnormalities for the basal ganglia in three patients. DISCUSSION: Various mechanisms may contribute to the development of parkinsonian camptocormia: dopaminergic depletion in Parkinson's disease induces functional changes in the organisation of the corticospinal and reticulospinal tracts, where dysfunction could contribute to axial rigidity. Furthermore, rigidity of the spinal flexion muscles could lead to under-use of the spinal extension muscles, which become progressively atrophic. Rigidity may also induce spinal deformations, leading to a neurogenic syndrome via compression of the spinal nerves. CONCLUSION: The screening and early management of camptocormia in Parkinson's disease is likely to be important for preventing axial disorders and spinal deformations.

[Leather corset for the treatment of camptocormia: 31 cases]. / Appareillage par corset cuir des postures camptocormiques: à propos de 31 cas.

INTRODUCTION: Camptocormia is an acquired postural disease leading to wide-ranging emerging rachidian kyphosis. Kyphosis can be observed when the patient stands up, walks or sits. The functional impact can be significant. When the etiology is better known, personalized treatments are often deceitful. Physical therapy and orthesis may be proposed. Classical antikyphotic orthesis for the trunk are usually not well tolerated and are quickly abandoned. We proposed the use of traditional leather orthesis for such cases. MATERIALS AND METHOD: This retrospective study undertaken between April 2001 and April 2003 included 31 patients with camptocormia for whom orthesis was indicated. Eight patients benefited from use of a classical lumbar belt. All assessed the ortheses as not satisfactory. In 27 patients, leather orthesis was prescribed, and 20 used it, 19 of whom answered a questionnaire assessing functional benefits as follows: the patient is well or very well straightened, suffers less from trunk pain, suffers less or no longer when standing up without assistance during a long period, has less or no difficulty to walk, feels less or no longer tired because of the effort to stay straight without the orthesis, does not resent the alteration of social life because of the orthesis, and assesses active life as satisfactory. RESULTS: The average time to wear the othesis was 33 months. Sixty-eight percent of patients wore it at least 9 hours a day; 84% were able to put it on by themselves. The respiratory and cutaneous consequences were judged good and digestive and urinary tolerance adequate. With the orthesis, 74% of the patients responded positively to 5 of the 7 functional areas assessed. Why patients do not wear ortheses is often explained by the failure to obtain a satisfactory straight position and/or an ankle flexion, associated significant pathology, lack of motivation and difficulty in putting the orthesis on alone.

[Cognitive disorders and falls: experience of the Lille multidisciplinary falls service]. / Troubles cognitifs et chutes: l'expérience de la consultation multidisciplinaire de la chute de Lille.

BACKGROUND: Falls and dementia are two major public health problems which concern the elderly population. Cognitive impairment, as a result of Alzheimer's disease or non-Alzheimer dementia, is recognized as a risk factor for falling. Through the experience of the Multidisciplinary Falls Consultation, our aims were first, to evaluate the prevalence of a cognitive decline among outpatients who consult for falls, and second, to determine whether the cognitive impairment was known and diagnosed before the consultation or not. METHODS: Data concerning the first 300 outpatients who completed the initial evaluation are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home. Cognitive impairment was defined as a Mini-Mental State Examination (MMSE) score<24. RESULTS: Of the 300 patients, 228 patients completed the initial evaluation. Among them, 97 (42.5 percent) had a MMSE score<24; 55 had mild stage dementia (MMSE score between 23 and 18) and 42 were at a moderate or severe stage (MMSE score< or =17/30). The cognitive decline was not diagnosed before the consultation in 80 of the 97 patients (82 percent). CONCLUSION: The findings show that a large proportion of old persons presenting with gait disturbance at the Multidisciplinary Falls Consultation have an underlying cognitive decline. Assessment of cognitive functions is required in every elderly faller.

Benefits of home visits for falls and autonomy in the elderly: a randomized trial study.

OBJECTIVE: To investigate whether home visits by a occupational therapist reduces the risk of falling and improves the autonomy of older patients hospitalized for falling. DESIGN: In this randomized, controlled trial set in a geriatric hospital, 60 patients (mean age, 83.5 yr) who were hospitalized for falling were recruited from the acute medicine department. A home visit from an occupational therapist and an ergotherapist assessed patients' homes for environmental hazards and recommended modifications. The outcomes measured were falls, autonomy, hospitalization for falling, institutionalization, and death. RESULTS: During the follow-up period, the rate of falls, hospitalization for falls, institutionalization, and death were not significantly different between the two groups. Both groups had a loss of dependence at 12 mo. This loss of dependence was significant in the control group but not in the intervention group. CONCLUSIONS: Home visits from occupational therapists during hospitalization of older patients at risk for falling can help to preserve the patient's autonomy.

Successes and setbacks of the falls consultation: report on the first 150 patients.

OBJECTIVE: We report the results of a Falls Consultation. DESIGN: Data concerning the first 150 patients are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home, and was reassessed by the same geriatrician 6 mo later. RESULTS: Of the 150 patients, 135 patients completed the initial evaluation. Most of them were frequent fallers. The population was very heterogeneous regarding the health status and the degree of disability. In most cases, falls were the result of several interacting factors. The most frequent recommendations from the staff were physical therapy, environmental changes, and medication changes. Over the following 6 mo, approximately one out of four patients had experienced new falls. However, the risk of falling was significantly reduced (5.3 +/- 7.3 falls in 6 mo before vs. 0.8 +/- 1.6 falls in 6 mo after the intervention). The Activities of Daily Living score was a predictor of recurrent falls, hospitalization, and institutionalization. CONCLUSION: Our results show that a multidisciplinary falls consultation can be efficient in reducing the risk of falls in nonselected elderly fallers but suggest that differential strategies are needed to manage adequately the more vigorous and the frail old person as well.