Should primary care patients be screened for orthostatic hypotension?

BACKGROUND: Primary care physicians test for orthostatic hypotension to find risk factors they can modify. By doing so, they may prevent adverse outcomes related to falls and ischemic organ injury due to hypoperfusion. Varied recommendations have been made regarding which patients to test, measurement methods, and the definition of a clinically significant postural decline in blood pressure. METHODS: We identified research articles relating to orthostatic hypotension by doing a literature review. Eleven articles were selected on the basis of quality of research methods and applicability to primary care practice from which prevalence, associated factors, and outcomes related to orthostatic hypotension were reported. RESULTS: The prevalence of orthostatic hypotension varied from 13% to 30.3% in elderly patients. Hypertension was the most consistently associated diagnosis. Two of 3 studies did not find an association between orthostatic hypotension and mortality, and the third found that association only in patients with diabetes and hypertension. CONCLUSIONS: The information available does not support postural blood pressure testing as a screening device among patients attending primary care practices. However, there is evidence to support the testing of high-risk subgroups of patients. Answers to the proposed research questions will clarify how testing for orthostatic hypotension can be most effectively applied in primary care.

Multidimensional correlates of falls in older women.

Older women who had fallen within the last year (n = 63) were compared with those who had not fallen (n = 67) on several psychological and motor measures. Both fallers and nonfallers demonstrated high levels of functioning. Discriminant analysis results indicated that a combination of variables, including physical activity and both psychological (general well-being, self-efficacy) and motor (functional reach, mobility) measures differentiated fallers and nonfallers. Results suggest that falling is a multidimensional phenomenon, that small declines on multiple factors may increase risk of falls, and that multifaceted interventions may help maintain high levels of functioning and prevent declines often associated with increased age.

Accuracy of patient recall and chart documentation of falls.

BACKGROUND: This 1-year prospective study examined the accuracy of patient recall of falls and fall injuries and completeness of chart documentation of these events. METHODS: One hundred ambulatory geriatric family practice patients reported falls weekly by postcard with telephone call follow-up. On a final postcard they reported their recall of falls and fall injuries in the preceding 3-, 6-, and 12-month periods. Patient charts were reviewed for fall documentation. RESULTS: For the 3-, 6-, and 12-month periods, respectively, 31 percent, 44 percent, and 89 percent of participants who had reported a fall recalled at least one fall. Sixty-eight percent of participants who had reported an injury recalled one at the year's end. The positive predictive value of recalling a fall was 92 percent and of recalling a fall injury was 72 percent for the 1-year period. Only 10 of 56 (18 percent) reported falls were documented in the patient's chart. CONCLUSIONS: Patients recalled falls and injuries in the previous 12 months well, but they were less accurate for recall periods of 3 and 6 months. Few reported falls were documented by the patient's physician. Awareness of falls can be increased by asking the patient about falls during the previous year and by documenting all reported and recalled falls.

Characteristics and predictors of falls in elderly patients.

BACKGROUND: Poor performance on mobility testing is one of a number of factors associated with increased falls in community-dwelling elderly. The significance of these associations has not previously been tested in a sample drawn exclusively from a primary care practice. METHODS: This 1-year prospective study recorded falls, fall injuries, and related factors in 120 ambulatory geriatric outpatients of a family medicine practice. The association of mobility score, physician's estimate of mobility score, physician's estimate of likelihood to fall, and other fall risk factors was assessed with whether participants fell. Subjects recorded falls and injuries on weekly postcards. Follow-up by telephone was done to ensure compliance. RESULTS: Thirty-seven (36%) of the 102 participants who completed the study fell once or more. There were 56 total falls, of which 27 (48%) caused injuries. Thirty-six (64% of total) falls occurred in or around the subject's home, and significantly more (chi 2 = 10.93, P less than .001) of these falls had intrinsic causes compared with falls away from home. Prestudy history of subject's falls was significantly associated with subjects' falls during the study, although its sensitivity was only 41%. All other factors studied, including mobility score and the physician's estimates, were not significantly associated with fall status. CONCLUSIONS: This study did not support the use of risk-factor determination to select primary care patients who should be assessed further for fall risk. The high prevalence of falls and injuries in this sample suggests that all elderly patients should be given fall prevention advice.

Physician estimates as predictors of elderly patients' mobility scores.

In a previous study, residency physicians' estimates of patients' mobility scores were strongly associated with the patients' actual scores. The present study tested the hypothesis that community physicians would similarly be able to predict patients' mobility scores. Dysmobility risk-factor questionnaires were given during routine office visits to 120 ambulatory and mentally competent patients older than age 65. After the visit, the attending physician estimated the patient's mobility score (PEMS), and the patient independently underwent mobility testing. The PEMS was 71% sensitive and 80% specific in selecting those patients who had a mobility score of less than 30. Choosing patients with low PEMS or high age (75+) increased sensitivity (96%) while decreasing specificity (53%). Alternatively, selecting only patients over age 75 with low PEMS or problems walking had a sensitivity of 78% and specificity of 86%. This study suggests that by using pretests, the physician can exclude many elderly patients from mobility testing while detecting most of those who are dysmobile.

Predicting elderly patients' mobility using fall history and physician assessment.

This study tested whether a patient's history of falls or an office clinician's general assessment can predict which ambulatory elderly patients will do poorly on mobility testing. Ambulatory patients making routine visits who were age 65 or older, mentally competent, and not acutely ill were eligible. Fifty-two (91%) of these patients participated by completing a fall history questionnaire and undergoing mobility testing. After the visit, the attending physician estimated how the patient would score on the mobility test. Twelve (23%) of the patients reported falls and seven (13.5%) reported fall injuries in the preceding year. Both fall history and physician estimate of mobility score significantly correlated with the measured mobility score. Only the physician estimate of mobility score, however, had adequate sensitivity (94.4%) and specificity (82.4%) to be clinically useful. This estimate will allow the clinician to selectively apply mobility testing to those patients likely to score poorly.

Leprosy presenting as peripheral neuropathy.

Cases of leprosy are increasing in the United States because of immigration from countries where the disease is endemic. Infection may not become apparent for several years after immigration. Symptoms related to involvement of peripheral nervous tissue are often the presenting complaint. Prompt treatment can prevent the potentially severe sequelae of this disease. Current regimens utilize rifampin with dapsone to decrease the development of drug resistance.