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Falls in Older People: Risk Factors and Strategies for Prevention.
  1. L Day
  1. Senior Research Fellow, Accident Research Centre, Monash University, Melbourne, Australia; Lesley.Day{at}general.monash.edu.au

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    By S R Lord, C Sherrington, and H B Menz. (Pp 249; A$85.00.) Cambridge University Press (Private Bag 31, Port Melbourne, VIC 3207, Australia), 2001. ISBN 0-521-58964-9.

    This book has been written with a view to consolidating the now substantial body of research on falls aetiology, and the growing literature on proven falls prevention measures. It does not include falls injury and the specific prevention of injuries arising as the result of a fall, such as that provided by external hip protectors. It has primarily been written for readers with a medical, allied health, or research background. Many falls prevention practitioners with a health promotion or health science background will also find this, on the whole, a very useful resource.

    The book is in three sections: risk factors for falls, strategies for prevention, and research issues. Each chapter has good headings which provide useful signposts for the reader and is comprehensively referenced. A conclusion is provided at the end of each chapter, although at times these tend to be a little too broad.

    Section I (risk factors for falls) covers the general falls epidemiology, postural stability, sensory and neuromuscular risk factors, medical risk factors, medications, environmental risk factors, and finishes with a summary chapter. The first chapter provides a good overview of falls epidemiology. The issue of “near-falls” and the relationship to falls is not mentioned. This is an area where thoughtful discussion could be very useful to the field, since prevention programs are sometimes directed at slips, trips, and stumbles. The section on the cost of falls provides a conscientious summary of the economic cost of older persons’ falls, but misses an opportunity to point to the real benefit of costing of falls, that is, assisting policy makers and falls prevention practitioners to select the best value intervention from the growing range of proven interventions. Chapter 2 provides a fascinating insight into the mechanism of balance maintenance.

    Perhaps the most challenging area to incorporate into fall aetiology is that of environmental risk factors. Here the research base is smaller than that for other types of risk factors. Research in this area has typically been less rigorous or has been troubled by methodological limitations, some of which have been overlooked in this book. The authors correctly list the hierarchy of research design: cohort studies, case-control studies, and cross sectional surveys. However, in the study of a transient risk factor such as environmental factors, even cohort studies may sometimes be limited as such risk factors can change between baseline and any fall which may occur subsequently. Another methodological limitation which was not raised is that of insufficient statistical power—some of the case-control studies presented may well have lacked power, having fairly small numbers of cases. On balance, though, the evidence presented in this chapter suggests that environmental risk factors play a part in fall aetiology at least among certain subgroups, including those who report environmental factors which interfere with their activities of daily living, among those with a particular disability, and among more vigorous older people. It is curious then, that in the final summary chapter in this section, the evidence for home hazards as a fall risk factor is rated as non-existent when the evidence presented would appear to be more appropriately rated as weak.

    Section II (strategies for prevention) covers exercise, environmental modification, footwear, assistive devices, hospitals and residential aged care facilities, medical management, medication modification, targeted strategies, and a physiological profile approach for falls prevention. This section takes a fairly clinical or individual patient approach to falls prevention which may well be the most appropriate for the intended audience. Some discussion of the population based approach would have been a particularly useful contribution, as policy makers embrace the challenge of providing for our increasingly aged population. Nonetheless, this section delivers a high quality summary of evidence based falls prevention strategies. Given the opportunity for falls prevention in general practice and family medicine, the chapters on medical management and medication modification are particularly timely.

    The structure of the chapter on exercise options, in my view, does not give a clear overview of the evidence base for this intervention strategy. The chapter begins with an introductory summary of the key trials, finding evidence for and against a protective effect of exercise. This is followed by a section on exercise options, falls, and fall risk factors which systematically presents the results of various studies under four subsections: resistance training, endurance training, individual physiotherapy, and general exercise. Some of the most important studies in this area are not included in these sections, presumably because these were mentioned in the introductory section. These headings are a mix of exercise type (resistance, endurance, general exercise) and method of delivery (individual physiotherapy). There would have been considerable merit in including balance improvement as one of these headings, since two or three of the studies mentioned in different parts of the chapter pointed to a specific benefit of balance improvement on falls prevention. Resistance training was included as a section and yet there is no evidence that this approach reduces falls, although strength is improved. The section on individual physiotherapy reports that research is yet to examine the effect of such one-on-one training on falls outcome. I would have thought that the study by Campbell et al mentioned in the introduction could be considered one such study. This study reported a protective effect of an intervention that consisted of a selection of exercises prescribed by a physiotherapist for each participant. This chapter would have benefited greatly from a summary table of exercise programs tested in randomised trials. By using separate columns to report the impact of these programs on falls risk factors and falls outcome, the message would have been delivered more clearly.

    The greatest strengths of this most welcome book are its analytic and comprehensive nature. Whatever limitations the book may have are more than compensated for by its merits. It brings together the most salient issues for falls prevention for the first time in a specialised text. It critically appraises some of the standard clinical tests, ensures that compliance is addressed in prevention programs, and introduced the concept of using physiological profiles to direct the emphasis of individually tailored preventionstrategies. This authoritative book should become a well worn and dog-eared part of every falls prevention practitioner’s resource library.

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