Frédéric Bloch

Psychotropic Drugs and Falls in the Elderly People: Updated Literature Review and Meta-Analysis:

Objective: To carry out meta-analyses on psychotropic drugs and to provide an update of the risk of falling in the elderly people related to psychotropic drugs. Design: Meta-analyses of studies on psychotropic drugs. Results: 177 studies are included, of which 71 have data on risk factors associated with psychotropic drugs. The odds ratio and 95% Cl for associations between use of psychotropic drugs and fall are 1.78 and 1.57-2.01, respectively. This result is statistically heterogeneous. This heterogeneity disappears in the group of very old participants for each class. Conclusion: Our study confirms the association between falls in the elderly people and psychotropic drugs. These results are similar to those of former meta-analyses but with different methods. It shows that these meta-analyses on psychotropic drugs have a small impact on prescribing habits. They only give evidence to support the association between psychotropic drugs and falls even if there is no proven link.

Impact of physical activity and sedentary behaviour on fall risks in older people: a systematic review and meta-analysis of observational studies

The objective of this work was to summarise and evaluate the evidence showing that physical activity is a protector factor as regards falls in older people. Relevant studies were identified through a systematic search in the MEDLINE and Cochrane Library, under the keywords of accidental fall/numerical data and risk factors, and with the bibliographies of retrieved papers. The combined odds ratio (OR) [95% confidence interval] for physical activity was 0.75 [0.64, 0.88] with moderate heterogeneity (I2 = 33%). For fall injury, it was 0.59 [0.47, 0.74] and, for falls in general, it rose to 0.94 [0.76, 1.17] with nil heterogeneity. The combined OR for sedentary factors was 1.14 [1.10, 1.82] with moderate heterogeneity (I2 = 36%). Regular physical activity in daily life yields significant reduction in falls in older people, especially falls with injuries.

Do ED staffs have a role to play in the prevention of repeat falls in elderly patients

BACKGROUND Fall-related morbidity is a serious public health issue in older adults referred to emergency departments (EDs). Emergency physicians mostly focus on immediate injuries, whereas the specific assessment of functional consequences and opportunities for prevention remain scarce. The aim of this study was to determine the factors influencing 6-month independence. METHODS We used a prospective observational study at the ED of a tertiary teaching hospital over a 6-month period. Uni- and multivariate assessments of factors related to loss of independence were examined. RESULTS A total of 367 patients survived to 6 months, mean age was 86 years, and 79% were women. The population was initially healthy and independent. Because this independence reassured the medical staff, more than 42% percent were directly discharged home without any improvement of home facilities; only 63% had recovered their independence at the end of the follow-up. There were 111 patients were hospitalized for 30 days or more. Older patients, initial Katz score, and absence of immediate trauma consequences were associated with an increased risk for loss of independence. CONCLUSIONS Because prevention is an emerging role of ED, a multidisciplinary team should evaluate fallers and propose medical and environmental changes as required for those discharged after their ED visit.

Anxiety after a fall in elderly subjects and subsequent risk of developing post traumatic stress disorder at two months. A pilot study.

BackgroundThe psychological burden suffered by elderly subjects after a fall adds to rehabilitation difficulties. We hypothesised that Post Traumatic Stress Disorder (PTSD) may be at the root of these psychological post-fall problems. The immediate psychological state was examined after 2 months post-fall in order to determine the prevalence of anxiety and PTSD and their possible correlates.MethodA single centre prospective survey including elderly subjects referred to an emergency department (ED) after a fall with a 2-month follow-up.Results30.5% of patients showed a significant level of anxiety after their fall and (26%) showed evidence supporting the presence of PTSD at 2-months. Immediate anxiety, ability to re-establish upright posture and a history of repeated falls were significant predictors of PTSD at 2-months.Conclusionpersistent psychological problems post fall may be related to PTSD which is significantly correlated to immediate anxiety. This study can be seen as a first step in patient characterisation, and predicts who may benefit from which of the various approaches of rehabilitation.

Estimation of the risk factors for falls in the elderly: Can meta‐analysis provide a valid answer?

The objective of this study was to analyze whether a meta‐analysis could allow us to draw useful conclusions about the risk factors for falls in the elderly. A systematic review was carried out of various databases and completed manually. To satisfy the inclusion criteria, an article had to examine a population of subjects aged over 60 years to pertain to falls occurring during daily living activities, and to involve observational or interventional studies. This review identified 4405 indexed articles published between 1981 and 2011. Of the 220 studies with available data that were included in the final study, just 4% were interventional. Among these 220 studies, just 45% offered a satisfactory level of scientific proof. In total, 88 meta‐analyses were carried out on the 156 potential protectors or risk factors that were identified. Our systematic review and meta‐analyses ensured that high‐quality results were obtained from this comprehensive literature search and included a detailed assessment of the quality of the included studies. Several factors appeared to be disproportionately represented in the literature, a fact that likely reflects the objective and precise assessment of these factors rather than their importance in the falls of the elderly. Thus, we cannot be certain that we obtained the most comprehensive analysis of the risk factors for falling with this method. Meta‐analyses can help to define the association between falls and various risk factors, but they have to be used complementary to systematic review for the assessment of risk factors. Geriatr Gerontol Int 2013; 13: 250–263.

Effect of sublingual administration of interferon-α on the immune response to influenza vaccination in institutionalized elderly individuals

A randomized double-blind placebo-controlled study was conducted to determine the effect of sublingual administration of IFNalpha on the immune response to influenza vaccination in elderly institutionalized individuals. Sublingual administration of 10 million IU of IFNalpha immediately prior to vaccination, reduced the geometric mean haemagglutination inhibitory (HAI) and IgG2 circulating antibody titers, and the secretory IgA (sIgA) response in saliva, to the New York strain of influenza A virus, 21 days post-vaccination, without detectable drug-related local or systemic toxicity. IFN treatment did not inhibit the immune response to the other components of the vaccine; the New Caledonia strain of influenza A virus, or the Jiangsu strain of influenza B virus. At the dose tested sublingual administration of IFNalpha reduces the immune response to influenza vaccination in elderly institutionalized individuals.

Laxatives as a Risk Factor for Iatrogenic Falls in Elderly Subjects Myth or Reality

AbstractBackground The multifactorial nature of falls is well known, and several studies on falls in the elderly have reported that laxatives can be a risk factor, but without attempting to discuss possible mechanisms to explain this role. Objective We aimed to isolate studies in which the risk factors for falls in the elderly related to laxatives have been evaluated and to carry out a meta-analysis combining the results of all identified good-quality studies. Methods Systematic literature review using the keywords ‘accidental fall/numerical data’ and ‘risk factors’. This was followed by a manual search for articles cited in the previously identified publications. Articles were analysed if they had study populations aged ≥60 years, reported on falls occurring in everyday life, were observational or interventional studies that identified laxatives as a risk factor for falls, and were written in French or English. Articles of this type that were considered to be of good quality were included in the meta-analysis. Results 3747 indexed articles published between 1981 and 2007 were identified. Of these, seven articles met all inclusion criteria and were analysed. The odds ratio (95% CI) for the association between use of laxatives and fall occurrence in subjects participating in the good-quality trials (n = 4) included in the meta-analysis was 2.03 (1.52, 2.72). This result was statistically homogeneous (percentage of the total variation across studies due to heterogeneity [I2] = 0). ConclusionsElderly subjects treated with laxatives were twice as likely to fall compared with non-laxative users. The causal relationship was probably not directly attached to a side effect of the substance used, but rather a reflection of other pathologies (e.g. older age, confinement to bed, concomitant Parkinson’s disease) that may themselves cause falls.

Rehabilitation of the psychomotor consequences of falling in an elderly population: A pilot study to evaluate feasibility and tolerability of virtual reality training.

BACKGROUND A fall in elderly subjects can lead to serious psychological consequences. These symptoms can develop into Fear of Falling with behavioural disorders comparable to PTSD that may severely limit autonomy. Virtual reality training (VRT) could be seen as a worthwhile therapeutic approach for this syndrome since it has been shown to be a useful tool for motor rehabilitation or combat-related PTSD. We thus developed a training scenario for VRT with psychomotor therapists. OBJECTIVE To test the feasibility and acceptability of VRT when used by elderly adults for fall rehabilitation. METHODS Our population of 8 patients older than 75 years, with a Mini Mental Score Examination greater than 18/30 performed sessions of VRT and answered a questionnaire on the feasibility and acceptability of it. RESULTS This sample showed a highly favourable response to the prototype of VRT. They found it easy to use, enjoyed the experience, and thought it realistic and helpful. CONCLUSION The conclusions of our study are limited by sample size. However, applications with VRT can offer the potential of an acceptable technique for elderly subjects. The next step will be to show the efficacy of this method in the management of post-fall PTSD.

Not only the traumatic falls in elderly subjects requires awareness but all the falls even those hitherto regarded as unimportant

The problem of falling in the elderly is now widely recognised as a serious public health problem because of the significant resulting complications. The literature on this subject is profuse, reflecting the importance given to this issue. While the prevalence of falling, which affects about half of the over 80 population, is unanimously and internationally recognised [1] other points of interest are less consensual. Many of the published studies focus on populations with traumatic consequences of falling, including hip fractures [2], giving the false impression that this population could represent the gold standard of the population of fallers in terms of research on this topic. This is obviously rather simplistic. Their assumption is that these traumatic falls are those that should be the focus of medical interest. It is also, often, the economic interest that appears to prevail in view health expenditure costs that these injuries generate. There is therefore, an amalgam sustained by these publications which maintains the confusion that only falls with fractures lead to consequences in terms of loss of autonomy, social withdrawal or mortality. Because the authors came to these conclusions for this population of fallers does not mean that this cannot apply to all the other types of falls. Furthermore, by focusing only on the consequences of traumatic falls, we sustain this idea, reinforcing the desire to pursue research in this group and neglecting other types of falls. This affects firstly the quality of the reporting of falls [3], which is unreliable as a lot of falls seemingly banal stays unnoticed to the medical profession or even the elderly subject’s entourage. But, above all, from an epidemiological point of view, only being interested in these falls with fractures is to ignore a large part of falls that may be equally responsible for serious consequences, in a more or less long-term, such as fear of falling, depression, social isolation or institutionalisation. Critical falls [4], i.e. falls characterized by an inability to stand, with or without trauma but whatever the reason, loss of consciousness or inability to raise the alarm, double for instance the risk of mortality at 6 months. A prolonged immobilisation on the ground will have, indeed, many repercussions, essentially pressure sores, dehydration, hypothermia, rhabdomyolysis, or renal failure; likely to compromise the survival. Nevertheless, falls must be classified according to their consequences because it is ultimately the prevention of serious consequences of falls which is the first goal of the falls prevention policy. However, the prevention of serious falls must proceed through the identification of all falls as the main risk factor is a history of falls. In order to obtain sight on the complete spectrum of falls and the underlying causes, a proper classification standardized and referenced is necessary. It will also help to combine more easily the data from separate studies and to be able, for instance to compare the effect of various sorts of intervention on all these defined types of falls, not only traumatic. And because the term of ‘serious fall’ is too often used only in the narrow sense of ‘fall with serious traumatic consequence’, a new terminology imposes itself. Introducing the term of ‘critical falls’ can be criticized for increasing the risk of heterogeneity, but this participate to the goal of data F. Bloch (&) Department of Gerontology, Hôpital Broca (Assistance Publique-Hôpitaux de Paris), 54/56 rue Pascal, 75013 Paris, France e-mail: frederic.bloch@brc.aphp.fr

Production of TNF-alpha ex vivo is predictive of an immune response to flu vaccination in a frail elderly population.

ObjectiveTo investigate the relationship between the response to influenza vaccination and the ability to produce proinflamatory cytokines in elderly subjects.MethodsWhole blood samples from 25 elderly subjects collected before influenza vaccination were stimulated with the influenza vaccine in order to evaluate the secretion of five specific cytokines: TNFα, IFNα, IFNγ, IL2 and IL10. The results were correlated with the increased HAI antibody titres two weeks after vaccination.ResultsOnly 30% of elderly individuals seroconverted after vaccination. Although 50 to 70% of the cohort did not produce TNFα, IFNα, IFNγ, IL2 or IL10, all of the individuals who seroconverted were able to produceTNFα. Furthermore production of IFNγ, with or without production of IFNα/β, was not associated with a better response to the vaccine.ConclusionProduction of TNFα appears to be primordial for an efficient vaccine response, and may provide a predictive marker for the humoral response to vaccination. It may also provide the basis for evaluating agents designed to rescue TNFα-producing cells. This study emphasises a need to rescue TNF-producing cell function.