Correspondence

Reducing the Risk of Falls among the Elderly

N Engl J Med 1995; 332:268-269January 26, 1995

Article

To the Editor:

Tinetti et al. (Sept. 29 issue)1 demonstrated that assessment and intensive treatment of older patients reduces several risk factors for falls and decreases the risk of falling by 30 percent. They showed that a program of gait, balance, and strength training with a review of medications, education about the use of sedatives, and environmental modifications by visiting nurses and physical therapists can reduce the risk of falls, which should, in turn, reduce fractures.

I was the director of the Physical Functioning and Performance Program at the National Institute on Aging when the institute funded, in part, the studies reported by Tinetti et al.1,2 and by Fiatarone et al. (June 23 issue).3 Since going into private practice, I have found it discouraging that Medicare does not support the types of outpatient programs studied by these groups of investigators. Medicare pays approximately $720 a year for physical therapy.4 As a practical matter, the necessary services cannot be paid for without exhausting a patient's limited resources from Medicare.

Balance training, strengthening exercises, and transfer and gait training are relatively inexpensive interventions that help prevent dependence and dysfunction. They probably save much more money than they cost. Either the research on these preventive programs should be terminated or Medicare should pay for them.

Michael S. Kaplan, M.D., Ph.D.
816 Frederick Rd., Catonsville, MD 21228

4 References

1
Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-827
Full Text | Web of Science | Medline

2
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-1707
Full Text | Web of Science | Medline

3
Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994;330:1769-1775
Full Text | Web of Science | Medline

4
Medicare handbook. Baltimore: Department of Health and Human Services, 1994.

To the Editor:

Tinetti and colleagues report a reduction in the risk of falling among elderly people that resulted from a multifactorial intervention program. The results are interesting and justify the costs of preventive measures. But some unanswered questions remain.

The authors distinguish three types of intervention: adjustment in medications, behavioral instructions, and exercise programs. No clear statements are made about the relative effects of the various interventions. The data in Table 4 and Table 5, however, indicate that the adjustment in medications and the exercise program are probably the most important of the three. An adjustment in medications can be made easily, but does it really influence the risk of falling? If not, then only the exercise program is effective. Unfortunately, changes in the strength of leg and arm muscles were not measured. However, Fiatarone et al. have shown that high-resistance weight training leads to significant gains in muscle strength and size and in functional mobility among frail nursing home residents up to 96 years of age.1 If the main effect of the risk-reduction program was due to the exercises, the intervention program could be made cheaper and simpler.

Martin Burtscher, M.D., Ph.D.
Austrian Alpine Club, A-6020 Innsbruck, Austria

1 References

1
Fiatarone MA, Marks EC, Ryan ND, Meredith CN, Lipsitz LA, Evans WJ. High-intensity strength training in nonagenarians: effects on skeletal muscles. JAMA 1990;263:3029-3034
CrossRef | Web of Science | Medline

To the Editor:

Tinetti et al. and Cummings and Nevitt in their accompanying editorial (Sept. 29 issue)1 tell us much about falls among older people. Visual impairment obviously can contribute to falls, but visual impairment does not seem to be discussed. Almost everyone who lives long enough becomes presbyopic. Those who use bifocals, trifocals, or variable-focus lenses do not clearly see the details of the surfaces on which they are putting their feet, especially when they are going downstairs. . . .

Richard Bettigole, M.D.
53 Wiltshire Rd., Williamsville, NY 14221

1 References

1
Cummings SR, Nevitt MC. Falls. N Engl J Med 1994;331:872-873
Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Bettigole correctly points out that visual impairment was not targeted as a risk factor in our intervention trial. Visual impairment was excluded for two reasons. First, most epidemiologic studies have not identified impairment in near or far visual acuity as an independent risk factor for falling. As Dr. Bettigole's mention of bifocals and trifocals suggests, visual functions such as depth perception and contrast sensitivity may be more relevant than mere visual acuity to mobility and the risk of falling.1 Assessment of these more complicated visual functions and appropriate interventions were not feasible in our clinical trial.

Second, we believe that periodic ophthalmologic evaluations and provision of corrective eyewear are components of usual care. Therefore, all subjects in the intervention and usual-care groups in our study who had decreased visual acuity detected by our screening were referred for further evaluation and appropriate treatment.

Dr. Burtscher comments on the lack of a clear statement in our article about the relative effects of the various components of the intervention. He states that if the main effects of the intervention resulted from a single component — he mentions exercise — the intervention program could be made cheaper and simpler. This is a common argument against multifactorial intervention studies. As we point out, however, falling is inherently multifactorial, resulting less often from a single impairment than from the effect of multiple impairments. We therefore believe that modification of multiple risk factors is the most appropriate strategy, even if it precludes the measurement of the effects of individual components of the intervention program. The finding that the risk of falling decreased by 11 percent with each decrease in the number of risk factors certainly suggests that no single risk factor accounted for the entire treatment effect and that the multifactorial approach is more effective than an approach that targets a single risk factor. Unfortunately, as in many studies, the process was more complicated to study than the outcome.

We appreciate Dr. Kaplan's frustration with the lack of Medicare funding for preventive services such as physical therapy. Medicare administrators are presumably cautious because, as recently pointed out, the potential costs of preventive services are high, and their effectiveness has often not been proved.2 It is our hope that evidence from controlled trials such as ours or from well-designed observational studies will lead to carefully considered decisions to pay for the preventive services that prove to be both effective and cost effective.

Mary Tinetti, M.D.
D.I. Baker, R.N., Ph.D.
Yale University, New Haven, CT 06504

2 References