Editorial For reprint orders, please contact [email protected]
Pharmacologic therapy and the impact on falls in the elderly Expert Rev. Clin. Pharmacol. 1(6), 721–723 (2008)
Hedva Barenholtz Levy, PharmD, BCPS, CGP Director, HbL PharmaConsulting, 9648 Olive Boulevard, #309, Saint Louis, MO 63132, USA Tel.: +1 314 994 9409 Fax: +1 314 994 9409 [email protected]
“Clinicians … need to be vigilant to pharmacologic agents that
can increase the risk of falls and be aware of mechanisms by which agents marketed in the last 10–15 years might impact fall risk in the elderly.” Falls are the leading cause of injury-related deaths among older adults in the USA [1] . A total of 25% of older adults who experience a hip fracture subsequent to a fall die within 1 year. Another 50% do not return to normal baseline functioning [101] . Approximately a third of the communitydwelling elderly population will experience a fall (range: 18–32%) [2–4] . Higher estimates of approximately 40% annually are seen in hospitalized and nursing home patients [3] . Without question, the event of an unintentional fall can have devastating effects on patients, resulting in death, hip fracture or other injury, nursing home admission and increased medical costs. As a result, efforts to increase awareness of fall risks and reduce the incidence of accidental falls have received national attention in the USA recently [5] .
“…pharmacologic therapy is one of the most visible and modifiable targets for reducing the risk of a fall.” There is no standardized list of risk factors for falls, but pharmacologic therapy – either with specific high-risk agents or through multiple medication use – is mentioned uniformly. Other risk factors commonly include age, muscle weakness, impaired gait, balance and vision, stroke, orthostatic hypotension, medical conditions (such as infection, anemia, depression or dementia), electrolyte and glucose abnormalities, and alcohol use. History of a previous fall is an important predictor for a subsequent fall [6,7] . Of these various factors, pharmacologic therapy is one of the most visible and modifiable targets for reducing the risk of www.expert-reviews.com
10.1586/17512433.1.6.721
a fall. Abundance of international literature on the role of medications and fall risk confirms a global interest in the topic. In light of the aging population and increased use of medications in general, efforts to promote awareness of this timely topic invites healthcare professionals to minimize highrisk medication use whenever possible with the patients they encounter. Pharmacologic basis for fall risk
Pharmacologic agents that have been implicated in fall risks traditionally include tricyclic antidepressants (TCAs), antipsychotic agents, hypnotics–anxiolytics, anticonvulsants and cardiovascular agents, such as diuretics, nitrates and antihypertensives. Mechanisms by which certain pharmacologic agents increase fall risk involve the ability of an agent to cause confusion, cognitive impairment, decreased alertness, dizziness, sedation, impaired balance and orthostatic hypotension. These mechanisms reflect medication side effects and/or therapeutic extensions of pharmacologic effects. The latter is seen with antihypertensive agents, nitrates and other vasodilators (e.g., therapies that can cause orthostatic hypotension or dizziness from hypotension). Similarly, benzodiazepines (BZDs) used for sleep can cause excessive or prolonged sedation if used improperly. Fall risk is directly related to the number of medications prescribed and risk increases significantly with the use of multiple high-risk agents [8] . Challenges in identifying a causal relationship between medications and fall risks are multifold. The original information regarding medications associated with fall risk was based on studies published before 1995. Use of these data today is
© 2008 Expert Reviews Ltd
ISSN 1751-2433
721
Editorial
Levy
often limited by study design, ability to control for confounding factors, health or setting of the study population, and exclusion of newer therapeutic agents. Since 1995, important pharmacologic agents have become widely used in many of those same drug classes, some of which have a perceived or real improved side-effect profile regarding fall risk. Often, general drug categories continue to be listed as high risk (e.g., antidepressants or cardiovascular agents) without delineating specific agents or drug classes. In addition, there is sparse or nonexistent information on new, unrelated pharmacologic agents that are used frequently in the elderly. Yet these agents still need to be considered for their propensity to increase fall risk. Clinicians thus need to be vigilant to pharmacologic agents that can increase the risk of falls and be aware of mechanisms by which agents marketed in the last 10–15 years might impact fall risk in the elderly. To illustrate the growing and changing need for new research regarding medications and fall risk, I will briefly describe the available evidence for three categories of psychotropic agents. Psychotropic agents, as an example
Since the early 1990s, selective serotonin reuptake inhibitors (SSRIs) have largely supplanted the use of TCAs for treatment of depression, especially in the elderly. Pharmacologic mechanisms for fall risks of TCAs include orthostatic hypotension, sedation, dizziness and anticholinergic effects. SSRIs do not typically cause orthostatic hypotension or dizziness and most lack anticholinergic effects, an exception being paroxetine. SSRIs are reported to cause either insomnia or sedation, a side effect that often cannot be predicted. A small number of studies have evaluated fall or hip fracture risk with SSRIs compared with TCAs. They were conducted across various patient-care settings, with no difference seen in fall risk between the two classes of antidepressants [9] . Traditional antipsychotics are associated with increased fall risk via side effects that include dizziness, orthostatic hypo tension, sedation, blurred vision, confusion, decreased alertness and extrapyramidal symptoms (EPS). Atypical antipsychotics first became available in the USA in the mid-1990s. They carry a lower risk of EPS, anticholinergic effects and orthostatic hypo tension, although they can still cause sedation. Subsequently, atypical antipsychotic agents have been widely prescribed in the USA because of an overall safer adverse-event profile. Limited data from two observational studies did not find a benefit with the newer atypical agents [9] . Zolpidem, the first non-BZD hypnotic agent in the USA, was introduced in 1992, followed by zaleplon and eszoplicone. These agents have become widely prescribed and typically are preferred for the elderly. Their pharmacologic advantage compared with traditional BZD hypnotics is a shorter half-life of 1–6 h, depending on the agent (zaleplon < zolpidem < eszoplicone), compared with a half-life of temazepam averaging 9 h [10,11] . In addition, zaleplon and zolpidem possess unique binding characteristics, which theoretically might translate to a lower potential to impact fall risk [11] . A recent review carefully summarized data regarding fall risks related to both BZDs and non-BZDs, with a focus on 722
non-BZD data [11] . The authors found very little data available from clinical studies regarding non-BZD agents. Although nonBZD use was included in some of the ‘BZD’ studies, data were not reported separately, probably because non-BZD use was too small. Other studies were reviewed pertaining to non-BZDs and fall potential, for example, postural sway was evaluated in healthy patients over 70 years of age. In this small study, zolpidem was associated with less postural sway compared with lormetazepam and zopiclone; the latter two drugs are not marketed in the USA. Interestingly, short-acting BZDs have been found to be no safer than long-acting BZDs regarding fall risk. Rather, fall risk with BZDs probably has more to do with patient-care setting, duration of use and concomitant medications. Despite a paucity of evidence, the authors of the review recommended non-BZD compounds as preferred agents for insomnia, with zolpidem being the first choice agent [11] . Clearly, additional research is needed regarding fall risk with these newer hypnotic agents.
“Reducing fall risk begins with an awareness of risk factors, of which pharmacologic therapy is merely one.” The mentioned examples illustrate the need for increased research regarding medications and fall risk. Other pharmacologic agents with CNS activity, newer cardiovascular agents that might affect orthostasis, as well as possible drug interactions involving newer pharmacologic agents, must be anticipated for their potential to impact fall risk, despite the absence of evidence. Examples of some agents that warrant investigation include: • Analgesics, such as tramadol or NSAID use in the community setting • Antimuscarinic agents used for urinary incontinence, namely tolterodine versus newer urinary selective agents, such as darifenacin and solifenacin • Non- or low-sedating antihistamines, such as cetirizine • Second-generation anticonvulsants, such as gabapentin, which can be used to treat neuropathic pain in the elderly Impact of improving pharmacologic therapy
Many studies designed to reduce fall risk have incorporated interventions to improve pharmacologic therapy as an integral component. It is encouraging that several of these international studies have found a significant reduction in fall risk [12–16] . Future studies should ideally confirm sustainability as well as patient acceptance, as most study designs lasted only 2–8.5 months. Role of the clinician
Reducing fall risk begins with an awareness of risk factors, of which pharmacologic therapy is merely one. Patients who have fallen or who are at risk of a fall need to be evaluated; however, discussion of this important topic is beyond the scope of this commentary. Medications can increase the risk of a fall via their side effects or through an extension of their pharmacologic Expert Rev. Clin. Pharmacol. 1(6), (2008)
Pharmacologic therapy & the impact on falls in the elderly
effect. Many other types of pharmacologic agents – beyond the psychotropics highlighted above – also can increase fall risks in susceptible patients. Existing literature falls short of addressing our questions concerning some of the newer pharmacologic agents and their fall-risk potential. Thus, we must rely on clinical judgment that considers the pharmacologic basis of fall risks for individual agents, namely side-effect profile and mechanism of action, as well as drug interaction potential. Clinicians need to evaluate the propensity for a medication to affect a person’s functioning, for example, motor coordination, mental status and balance, and weigh those risks against benefits. As we use pharmacologic therapy to improve
1
2
3
4
Bulat T, Castle SC, Rutledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly – part 2, summary algorithm. JAMA 20, 1–4 (2008). Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? J. Am. Med. Assoc. 297(1), 77–86 (2007).
5
Anonymous. Fatalities and injuries from falls among older adults – United States, 1993–2003 and 2001–2005. JAMA 297(1), 32–33 (2007).
6
Edelberg HK. Falls and function: how to prevent falls and injuries in patients with impaired mobility. Geriatrics 56(3), 41–45 (2001).
7
8
9
Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin. Geriatr. Med. 18, 141–158 (2002). Lee JSW, Kwok T, Leung PC, Woo J. Medical illnesses are more important than medications as risk factors of falls in older community dwellers? A cross-sectional study. Age Ageing 35, 246–251 (2006).
American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls
www.expert-reviews.com
the health of our aging patients, we cannot lose sight of potential harms. It is one of the greatest services that healthcare providers can offer their patients. Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
Prevention. Guideline for the prevention of falls in older persons. J. Am. Geriatr. Soc. 49(5), 664–672 (2001).
References
Ziere G, Dieleman JP, Hofman A, Pols HAP, van der Cammen TJM, Stricker BHC. Polypharmacy and falls in the middle age and elderly population. Br. J. Clin. Pharmacol. 61(2), 218–223 (2006). Bulat T, Castle SC, Rutledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly – part 4, anticoagulants, anticonvulsants, anticholinergics/bladder relaxants, and antipsychotics. J. Am. Acad. Nurs. Pract. 20, 181–190 (2008).
10
Semla TP, Beizer JL, Higbee MD. Geriatric Dosage Handbook. Lexi-Comp, Hudson, USA (2007).
11
Allain H, Bentue-Ferrer D, Polard E, Akwa Y, Patat A. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly. Drugs Aging 22(9), 749–765 (2005).
12
Editorial
van der Velde N, Stricker BHC, Pols HAP, van der Cammen TJM. Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br. J. Clin. Pharmacol. 63(2), 232–237 (2007).
13
van der Velde N, van den Meiracker AH, Pols HAP, Stricker BHC, van der Cammen TJM. Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J. Am. Geriatr. Soc. 55(5), 734–739 (2007).
14
Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in residential care facilities, a cluster randomized trial. Ann. Intern. Med. 136(10), 733–741 (2002).
15
Tinetti ME, Baker DI, King M et al. Effect of dissemination of evidence in reducing injuries from falls. N. Engl. J. Med. 359(3), 252–261 (2008).
16
Haumschild MJ, Karfonta TL, Haumschild MS, Phillips SE. Clinical and economic outcomes of a fall-focused pharmaceutical intervention program. Am. J. Health Syst. Pharm. 60(10), 1029–1032 (2003).
Website 101
Hip fractures among older adults www.cdc.gov/ncipc/factsheets/ adulthipfx.htm (Accessed 15 September 2008)
723
Pharmacologic therapy and the impact on falls in the elderly Expert Rev. Clin. Pharmacol. 1(6), 721–723 (2008)
Hedva Barenholtz Levy, PharmD, BCPS, CGP Director, HbL PharmaConsulting, 9648 Olive Boulevard, #309, Saint Louis, MO 63132, USA Tel.: +1 314 994 9409 Fax: +1 314 994 9409 [email protected]
“Clinicians … need to be vigilant to pharmacologic agents that
can increase the risk of falls and be aware of mechanisms by which agents marketed in the last 10–15 years might impact fall risk in the elderly.” Falls are the leading cause of injury-related deaths among older adults in the USA [1] . A total of 25% of older adults who experience a hip fracture subsequent to a fall die within 1 year. Another 50% do not return to normal baseline functioning [101] . Approximately a third of the communitydwelling elderly population will experience a fall (range: 18–32%) [2–4] . Higher estimates of approximately 40% annually are seen in hospitalized and nursing home patients [3] . Without question, the event of an unintentional fall can have devastating effects on patients, resulting in death, hip fracture or other injury, nursing home admission and increased medical costs. As a result, efforts to increase awareness of fall risks and reduce the incidence of accidental falls have received national attention in the USA recently [5] .
“…pharmacologic therapy is one of the most visible and modifiable targets for reducing the risk of a fall.” There is no standardized list of risk factors for falls, but pharmacologic therapy – either with specific high-risk agents or through multiple medication use – is mentioned uniformly. Other risk factors commonly include age, muscle weakness, impaired gait, balance and vision, stroke, orthostatic hypotension, medical conditions (such as infection, anemia, depression or dementia), electrolyte and glucose abnormalities, and alcohol use. History of a previous fall is an important predictor for a subsequent fall [6,7] . Of these various factors, pharmacologic therapy is one of the most visible and modifiable targets for reducing the risk of www.expert-reviews.com
10.1586/17512433.1.6.721
a fall. Abundance of international literature on the role of medications and fall risk confirms a global interest in the topic. In light of the aging population and increased use of medications in general, efforts to promote awareness of this timely topic invites healthcare professionals to minimize highrisk medication use whenever possible with the patients they encounter. Pharmacologic basis for fall risk
Pharmacologic agents that have been implicated in fall risks traditionally include tricyclic antidepressants (TCAs), antipsychotic agents, hypnotics–anxiolytics, anticonvulsants and cardiovascular agents, such as diuretics, nitrates and antihypertensives. Mechanisms by which certain pharmacologic agents increase fall risk involve the ability of an agent to cause confusion, cognitive impairment, decreased alertness, dizziness, sedation, impaired balance and orthostatic hypotension. These mechanisms reflect medication side effects and/or therapeutic extensions of pharmacologic effects. The latter is seen with antihypertensive agents, nitrates and other vasodilators (e.g., therapies that can cause orthostatic hypotension or dizziness from hypotension). Similarly, benzodiazepines (BZDs) used for sleep can cause excessive or prolonged sedation if used improperly. Fall risk is directly related to the number of medications prescribed and risk increases significantly with the use of multiple high-risk agents [8] . Challenges in identifying a causal relationship between medications and fall risks are multifold. The original information regarding medications associated with fall risk was based on studies published before 1995. Use of these data today is
© 2008 Expert Reviews Ltd
ISSN 1751-2433
721
Editorial
Levy
often limited by study design, ability to control for confounding factors, health or setting of the study population, and exclusion of newer therapeutic agents. Since 1995, important pharmacologic agents have become widely used in many of those same drug classes, some of which have a perceived or real improved side-effect profile regarding fall risk. Often, general drug categories continue to be listed as high risk (e.g., antidepressants or cardiovascular agents) without delineating specific agents or drug classes. In addition, there is sparse or nonexistent information on new, unrelated pharmacologic agents that are used frequently in the elderly. Yet these agents still need to be considered for their propensity to increase fall risk. Clinicians thus need to be vigilant to pharmacologic agents that can increase the risk of falls and be aware of mechanisms by which agents marketed in the last 10–15 years might impact fall risk in the elderly. To illustrate the growing and changing need for new research regarding medications and fall risk, I will briefly describe the available evidence for three categories of psychotropic agents. Psychotropic agents, as an example
Since the early 1990s, selective serotonin reuptake inhibitors (SSRIs) have largely supplanted the use of TCAs for treatment of depression, especially in the elderly. Pharmacologic mechanisms for fall risks of TCAs include orthostatic hypotension, sedation, dizziness and anticholinergic effects. SSRIs do not typically cause orthostatic hypotension or dizziness and most lack anticholinergic effects, an exception being paroxetine. SSRIs are reported to cause either insomnia or sedation, a side effect that often cannot be predicted. A small number of studies have evaluated fall or hip fracture risk with SSRIs compared with TCAs. They were conducted across various patient-care settings, with no difference seen in fall risk between the two classes of antidepressants [9] . Traditional antipsychotics are associated with increased fall risk via side effects that include dizziness, orthostatic hypo tension, sedation, blurred vision, confusion, decreased alertness and extrapyramidal symptoms (EPS). Atypical antipsychotics first became available in the USA in the mid-1990s. They carry a lower risk of EPS, anticholinergic effects and orthostatic hypo tension, although they can still cause sedation. Subsequently, atypical antipsychotic agents have been widely prescribed in the USA because of an overall safer adverse-event profile. Limited data from two observational studies did not find a benefit with the newer atypical agents [9] . Zolpidem, the first non-BZD hypnotic agent in the USA, was introduced in 1992, followed by zaleplon and eszoplicone. These agents have become widely prescribed and typically are preferred for the elderly. Their pharmacologic advantage compared with traditional BZD hypnotics is a shorter half-life of 1–6 h, depending on the agent (zaleplon < zolpidem < eszoplicone), compared with a half-life of temazepam averaging 9 h [10,11] . In addition, zaleplon and zolpidem possess unique binding characteristics, which theoretically might translate to a lower potential to impact fall risk [11] . A recent review carefully summarized data regarding fall risks related to both BZDs and non-BZDs, with a focus on 722
non-BZD data [11] . The authors found very little data available from clinical studies regarding non-BZD agents. Although nonBZD use was included in some of the ‘BZD’ studies, data were not reported separately, probably because non-BZD use was too small. Other studies were reviewed pertaining to non-BZDs and fall potential, for example, postural sway was evaluated in healthy patients over 70 years of age. In this small study, zolpidem was associated with less postural sway compared with lormetazepam and zopiclone; the latter two drugs are not marketed in the USA. Interestingly, short-acting BZDs have been found to be no safer than long-acting BZDs regarding fall risk. Rather, fall risk with BZDs probably has more to do with patient-care setting, duration of use and concomitant medications. Despite a paucity of evidence, the authors of the review recommended non-BZD compounds as preferred agents for insomnia, with zolpidem being the first choice agent [11] . Clearly, additional research is needed regarding fall risk with these newer hypnotic agents.
“Reducing fall risk begins with an awareness of risk factors, of which pharmacologic therapy is merely one.” The mentioned examples illustrate the need for increased research regarding medications and fall risk. Other pharmacologic agents with CNS activity, newer cardiovascular agents that might affect orthostasis, as well as possible drug interactions involving newer pharmacologic agents, must be anticipated for their potential to impact fall risk, despite the absence of evidence. Examples of some agents that warrant investigation include: • Analgesics, such as tramadol or NSAID use in the community setting • Antimuscarinic agents used for urinary incontinence, namely tolterodine versus newer urinary selective agents, such as darifenacin and solifenacin • Non- or low-sedating antihistamines, such as cetirizine • Second-generation anticonvulsants, such as gabapentin, which can be used to treat neuropathic pain in the elderly Impact of improving pharmacologic therapy
Many studies designed to reduce fall risk have incorporated interventions to improve pharmacologic therapy as an integral component. It is encouraging that several of these international studies have found a significant reduction in fall risk [12–16] . Future studies should ideally confirm sustainability as well as patient acceptance, as most study designs lasted only 2–8.5 months. Role of the clinician
Reducing fall risk begins with an awareness of risk factors, of which pharmacologic therapy is merely one. Patients who have fallen or who are at risk of a fall need to be evaluated; however, discussion of this important topic is beyond the scope of this commentary. Medications can increase the risk of a fall via their side effects or through an extension of their pharmacologic Expert Rev. Clin. Pharmacol. 1(6), (2008)
Pharmacologic therapy & the impact on falls in the elderly
effect. Many other types of pharmacologic agents – beyond the psychotropics highlighted above – also can increase fall risks in susceptible patients. Existing literature falls short of addressing our questions concerning some of the newer pharmacologic agents and their fall-risk potential. Thus, we must rely on clinical judgment that considers the pharmacologic basis of fall risks for individual agents, namely side-effect profile and mechanism of action, as well as drug interaction potential. Clinicians need to evaluate the propensity for a medication to affect a person’s functioning, for example, motor coordination, mental status and balance, and weigh those risks against benefits. As we use pharmacologic therapy to improve
1
2
3
4
Bulat T, Castle SC, Rutledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly – part 2, summary algorithm. JAMA 20, 1–4 (2008). Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? J. Am. Med. Assoc. 297(1), 77–86 (2007).
5
Anonymous. Fatalities and injuries from falls among older adults – United States, 1993–2003 and 2001–2005. JAMA 297(1), 32–33 (2007).
6
Edelberg HK. Falls and function: how to prevent falls and injuries in patients with impaired mobility. Geriatrics 56(3), 41–45 (2001).
7
8
9
Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin. Geriatr. Med. 18, 141–158 (2002). Lee JSW, Kwok T, Leung PC, Woo J. Medical illnesses are more important than medications as risk factors of falls in older community dwellers? A cross-sectional study. Age Ageing 35, 246–251 (2006).
American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls
www.expert-reviews.com
the health of our aging patients, we cannot lose sight of potential harms. It is one of the greatest services that healthcare providers can offer their patients. Financial & competing interests disclosure
The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
Prevention. Guideline for the prevention of falls in older persons. J. Am. Geriatr. Soc. 49(5), 664–672 (2001).
References
Ziere G, Dieleman JP, Hofman A, Pols HAP, van der Cammen TJM, Stricker BHC. Polypharmacy and falls in the middle age and elderly population. Br. J. Clin. Pharmacol. 61(2), 218–223 (2006). Bulat T, Castle SC, Rutledge M, Quigley P. Clinical practice algorithms: medication management to reduce fall risk in the elderly – part 4, anticoagulants, anticonvulsants, anticholinergics/bladder relaxants, and antipsychotics. J. Am. Acad. Nurs. Pract. 20, 181–190 (2008).
10
Semla TP, Beizer JL, Higbee MD. Geriatric Dosage Handbook. Lexi-Comp, Hudson, USA (2007).
11
Allain H, Bentue-Ferrer D, Polard E, Akwa Y, Patat A. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly. Drugs Aging 22(9), 749–765 (2005).
12
Editorial
van der Velde N, Stricker BHC, Pols HAP, van der Cammen TJM. Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br. J. Clin. Pharmacol. 63(2), 232–237 (2007).
13
van der Velde N, van den Meiracker AH, Pols HAP, Stricker BHC, van der Cammen TJM. Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J. Am. Geriatr. Soc. 55(5), 734–739 (2007).
14
Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in residential care facilities, a cluster randomized trial. Ann. Intern. Med. 136(10), 733–741 (2002).
15
Tinetti ME, Baker DI, King M et al. Effect of dissemination of evidence in reducing injuries from falls. N. Engl. J. Med. 359(3), 252–261 (2008).
16
Haumschild MJ, Karfonta TL, Haumschild MS, Phillips SE. Clinical and economic outcomes of a fall-focused pharmaceutical intervention program. Am. J. Health Syst. Pharm. 60(10), 1029–1032 (2003).
Website 101
Hip fractures among older adults www.cdc.gov/ncipc/factsheets/ adulthipfx.htm (Accessed 15 September 2008)
723
