Neurology -- Correspondence for Thurman et al., 70 (6) 473-479

Correspondence published:

Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based: Joseph H. Friedman (8 May 2008)

Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based: Beau B. Bruce, Valérie Biousse, Nancy J. Newman (8 May 2008)

Reply from the authors: David J. Thurman, MD, MPH, Judy A. Stevens, PhD, Jaya K. Rao, MD, MHS (8 May 2008)

Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based 8 May 2008

Joseph H. Friedman,
NeuroHealth/The Warren Alpert School of Medicine of Brown University
52 Bluff Rd/Barrington, RI 02806
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Re: Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based

joseph_friedman{at}brown.edu Joseph H. Friedman

Although some falls in patients with neurological disorders can be prevented, I have discovered that in Parkinson’s disease (PD), many cannot. I observed that a number of PD patients fall frequently, and despite being aware that they are at risk and can ably describe the situations in which they fall yet continue to fall on a frequent basis.
I prospectively collected information on fall frequency in every patient I saw and personally diagnosed with idiopathic PD, using UK Brain Bank criteria, in a five-week period during the winter of 2008. My definition of falls required the patient to contact the ground. This is not the definition employed by Thurman et al [1], and generally used in studies of falls [2], which defines a fall as coming to rest on the ground or a lower position. I believe patients are more likely to allow themselves to fall onto a sofa or into a chair if they are losing balance near a soft resting place so that my definition is more restrictive and underestimates the frequency. [3]
Of 160 patients evaluated, 72 were stage 3 or greater. Of these 72, 27 reported falls since their last visit or in the preceding three months if a new patient. Four of the 27 patients fell only on ice or snow, hence not really a fall. [1] Therefore 23 admitted falls, of whom four had frequent falls. The frequent fallers fell at least once daily, while the others generally fell less than once per month, with a single exception of once per week. There was a sharp divide in falling frequency.
Of the frequent fallers, two were Hoehn-Yahr stage 4 and one was stage 3. One was stage 5 in the office but 4 at home. Two of these were demented by DSM criteria, one had mild cognitive impairment and one was cognitively intact. All fell while walking. In addition to these fallers one demented stage 4 patient slipped out of her wheelchair at least once daily, and one demented stage 4 patient frequently slipped to the ground when exiting her bed (unknown number).
The problem of daily falls in PD is challenging because these patients, despite their cognitive impairments, are able to describe their falls and the situations producing them yet do not take preventive steps. [4]. It is difficult to devise effective safety interventions under these circumstances.
References
1. Thurman DJ, Stevens JA, Rao JK. Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008; 70:473-479.
2. Gibson MJ, Andres RO, Isaacs B, et al. The prevention of falls in later life. A report of the Kellogg International Work Group on the prevention of falls by the elderly. Danish Medical Bull 1987;34(suppl 4):1-24.
3. Pickering RM, Grimbergen YA, Rigney U, et al. A meta-analysis of six prospective studies of falling in Parkinson’s disease. Mov Disord 2007;22:1892-1900.
4. Bloem BR, Brimbergen YA, van Dijk JG, Munneke M. The “posture second” strategy: a review of wrong priorities in Parkinson’s disease. J Neurol Sci 2006;248:196-204.
Disclosure: The author reports no disclosures.

Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based 8 May 2008

Beau B. Bruce,
Emory University
1365B Clifton Rd, NE, Atlanta, GA 30322,
Valérie Biousse, Nancy J. Newman
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Re: Practice Parameter: Assessing patients in a neurology practice for risk of falls (an evidence-based

bbbruce{at}emory.edu Beau B. Bruce, et al.

We were pleased to see the Practice Parameter addressing the fall risk among neurological patients. [1] We believe that these guidelines will help improve the safety and quality of life of patients. We would like to emphasize the role of visual field deficits as an important neurologic cause of fall related morbidity.
Neurologic disorders frequently cause visual loss, especially visual field defects, and visual loss is common in the elderly. Loss of visual acuity or visual field has been associated with an increased risk of falls. [5,6] A recent, prospective population cohort study of 2520 older adults found that visual field loss was the most important component of vision related to increased fall risk. [6] In this study, there was 8% higher odds of falling for each 10% loss in binocular visual field the patient experienced. This risk remained after adjustment for other factors, including several neurologic conditions including poor balance, Parkinson disease, stroke, and decreased grip strength.
A homonymous hemianopia (a 50% loss of binocular visual field) increased a patient’s odds of falling by 47%, comparable to the increased odds of falling conveyed by poor balance (35%) or stroke (57%) in the same study. It has been shown that most patients with homonymous hemianopia secondary to stroke are not aware of the visual field defect, suggesting that homonymous visual field defects are often overlooked, both in patients with and without associated neurologic defects. [7,8]
As neurologists, we need to be alert to these deficits and their contribution to our patients’ fall risk. Patients with recurrent or unexplained falls should be referred for assessment of their visual acuity and visual field.
References

5. Coleman AL, Stone K, Ewing SK et al Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology. 2004;111:857-862.
6. Freeman AE, Muñoz B, Rubin G, West SK. Visual field loss increases the risk of falls in older adults: the Salisbury Eye Evaluation. Invest Ophthalmol Vis Sci. 2007;48:4445-4450.
7. Gilhotra JS, Mitchell P, Healey PR, Cumming RG, Currie J. Homonymous visual field defects and stroke in an older population. Stroke. 2002;33:2417-2420.
8. Zhang X, Kedar S, Lynn MJ, Newman NJ, Biousse V. Homonymous hemianopias: clinical-anatomic correlations in 904 cases. Neurology. 2006;66:906-910.
Disclosure: The authors report no disclosures.

Reply from the authors 8 May 2008

David J. Thurman, MD, MPH,
Centers for Disease Control and Prevention
Atlanta, GA,
Judy A. Stevens, PhD, Jaya K. Rao, MD, MHS
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Re: Reply from the authors

dxt9{at}cdc.gov David J. Thurman, MD, MPH, et al.

We appreciate the comments of Dr. Friedman and those of Drs. Bruce, Biousse, and Newman.
Dr. Friedman’s observations describe the difficulty of trying to prevent falls among Parkinson disease (PD) patients. Unfortunately, similar limitations are also described in the more general population of older adults, where multi-factorial screening and intervention programs have been found on average to reduce the incidence of falls by only about 20%. [9] While such measures are partially effective and thus important, further treatment options need to be investigated. Dr. Friedman’s other observations underscore additional findings of our review that the risk of falls is amplified in people with more advanced PD and in people with multiple risk factors.
Dr. Bruce and colleagues emphasize that visual field defects are important risk factors for falls. We identified vision loss in general as a risk factor, although most of the studies we reviewed did not adequately address visual field defects. We therefore welcome this additional information and fully agree with the conclusions offered.
Both of these letters highlight the need for more study of specific neurologic conditions that contribute to the risk of falls and of specific interventions to more effectively reduce these risks.
Reference
9. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. “Interventions for preventing falls in elderly people (Cochrane Review)” The Cochrane Library, Issue 4. Chichester UK: John Wiley & Sons, 2003.
Disclosure: The authors report no disclosures.