The references cited below have been selected as reporting on Falls Clinics processes and outcomes, or other papers with relevance to the multi-factorial assessment and management procedures undertaken at Falls Clinics.

[A] [B] [C] [D] [E] [F] [G] [H] [I] [J] [K] [L] [M] [N] [O] [P] [Q] [R] [ S] [T] [U] [V] [W] [X] [Y] [Z]

A
ALSOP, K. and M. Mac Mahon (2001). "Withdrawing cardiovascular medications at a syncope clinic." Postgrad Med J 77(908): 403-5.
ABSTRACT: It is widely assumed in clinical practice that drug treatment associated with hypotension can result in falls and syncope, but there is actually very little evidence to support this. Therefore the data in all patients whose cardiovascular medications were stopped at a falls/syncope clinic were analysed to see if their symptoms were altered and if renewal of these medications was necessary at subsequent visits. Of 338 consecutive referrals, cardiovascular medications had been stopped in 65 (19%). At follow up 78% reported improvement in their original presenting symptoms and renewal of medication was not necessary in 77% off antianginals, 69% off antihypertensives, and 36% off antiarrhythmics. It was concluded that adjusting cardiovascular medications could help in the management of falls and syncope and may obviate the need for other treatment. These medications can be stopped in select patients if there is regular monitoring and this should reduce unwanted side effects and costs of these drugs.

B
BATH, A. P., R. M. Walsh, et al. (2000). "Experience from a multidisciplinary "dizzy" clinic." Am J Otol 21(1): 92-7.
ABSTRACT: OBJECTIVE: To describe the experience of a combined otolaryngology and neurology multidisciplinary clinic in the evaluation, investigation, and management of patients with dizziness. STUDY DESIGN: Prospective clinical study. SETTING: Patients were seen in a tertiary referral, multidisciplinary clinic at The Toronto Hospital, University of Toronto, Ontario, Canada. INTERVENTION: A thorough history, formal otoneurologic examination, and appropriate laboratory investigations were performed. After their assessment, the patient's diagnoses were classified as peripheral, central, psychogenic, or undiagnosed and were then subdivided into specific clinical diagnoses. RESULTS: The first 812 consecutive patients seen in the multidisciplinary clinic from January 1, 1993 to December 31, 1998 are reported. Five hundred twenty-five (64.7%) patients were found to have a peripheral vestibular cause for their dizziness, 66 (8.1%) had a central cause, 108 (13.3%) had a diagnosis unknown, and 73 (9.0%) were thought to be psychogenic. In 40 (4.9%) patients, a peripheral and central cause were found. More than one type of peripheral disorder was noted in 17.9% of patients with a peripheral vestibular cause for their dizziness, and 12.3% of patients with a central cause for their dizziness had more than one specific type of central nervous system disorder. CONCLUSIONS: Most patients that were seen in a multidisciplinary clinic had a peripheral vestibular disorder. Central causes of dizziness were relatively uncommon. Serious diseases such as tumor, multiple sclerosis, and encephalitis were rare and unlikely to present with dizziness only. It is important to realize that a patient may have more than one type of disorder accounting for the symptoms, which may represent a spectrum of disease affecting the inner ear.

BROWN, KE, Whitney SL, Wrisley DM, Furman JM. (2001) "Physical therapy outcomes for persons with bilateral vestibular loss". Laryngoscope. 111; 1812-7.
ABSTRACT: OBJECTIVE: The purpose of the study was to assess the efficacy of physical therapy for patients with bilateral vestibular loss. STUDY DESIGN: Retrospective case series. METHODS: Twenty-four patients with a diagnosis of bilateral vestibular loss were identified by a retrospective chart review. Thirteen of the 24 patients met the inclusion criteria of having a moderate or greater loss of vestibular function bilaterally as rated by an otoneurologist based on the patient's vestibular function tests. These patients were treated with a custom-designed physical therapy program for a mean of 4.6 visits over an average period of 3.8 months. Patients completed the Dizziness Handicap Inventory and the Activities-specific Balance Confidence Scale at initial evaluation and discharge. Patients were asked to perform the balance and gait tasks of the Dynamic Gait Index, Sensory Organization Test of computerized dynamic posturography, and the Timed "Up and Go" test at their first and last physical therapy sessions. The number of falls in the previous 4 weeks and the use of an assistive device at initial evaluation and discharge were reported. Composite score, an overall score of clinical outcome, was calculated to determine clinically significant changes in physical performance and subjective information. RESULTS: On a population basis, statistically significant improvement was observed after physical therapy for each of the outcome measures including the composite score (P < .05). Clinically significant changes were demonstrated by 33% to 55% of the patients on the various outcome measures. No change was noted in the patients' risk of falling, their number of falls, and the use of assistive devices. CONCLUSION: Many patients with bilateral vestibular loss benefit from an individualized vestibular physical therapy exercise program based on improved physical function and reduced self-perceived levels of handicap.

C
CAINE, S. and M. MacMahon (1998). "Treatable cardiovascular risk factors in fracture patients attending a falls clinic." Journal of the American Geriatrics Society 46(9): 110. CHIU, AY, Au-Yeung SS, Lo SK. (2003) "A comparison of four functional tests in discriminating fallers from non-fallers in older people". Disabil Rehabil. 25; 45-50.
ABSTRACT: PURPOSE: Which functional tests on mobility and balance can better screen older people at risk of falls is unclear. This study aims to compare the Berg Balance Scale (BBS), Tinetti Mobility Score (TMS), Elderly Mobility Scale (EMS) and Timed Up and Go test (TUG) in discriminating fallers from non-fallers in older people. METHOD: This was a case-control study involving one rater who conducted a mobility and balance assessment on subjects using the four functional tests in random sequence. Subjects recruited included 17 and 22 older people with a history of single and multiple falls respectively from a public Falls Clinic, and 39 community-dwellers without fall history and whose age, sex and BMI matched those of the fallers. All subjects underwent the mobility and balance assessment within one day. RESULTS: Single fallers performed better than multiple fallers in all four functional tests but were worse than non-fallers in the BBS, TMS and TUG. The BBS demonstrated the best discriminating ability, with high sensitivity and specificity. The BBS item 'pick up an object from the floor' was the best at screening fallers. CONCLUSION: BBS was the most powerful functional test of the four in discriminating fallers from non-faller.

CLOSE, J., M. Ellis, et al. (1999). "Prevention of falls in the elderly trial (PROFET): a randomised controlled trial." Lancet 353: 93-7.
ABSTRACT: BACKGROUND: Falls in elderly people are a common presenting complaint to accident and emergency departments. Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences, and possibilities for future prevention. We undertook a randomised controlled study to assess the benefit of a structured interdisciplinary assessment of people who have fallen in terms of further falls. METHODS: Eligible patients were aged 65 years and older, lived in the community, and presented to an accident and emergency department with a fall. Patients assigned to the intervention group (n=184) underwent a detailed medical and occupational-therapy assessment with referral to relevant services if indicated; those assigned to the control group (n=213) received usual care only. The analyses were by intention to treat. Follow-up data were collected every 4 months for 1 year. FINDINGS: At 12-month follow-up, 77% of both groups remained in the study. The total reported number of falls during this period was 183 in the intervention group compared with 510 in the control group (p=0.0002). The risk of falling was significantly reduced in the intervention group (odds ratio 0.39 [95% CI 0.23-0.66]) as was the risk of recurrent falls (0.33 [0.16-0.68]). In addition, the odds of admission to hospital were lower in the intervention group (0.61 [0.35-1.05]) whereas the decline in Barthel score with time was greater in the control group (p<0.00001). INTERPRETATION: The study shows that an interdisciplinary approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment.

COLEMAN, E., L. Grothaus, et al. (1999). "Chronic care clinics: A randomised controlled trial of a new model of primary care for frail older adults." Journal of the American Geriatrics Society 47: 775-83.
ABSTRACT: OBJECTIVE: To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults. DESIGN: Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care. SETTING: Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State. PARTICIPANTS: Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline. INTERVENTION: Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care. MEASUREMENTS: Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed. RESULTS: After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P = .10). CONCLUSIONS: Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.Cripps, D. L. and J. Sanford (1995). The falls clinic - A new program for dealing with older adults who are falling, J Aging Phys Activ.

COWAND JL, Wrisley DM, Walker M, Strasnick B, Jacobson JT. (1998) "Efficacy of vestibular rehabilitation". Otolaryngol Head Neck Surg. 118; 49-54
ABSTRACT: The purpose of this study was to determine significant changes in the Dizziness Handicap Inventory (DHI) scores in patients before and within 1 year after a vestibular rehabilitation program. Efficacy of a vestibular rehabilitation program was tested retrospectively in 37 patients by comparison of pretreatment and posttreatment DHI scores. A significant improvement in test scores was found, indicated by the Sign test at the 0.05 level after vestibular rehabilitation. This difference is evident in the total score and in the functional and physical subscore component. Prerehabilitation and postrehabilitation differences among diagnostic categories were analyzed by using the Kruskal-Wallis test. Patients with peripheral lesions demonstrated greater improvement in the emotional component of the DHI as compared with patients with central or mixed lesions. The Wilcoxon two-sample test assessed the influence of compliance with a home exercise program after discharge from a vestibular physical therapy program. There was no significant difference in improvement between patients who performed home exercises for at least a month after discharge and those who did not.

D
DEPARTMENT OF HUMAN SERVICES (Acute Health Division) (2001). Falls and mobility clinics: Program guidelines and performance indicators. Melbourne.

DEY AB, Bexton RS, Tyman MM, Charles RG, Kenny RA. (1997) "The impact of a dedicated "syncope and falls" clinic on pacing practice in northeastern England". Pacing Clin Electrophysiol. 20; 815-7.
ABSTRACT: This study examined whether the increased demand for pacemaker implants for carotid sinus syndrome (CSS) at the Regional Pacing Service in northeastern England was related to the establishment of a dedicated "syncope and falls" clinic or to the publication of NASPE and BPEG guidelines for pacing symptomatic bradycardia. To this end, pacemaker rates for various indications at this institution were compared with those of a comparable region (Liverpool), as well as with BPEG's national pacemaker database. Findings indicate a distinct impact of the Newcastle syncope and falls clinic on recognition and pacemaker treatment of CSS. DHESI JK, Jackson SH, Bearne LM, Moniz C, Hurley MV, Swift CG, Allain TJ. (2004). "Vitamin D supplementation improves neuromuscular function in older people who fall". Age Ageing. 33: 589-95. ABSTRACT: BACKGROUND: vitamin D supplementation reduces the incidence of fractures in older adults. This may be partly mediated by effects of vitamin D on neuromuscular function. OBJECTIVE: to determine the effects of vitamin D supplementation on aspects of neuromuscular function known to be risk factors for falls and fractures. DESIGN: randomised, double-blind, placebo-controlled study. SETTING: falls clinic taking referrals from general practitioners and accident and emergency department. SUBJECTS: 139 ambulatory subjects (>/=65 years) with a history of falls and 25-hydroxyvitamin D (25OHD)

DHESI JK, Moniz C, Close JC, Jackson SH, Allain TJ. (2002) "A rationale for vitamin D prescribing in a falls clinic population". Age Ageing. 31; 267-71.
ABSTRACT: OBJECTIVE: to assess the prevalence of vitamin D insufficiency in a falls clinic population. To identify simple clinical predictors of vitamin D insufficiency. DESIGN: prospective observational descriptive study. PARTICIPANTS: 400 consecutive patients who attended a falls clinic taking referrals from a casualty department or general practitioners. RESULTS: Hypovitaminosis D is very common, affecting at least 72% of a falls clinic population. The number of times an individual goes out per week and serum albumin are independent predictors of hypovitaminosis D, but the predictive value is low. CONCLUSIONS: the prevalence of vitamin D insufficiency is high in a falls clinic population. It is difficult to predict which individuals are most at risk within this population. The benefits of vitamin D supplementation in older people are well recognized. Therefore in the absence of toxic effects, a pragmatic approach may be to supplement all attendees at a falls clinic.

DHESI JK, Bearne LM, Moniz C, Hurley MV, Jackson SH, Swift CG, Allain TJ. (2002) Neuromuscular and psychomotor function in elderly subjects who fall and the relationship with vitamin D status. J Bone Miner Res. 17; 891-7.
ABSTRACT: Vitamin D and calcium supplementation significantly reduces the incidence of fractures. Evidence suggests vitamin D deficiency impairs neuromuscular function, causing an increase in falls and thereby fractures. The relationship between vitamin D, functional performance, and psychomotor function in elderly people who fall was examined in a prospective cross-sectional study. Patients were recruited from a falls clinic and stratified according to serum 25-hydroxyvitamin-D levels (25OHD): group 1, 25OHD < 12 microg/liter; group 2 25OHD, 12-17 microg/liter; and group 3, 25OHD > 17 microg/liter. Healthy elderly volunteers with 25OHD > 17 microg/liter comprised group 4 (n = 20/group). Measures included aggregate functional performance time (AFPT, seconds), isometric quadriceps strength (Newtons), postural sway (degrees), and choice reaction time (CRT, seconds). Serum bone biochemistry, 25OHD, and parathyroid hormone levels were measured. Patients who fell had significantly impaired functional performance, psychomotor function, and quadriceps strength compared with healthy subjects (AFPT: 51.0 s vs. 32.8 s,p < 0.05; CRT: 1.66 s vs. 0.98 s,p < 0.05; strength: 223N vs. 271N, t = 2.35, p = 0.02). Group 1 had significantly slower AFPT (66.0 s vs. 44.8 s, t = 4.15, p < 0.05) and CRT (2.37 s vs. 0.98 s, t = 3.59, p < 0.05) than groups 2 and 3. Group 1 had the greatest degree of postural sway and the weakest quadriceps strength, although this did not reach significance. Multivariate analysis revealed 25OHD as an independent variable for AFPT, CRT, and postural sway. PTH was an independent variable for muscle strength. Older people who fall have impaired functional performance, psychomotor function, and muscle strength. Within this group, those with 25OHD < 12 microg/liter are the most significantly affected.

E
ELL, S. (1999). "Prevention of falls in elderly people. (Correspondence)" The Lancet 353(9156): 928-9.

ELTRAFI, A., D. King, et al. (2000). "Role of carotid sinus syndrome and neurocardiogenic syncope in recurrent syncope and falls in patients referred to an outpatient clinic in a district general hospital." Postgrad Med J 76(897): 405-8.
ABSTRACT: Carotid sinus syndrome (CSS) and neurocardiogenic syncope (NCS) are recognised as important causes of recurrent syncope and falls in the elderly. In this study the role of CSS (diagnosed with carotid sinus massage) and NCS (diagnosed with prolonged head-up tilt) in a district general hospital were investigated. Over 27 consecutive months carotid sinus massage was performed in 139 patients. Of these 29 (20.8%) patients (mean (SD) age of 78 (9) years) showed a positive response. Of these 18 (62%) patients showed a positive response only when carotid sinus massage was performed with 70 (degrees) head-up tilt. Thirteen (8.7%) of the 149 patients who had prolonged head-up tilt testing were found to have NCS. The mean (SD) age for patients with NCS was 59 (26) years and the mean (SD) time required to produce a positive response during prolonged head-up tilt was 12 (5) minutes. It is concluded that carotid sinus massage and head-up tilt testing are useful in patients presenting with unexplained syncope and falls in a district general hospital setting. Carotid sinus massage should be repeated upon head-up tilt if a negative response is obtained in the supine position.

F
FERMO, K., L. Jurjevic, et al. (2001). Falls and Balance Service Evaluation: Bundoora Extended Care Centre. Melbourne, Centre for Applied Gerontology.

G
GILLESPIE, L. D., W. J. Gillespie, et al. (2001). "Interventions for preventing falls in elderly people (Cochrane Review)." Cochrane Database Syst Rev 3: CD000340.
ABSTRACT: BACKGROUND: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention. OBJECTIVES: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care). SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Group specialised register (January 2001), Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2001), MEDLINE (1966 to February 2001), EMBASE (1988 to 2001 Week 14), CINAHL (1982 to March 2001), The National Research Register, Issue 1, 2001, Current Controlled Trials (www.controlled-trials.com accessed 25 May 2001), and reference lists of articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomised trials of interventions designed to minimise the effect of, or exposure to, risk factors for falling in elderly people. Main outcomes of interest were the number of fallers, or falls. Trials reporting only intermediate outcomes were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Data were pooled using the fixed effect model where appropriate. MAIN RESULTS: Interventions likely to be beneficial:
• A programme of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98).
• A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73).
• Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (1 trial, 530 participants, RR 0.64, 95% CI 0.49 to 0.84). A reduction in falls was seen both inside and outside the home.
• Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74).
• Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes, both for unselected community dwelling older people (data pooled from 3 trials, 1973 participants, pooled RR 0.73, 95%CI 0.63 to 0.86), and for older people with a history of falling, or selected because of known risk factors (data pooled from 2 trials, 713 participants, pooled RR 0.79, 95%CI 0.67 to 0.94). Interventions of unknown effectiveness:
• Group-delivered exercise interventions (9 trials, 2177 participants). • Nutritional supplementation (1 trial, 50 participants).
• Vitamin D supplementation, with or without calcium (3 trials, 679 participants).
• Home hazard modification in association with advice on optimising medication (1 trial, 658 participants), or in association with an education package on exercise and reducing fall risk (1 trial, 3182 participants).
• Pharmacological therapy (raubasine-dihydroergocristine, 1 trial, 95 participants).
• Fall prevention programmes in institutional settings.
• Interventions using a cognitive/behavioural approach alone (2 trials, 145 participants).
• Home hazard modification for older people without a history of falling (1 trial, 530 participants).
• Hormone replacement therapy (1 trial, 116 participants). Interventions unlikely to be beneficial:
• Brisk walking in women with an upper limb fracture in the previous two years (1 trial, 165 participants).

REVIEWER'S CONCLUSIONS: Interventions to prevent falls that are likely to be effective are now available; less is known about their effectiveness in preventing fall-related injuries. Costs per fall prevented have been established for four of the interventions and careful economic modelling in the context of the local healthcare system is important. Some potential interventions are of unknown effectiveness and further research is indicated.

H
HILL, K., R. Smith, et al. (2001). "Falls clinics in Australia: a survey of current practice, and recommendations for future development." Australian Health Review 24(4): 163-174.
ABSTRACT: The aim of this study was to identify common themes and differences in structure and function of Falls Clinics in Australia, to provide a framework for planning future activity. A paper-based survey was circulated to 20 identified Falls Clinic services throughout Australia in late 2000. Fifteen responses (75%) were received, although two of the 15 Clinics were not operating at the time of the survey, and so their responses were not included. Nine of the Clinics had commenced operation since 1998. Staffing commonly included a physiotherapist, geriatrician, and an occupational therapist, with the comprehensive multidisciplinary assessment process taking an average of 130 minutes. Although standard assessment tools were used by more than half of the Clinics, there were no universally applied assessment tools. Waiting lists for initial assessments ranged up to 16 weeks (average 6 weeks). Most Clinics instituted a number of management options themselves, but also used a range of existing community services to provide some of the planned interventions. Limited formal evaluation of the effectiveness of Clinics was reported. Recommended future activity included increasing staff levels and operating times for Clinics to more adequately meet identified need, increased networking and data sharing between Clinics, and a greater emphasis on research and staff training. We conclude that the recent increase in the number of Falls Clinics around Australia has occurred in a relatively unstructured manner, with many differences in staffing, operation and evaluation. There is a need for improved communication and standardisation of core procedures and assessment tools to facilitate best practice in all Clinics, and to provide a framework for a systematic evaluation of the effectiveness of Falls Clinics in Australia.

HILL, K. D., J. Dwyer, et al. (1994). "A Falls and Balance Clinic for the elderly." Physiotherapy Canada 45: 20-27.
ABSTRACT: A Falls and Balance Clinic for the elderly has been developed with the aim of identifying those at risk of subsequent falls, and recommending intervention strategies to reduce this risk. The physical and functional status of 149 clients referred to the Clinic are reported. Neurological and musculoskeletal pathologies were identified as the cause of falls in the majority of clients. Measures of gait velocity and stride length, and ability to stand on one leg were markedly reduced compared with normative data for healthy elderly. A number of other measures of balance, strength, and function are also reported. The results of a questionnaire about home environment indicated that only 28% of those referred had been assessed in their own home in the previous year. Home environment was considered a potential risk in a further 28% of clients and a home visit was instituted in these cases. Other intervention strategies included referral for further investigations (36%), Day Hospital (33%), provision of a home program of balance or strengthening exercises (27%), and medication change (15%). Issues related to the establishment, operation and long term evaluation of the effectiveness of a specialist Falls and Balance Clinic for the elderly are discussed.Hill, S., J. Mossman, et al. (2000). "A randomised controlled trial of a nurse-led falls prevention clinic." Age and Ageing 29(Supp 2): 20.

HO, A. (1999). "MSc dissertation abstract session. Telephone follow-up and one year reassessment of elderly clients from a fall clinic in Hong Kong." Hong Kong Physiotherapy Journal 17: 21. The objective of the study was to determine the functional mobility status, as measured by fall incident(s), balance and mobility performance, of three faller risk groups post-intervention from a Fall Clinic in Hong Kong using bimonthly telephone calls and a one-year reassessment evaluation. Subjects were recruited from clients who visited the Fall Clinic between July 1996 to April 1997. Clients (n=52) with three or more fall risk factors were classified into three groups. Based on the incident(s) of fall in the past 12 months, there were 13 "Non-fallers"(no fall incident), 20 "Fallers" (one fall incident) and 19 "Multiple-fallers" (two or more fall incidents). A post-intervention bi-monthly telephone call was used to monitor the incident of falls over 12 months (n=35 clients). A follow-up reassessment occurred at one-year using three measures, the "Timed Up & Go Test" (TUGT), the Self Paced Walk Test (SPWT) and the Berg Balance Scale (BBS). Based on mean scores, the Berg Balance Scale (BBS) was the only measure to reflect changes in performance among the three groups at a given time period (i.e., the initial assessment, post intervention or at the one-year reassessment; one-way ANOVA). Initially, mean scores on the BBS indicated that the Non-faller risk group had significantly better balance performance than the Multiple-faller group. Following intervention, improved balance performance resulted in similar mean BBS scores for the three groups (n=52). At the one-year reassessment (n=35), a trend toward different mean levels of balance performance (BBS) was observed between subjects in the three groups. For 14 clients in the original Multiple-faller group who completed the follow-up reassessment, the average decrease in fall number from 3.4 to 1.4 falls per client supports that the activities of the Fall Clinic were successful in fall prevention. Despite their continuing risk factors for falls, all clients in the Non-faller group were successfully maintained at the no fall status at the one year follow-up reassessment. Based on the decreased number of falls reported among the 35 clients over the 12 month follow-up period (12 vs. 60 initial falls), a significant improvement in the level of faller risk status was noted when clients were re-classified into the relevant faller risk group, i.e., Non-faller, Faller and Multiple-faller. The present study highlights the importance of follow-up procedures in clinical practice. The mean levels of mobility and balance performance of clients were maintained at the one-year reassessment. One explanation of these findings is that the telephone contact had a beneficial effect on client performance, but this remains to be tested.

HOGAN, D. B., F. A. MacDonald, et al. (2001). "A randomized controlled trial of a community-based consultation service to prevent falls." Canadian Medical Association Journal 165(5): 537-43.
ABSTRACT: BACKGROUND: Multifaceted programs that combine assessment with interventions have been shown to reduce subsequent falls in some clinical trials. We tested this approach to see whether it would be effective if offered as a consultation service using existing health care resources. METHODS: The subjects of this randomized controlled trial had to be aged 65 years or more and had to have fallen within the previous 3 months. They were randomly assigned to receive either usual care or the intervention, which consisted of in-home assessment in conjunction with the development of an individualized treatment plan, including an exercise program for those deemed likely to benefit. The primary outcomes were the proportion of participants who fell and the rate of falling during the following year. Visits to the emergency department and admissions to hospital were secondary outcomes. RESULTS: One hundred and sixty-three subjects were randomly assigned to either the control or the intervention group, and 152 provided data about their falls. There were no significant differences between the control and intervention groups in the cumulative number of falls (311 v. 241, p = 0.34), having one or more falls (79.2% v. 72.0%, p = 0.30) or in the mean number of falls (4.0 v. 3.2, p = 0.43). Analysis of secondary outcomes (health care use) also showed no significant differences between the intervention group and the control group. In the Cox regression analysis, there was no significant difference between the groups in the proportion of subjects having one or more falls (p = 0.55), but there was a significantly (p < 0.001) longer time between falls in the intervention group. In a post hoc subgroup analysis, subjects with more than 2 falls in the 3 months preceding study entry who had been assigned to the intervention group were less likely to fall (p = 0.046) and had a significantly longer time between falls (p < 0.001), when compared with the group who received usual care. INTERPRETATION: The intervention did not decrease significantly the cumulative number of falls, the likelihood of participants having at least one fall over the next year or the mean number of falls. It did increase significantly the time between falls in a survival analysis when age, sex and history of falling were used as covariates.

HOUGHTON S, Birks V, Whitehead CH, Crotty M. (2004) "Experience of a falls and injuries risk assessment clinic". Australian Health Review. 28; 374-81.
ABSTRACT: AIM: To describe the first 2 years of operation of a specialist Falls Clinic providing assessment of falls risk and individual preventive interventions in a public hospital setting. METHOD: Drawing from the available falls prevention evidence, a multidisciplinary Falls Clinic involving specialist medical assessment, physiotherapy assessment and treatment was established. RESULTS: Over 2 years, 386 patients were seen in the clinic with the majority referred by a GP. The most frequent intervention for patients was referral to a Falls Education Program run by allied health staff at the hospital. Patients attending balance and exercise classes through this program showed significant improvement in physiotherapy test scores, reducing their risk of falls. The detection and treatment of osteoporosis was another important outcome for older persons attending the clinic. CONCLUSIONS: The Falls Clinic provides access to evidence-based strategies for patients. Waiting lists for the clinic have increased dramatically since its inception. Ideally many of the interventions should be available in the primary care setting to increase access for those in the community at risk of falls.

M
McINTOSH, S., D. DaCosta, et al. (1993). "Outcome of an integrated approach to the investigation of dizziness, falls and syncope in elderly patients referred to a 'syncope' clinic." Age and Ageing 22: 53-8.
ABSTRACT: Sixty-five consecutive elderly patients (mean age 78 years) referred to a 'syncope' clinic over a six-month period were prospectively studied. Initial evaluation included ambulatory electrocardiography, carotid sinus massage before and after atropine and prolonged head-up tilt. Diagnostic criteria for causes of syncope were assigned at the beginning of the study. Overall, a diagnosis was attributed to symptoms in 92% of patients; overlap was present in a quarter. Diagnoses were cardioinhibitory carotid sinus syndrome (CSS; 5%), vasodepressor CSS (26%), mixed CSS (14%), orthostatic hypotension (32%), vasodepressor vasovagal syncope (11%), cardiac arrhythmia (21%), epilepsy (9%), cerebrovascular disease (6%) and others (12.5%). Sixty per cent of patients with vasodepressor CSS also had orthostatic hypotension or vasodepressor vasovagal syncope suggesting a common aetiology. Using an integrated approach incorporating head-up tilt and carotid sinus massage in a selected group of elderly patients referred to a 'syncope' clinic, the diagnostic yield was high.

O
O'SHEA, D., J. Lawson, et al. (1996). "Is it important to F.A.C.E the elderly pilot data for "Frail Elderly Fallers" - Clinic?" Age and Ageing 26(Supp 1): 13.

P
PUISIEUX, F., B. Pollez, et al. (2001). "Successes and setbacks of the falls consultation: Report on the first 150 patients." American Journal of Physical Medicine and Rehabilitation 80(12): 909-915.
ABSTRACT: OBJECTIVE: We report the results of a Falls Consultation. DESIGN: Data concerning the first 150 patients are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home, and was reassessed by the same geriatrician 6 mo later. RESULTS: Of the 150 patients, 135 patients completed the initial evaluation. Most of them were frequent fallers. The population was very heterogeneous regarding the health status and the degree of disability. In most cases, falls were the result of several interacting factors. The most frequent recommendations from the staff were physical therapy, environmental changes, and medication changes. Over the following 6 mo, approximately one out of four patients had experienced new falls. However, the risk of falling was significantly reduced (5.3 +/- 7.3 falls in 6 mo before vs. 0.8 +/- 1.6 falls in 6 mo after the intervention). The Activities of Daily Living score was a predictor of recurrent falls, hospitalization, and institutionalization. CONCLUSION: Our results show that a multidisciplinary falls consultation can be efficient in reducing the risk of falls in nonselected elderly fallers but suggest that differential strategies are needed to manage adequately the more vigorous and the frail old person as well.

S
SAHOTA O. (2003) A rationale for vitamin D prescribing in a falls clinic population (letter). Age Ageing 32; 681 (author reply 681-2). ABSTRACT: not available

STOLZ, D., M. Miller, et al. (2001). A multi-disciplinary falls clinic-is nutrition the weakest link? Australian Association of Gerontology, Canberra.

SUTHERLAND, M. and A. Burdon (1997). A community-based assessment and intervention program for falls prevention in older adults - A pilot study. Adelaide, Western DomCare.

T
TIDEIKSAAR, R. (1996). Reducing the risk of falls and injury in older persons: Contribution of a falls and immobility clinic. Falls, gait and balance disorders in the elderly: From successful aging to fraility. C. LaFont, A. Baroni, M. Allardet al. New York, Springer Publishing Company: 163-82.

W
WHITEHEAD, C., M. Crotty, et al. (2001). Evidence based clinical practice in falls prevention: A randomised controlled trial of a falls prevention service. Australian Association of Geriatric Medicine Conference, Blue Mountains.

WHITNEY SL, Wrisley DM, Brown KE, Furman JM. (2004) "Is perception of handicap related to functional performance in persons with vestibular dysfunction"? Otol Neurotol. 25; 139-43.
ABSTRACT: OBJECTIVE: The purpose of this study was to determine if scores between 0 and 30 (mild), 31 and 60 (moderate), and 61 and 100 (severe) on the Dizziness Handicap Inventory (DHI) differentiated a person's functional abilities. STUDY DESIGN: Retrospective case series. SETTING: Tertiary balance outpatient center. PATIENTS: Patients (n = 85; mean age, 61 years) with a variety of vestibular diagnoses participated. INTERVENTIONS: Patients completed the DHI, the Dynamic Gait Index (DGI), the 5 times sit to stand test (FTSST), the Activities-specific Balance Confidence (ABC) scale, gait speed, and the Timed "Up & Go" (TUG) during the same session. Reported numbers of falls within the last 4 weeks were recorded. MAIN OUTCOME MEASURES: The DGI, FTSST, ABC, gait speed, TUG, and gait speed were compared among DHI groups. RESULTS: Significant differences were identified using an analysis of variance between DHI groups on the DGI, the FTSST, ABC, and number of falls (p < 0.05). A significant difference was found between DHI groups (mild vs. severe and moderate vs. severe) on the DGI (p < 0.05) with greater DHI scores exhibiting more impaired walking. The FTSST was different between DHI groups mild and severe and DHI groups moderate and severe (p < 0.05), with slower FTSST scores with higher DHI scores. Reported falls were higher among the severe DHI group and the other 2 DHI groups (p < 0.05). All 3 DHI groupings were different from each other on the ABC (p < 0.001). CONCLUSION: Patients who perceive a greater handicap as a result of dizziness demonstrate greater functional impairment than patients who perceive less handicap from dizziness.

WOLF-KLEIN, G., F. Silverstone, et al. (1988). "Prevention of falls in the elderly population." Archives of Physical Medicine and Rehabilitation 69: 689-91.
ABSTRACT: In response to the challenge posed by falls in the elderly, the Jewish Institute for Geriatric Care established a Falls Clinic. The coordinated expertise of a geriatrician, neurologist, cardiologist, and physiatrist were combined with resources in audiology, ophthalmology, and podiatry. Thirty-six patients enrolled in the study had sustained a total of 36 falls, which resulted in 13 fractures and seven soft-tissue injuries. Falls were a daily occurrence for three patients, weekly for five patients, monthly for ten, semiannually for 14, and yearly for four patients. After a one-year follow-up, 77% of the patients experienced no further falls. We suggest that falls are a multidisciplinary issue and recommend a team approach for successful management.

WOOD, B., A. Bennie, et al. (1999). "Falls: a coordinated strategy." Aust Health Rev 22(3): 144-54.
ABSTRACT: Falls are a common and serious health problem. Responses to the problem should address the individual, the individual's environment, the system of health or residential care used by the individual, and the local community. This article describes a response to the issue of falls in Ryde Hospital and its surrounding community. This response has multiple components which include patient and staff education and interventions with people who have fallen. These initiatives have been developed without additional resources and incorporated into existing systems of care provision.

WRISLEY DM, Whitney SL, Furman JM. (2002) "Vestibular rehabilitation outcomes in patients with a history of migraine". Otol Neurotol. 23; 483-7.
ABSTRACT: OBJECTIVES: The purpose of this study was to assess the efficacy of physical therapy for patients with vestibular disorders with and without a history of migraine headaches. STUDY DESIGN: Retrospective case series. SETTING: Outpatient physical therapy clinic. PATIENTS: Thirty patients with both a history of migraine and a diagnosis of vestibular/balance disorder considered unrelated to migraine were identified by retrospective chart review. Thirty patients without a history of migraine, matched retrospectively by diagnosis, vestibular function, and age (+/-5 years), were used as a comparison group. INTERVENTIONS: Both groups were treated with a custom-designed physical therapy program for a mean of 4.1 visits over a mean of 3.3 months. MAIN OUTCOME MEASURES: Patients completed the Dizziness Handicap Inventory, the Activities-Specific Balance Confidence Scale, the Dynamic Gait Index, and the Timed Up & Go Test and rated the severity of their dizziness on an analog scale of 0 to 100. RESULTS: Significant differences were demonstrated within both groups between initial evaluation and discharge in each of the assessment measures used. Patients with a history of migraine demonstrated worse scores on all outcome measures than did the patients without a history of migraine. There were no statistically significant differences between the two groups' scores before and after therapy except for the total Dizziness Handicap Inventory score at discharge (p < 0.05). CONCLUSIONS: Patients with vestibular disorders with or without a history of migraine demonstrated improvements in both subjective and objective measures of balance after physical therapy. Patients with a history of migraine perceived a greater handicap from dizziness than did patients without a history of migraine that was greater than the difference in physical function performance measures between groups.

Y
YOUDE, J., C. Ruse, et al. (2000). "A high diagnostic rate in older patients attending an integrated syncope clinic." J Am Geriatr Soc 48(7): 783-7.
ABSTRACT: OBJECTIVES: To describe the findings in the first year of an integrated syncope clinic for older patients and to review the published literature on "integrated" syncope clinics investigating older people. DESIGN: Review of syncope clinic database and Medline search for relevant literature. SETTING: Outpatient syncope clinics in two district hospitals in the same city. PARTICIPANTS: Secondary referrals from the in- and outpatient population with recurrent unexplained presyncopal and syncopal symptoms. RESULTS: The results of testing in 76 patients over the age of 60 years were available for analysis. A diagnosis was achieved in 67 (88%) of the patients with 76% of the diagnoses being cardiovascular in origin. The prevalence rates of neurocardiogenic syncope (32%) and carotid sinus syndrome (17%), however, differed from previously reported rates. CONCLUSIONS: Evaluation of presyncopal and syncopal events in an "integrated syncope clinic" achieves a high diagnostic yield in older subjects.