Journal of the Royal Society of Medicine Volume 84 November 1991
Falls in the elderly In his stimulating editorial Dr Waterston (April 1991 JRSM, p 189) notes that many epidemiological studies have been carried out on populations of elderly fallers, but those which he cites do not do justice to the literature. He refers to a study of postural sway with age that was not population-based', and to a case series in which the falls ascertained were only a 20th of those occurring in the target population2. The latter study has been criticized for being biased heavily in favour of a selectively frail and ill sample, in whom the risk factors for falling and the associated prognosis are different from the majority of elderly fallers3. The relevant literature contains both retrospective4-6 and prospective7-9 studies of falling by elderly people at home in geographically-defined populations. Falling is common, and the causes are complex. Progress in treatment and prevention will depend on carefully designed research which can clearly be related to the available epidemiological evidence. S WINNER
University Division of Geriatric Medicine, The Radcliffe Infirmary, Oxford OX2 6HE
References 1 Overstall PW, Exton-Smith AN, Imms FJ, Johnson AL. Falls in the elderly related to postural imbalance. BMJ 1977;i:261-4 2 Wild D, Nayak USL, Isaacs B. How dangerous are falls in old people at home? BMJ 1981;282:266-8 3 Evans JG. Commentary: Falls and fractures. Age Ageing 1988;17:361-3 4 Prudham D, Grimley Evans J. Factors associated with falls in the elderly: a community study. Age Ageing 1981:10:141-6 5 Campbell AJ, Reinken J, Allan BC, Martinez GS. Falls in old age: a study of frequency and related clinical factors. Age Ageing 1981;10:264-70 6 Blake AJ, Morgan K, Bendall MJ et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17:365-72 7 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7 8 Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989;44:M112-17 9 Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19:136-41
Waiting list initiatives I read the article 'Waiting list initiatives: crisis management of targeting of resources?' by Mills and Heaton with interest (July 1991 JRSM, p 405). Waiting lists exist for a number of reasons as explained in the article. While consultants may organize an initiative, ENT registrars almost always undertake it as was the case here. Juniors have very little say in these ventures and it is usually their study leave or their half day that is forfeited often with no recompense either in time or money. Little can be said for the surgical experience gained for lists are usually unsupervised. Since there are so few research posts in our specialty such an erosion into time set aside for research is less than praiseworthy. These points were clearly illustrated by the waiting list initiatives undertaken in Birmingham both at
Selly Oak Hospital and at the Queen Elizabeth Hospital: the same registrar on rotation had to undertake both initiatives, one post was derived from waiting list monies and one was undertaken during time set aside for research. In addition no costing of surgical time was built into the bid at the Queen Elizabeth. In the past, one was left with the feeling that these initiatives were political exercises undertaken in collusion between consultants and management to paper over the inadequacies of the system without addressing the real reasons for waiting lists. Once the lists are culled, then theoretically, the surgeons may work more efficiently. Now there is no money for waiting list initiatives: the problem hastobe sorted out within the sessions available. Shorter lists should have more cases on them. Efficiency as envisaged by the production line mentality of the new health service management. Unless a consultant has no waiting list, there is a catch. Long waiting lists result in default and so the theatre lists are shorter! Unfortunately our new district management has put a block on replacing retiring consultants. Our new integrated (but split on two sites) department previously had an initiative in each hospital and now has a retirement. Yes, you have guessed it, he has the longest waiting list. A DRAKE-LEE
Consultant ENT Surgeon, 20 Vernon Road, Edgbaston, Birmingham B16 9SH
Crohn's disease of the vulva We read with interest the case report by Kingsland and Alderman (April 1991 JRSM, p 236). Crohn's disease of the vulva is rare as in one review it was noted that out of 431 cases of Crohn's disease in the female patients, eight women had intractable vulval vaginitis'. So far as we are aware only 16 cases of Crohn's disease ofthe vulva has been reported including the authors' case. Though the authors claim that their patient is unusual to have developed the vulval lesion within 20 years of the onset of the disease, we note that 10 patients with Crohn's disease of the gastrointestinal tract appeared to have developed the vulval lesions within 20 years. Ten women had vulval disease when they were not on any medication2. There is no consensus about therapy of this condition but it is generally agreed that if medical therapy fails, surgical therapy such as vulvectomy or debridement therapy may be required2. J HOSSAIN Departments of Medicine and Surgery King Khalid Hospital, M L BAzAZ Jeddah, Saudi Arabia
References 1 Davidson LB. Crohn's disease. Its gynaecological aspect. Am J Obstet Gynecol 1978;131:196-202 2 Burke T. A 34 year old woman with a history of Crohn's disease with recent vulvular cellulitis. N Engl J Med 1989;320:1741-7
Honey and healing of leg ulcers Dr Frank Tovey (July 1991 JRSM, p 447) advocates a sugar paste to be.applied to chronic leg ulcers, as a means of separating moist slough and promoting the healing of granulating wounds, especially in diabetic patients. For many centuries doctors have applied a wide variety of ointments and lotions to ulcers associated with oedema of the leg or foot.
693
Falls in the elderly In his stimulating editorial Dr Waterston (April 1991 JRSM, p 189) notes that many epidemiological studies have been carried out on populations of elderly fallers, but those which he cites do not do justice to the literature. He refers to a study of postural sway with age that was not population-based', and to a case series in which the falls ascertained were only a 20th of those occurring in the target population2. The latter study has been criticized for being biased heavily in favour of a selectively frail and ill sample, in whom the risk factors for falling and the associated prognosis are different from the majority of elderly fallers3. The relevant literature contains both retrospective4-6 and prospective7-9 studies of falling by elderly people at home in geographically-defined populations. Falling is common, and the causes are complex. Progress in treatment and prevention will depend on carefully designed research which can clearly be related to the available epidemiological evidence. S WINNER
University Division of Geriatric Medicine, The Radcliffe Infirmary, Oxford OX2 6HE
References 1 Overstall PW, Exton-Smith AN, Imms FJ, Johnson AL. Falls in the elderly related to postural imbalance. BMJ 1977;i:261-4 2 Wild D, Nayak USL, Isaacs B. How dangerous are falls in old people at home? BMJ 1981;282:266-8 3 Evans JG. Commentary: Falls and fractures. Age Ageing 1988;17:361-3 4 Prudham D, Grimley Evans J. Factors associated with falls in the elderly: a community study. Age Ageing 1981:10:141-6 5 Campbell AJ, Reinken J, Allan BC, Martinez GS. Falls in old age: a study of frequency and related clinical factors. Age Ageing 1981;10:264-70 6 Blake AJ, Morgan K, Bendall MJ et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17:365-72 7 Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7 8 Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol 1989;44:M112-17 9 Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19:136-41
Waiting list initiatives I read the article 'Waiting list initiatives: crisis management of targeting of resources?' by Mills and Heaton with interest (July 1991 JRSM, p 405). Waiting lists exist for a number of reasons as explained in the article. While consultants may organize an initiative, ENT registrars almost always undertake it as was the case here. Juniors have very little say in these ventures and it is usually their study leave or their half day that is forfeited often with no recompense either in time or money. Little can be said for the surgical experience gained for lists are usually unsupervised. Since there are so few research posts in our specialty such an erosion into time set aside for research is less than praiseworthy. These points were clearly illustrated by the waiting list initiatives undertaken in Birmingham both at
Selly Oak Hospital and at the Queen Elizabeth Hospital: the same registrar on rotation had to undertake both initiatives, one post was derived from waiting list monies and one was undertaken during time set aside for research. In addition no costing of surgical time was built into the bid at the Queen Elizabeth. In the past, one was left with the feeling that these initiatives were political exercises undertaken in collusion between consultants and management to paper over the inadequacies of the system without addressing the real reasons for waiting lists. Once the lists are culled, then theoretically, the surgeons may work more efficiently. Now there is no money for waiting list initiatives: the problem hastobe sorted out within the sessions available. Shorter lists should have more cases on them. Efficiency as envisaged by the production line mentality of the new health service management. Unless a consultant has no waiting list, there is a catch. Long waiting lists result in default and so the theatre lists are shorter! Unfortunately our new district management has put a block on replacing retiring consultants. Our new integrated (but split on two sites) department previously had an initiative in each hospital and now has a retirement. Yes, you have guessed it, he has the longest waiting list. A DRAKE-LEE
Consultant ENT Surgeon, 20 Vernon Road, Edgbaston, Birmingham B16 9SH
Crohn's disease of the vulva We read with interest the case report by Kingsland and Alderman (April 1991 JRSM, p 236). Crohn's disease of the vulva is rare as in one review it was noted that out of 431 cases of Crohn's disease in the female patients, eight women had intractable vulval vaginitis'. So far as we are aware only 16 cases of Crohn's disease ofthe vulva has been reported including the authors' case. Though the authors claim that their patient is unusual to have developed the vulval lesion within 20 years of the onset of the disease, we note that 10 patients with Crohn's disease of the gastrointestinal tract appeared to have developed the vulval lesions within 20 years. Ten women had vulval disease when they were not on any medication2. There is no consensus about therapy of this condition but it is generally agreed that if medical therapy fails, surgical therapy such as vulvectomy or debridement therapy may be required2. J HOSSAIN Departments of Medicine and Surgery King Khalid Hospital, M L BAzAZ Jeddah, Saudi Arabia
References 1 Davidson LB. Crohn's disease. Its gynaecological aspect. Am J Obstet Gynecol 1978;131:196-202 2 Burke T. A 34 year old woman with a history of Crohn's disease with recent vulvular cellulitis. N Engl J Med 1989;320:1741-7
Honey and healing of leg ulcers Dr Frank Tovey (July 1991 JRSM, p 447) advocates a sugar paste to be.applied to chronic leg ulcers, as a means of separating moist slough and promoting the healing of granulating wounds, especially in diabetic patients. For many centuries doctors have applied a wide variety of ointments and lotions to ulcers associated with oedema of the leg or foot.
693
![[Accidental falls in the elderly].](/assets/img/hold.png)
