JAGS AUGUST 2008–VOL. 56, NO.
8 LETTERS TO THE EDITOR
renal dysfunction, in contrast to what is typically expected
in nonrenal anemia. A study of 1,005 subjects aged 65 and
older demonstrated that the endogenous erythropoietin re-
sponse is sluggish with age and decline in renal function,
contributing to anemia.6 The findings in Table 1 lend some
credibility to the fact that chronic anemia in the Agnihotri
et al. study may have been, at least in part, secondary to
CKD, in which the endogenous erythropoietin response to
declining hemoglobin is known to be blunted, but the re-
sponse to recombinant epoetin alfa therapy is favorable. In
summary, many patients in the study, with a mean age in the
70s, may conceivably have had CKD of varying severity
(with or without additional comorbid conditions that cause
chronic anemia), and their favorable response to epoetin
alfa was to be expected. However, the relatively larger doses
of epoetin used (20–40,000 U weekly) bring into consider-
ation the presence of factors that cause resistance to epoe-
tin. Once hemoglobin increases in response to epoetin alfa,
better QOL (and less fatigue) likely follows.
Analyzing the data in Table 1 further, one would like to
know which category of patients (based on GFR, normal
versus CKD Stages 1 to 4, ferrokinetics, and non-renal ane-
mias) had a better or poorer response to epoetin and ac-
cordingly an effect on QOL. Is it ‘‘chronic anemia’’ (of any
etiology, based on the higher doses of epoetin used), or is it
‘‘anemia of CKD,’’ one cause of anemia of chronic disease,
that responded favorably to epoetin therapy and improved
QOL? These specific conclusions from the present study
may have important implications for management of
chronic anemia; the cause of anemia does matter!
T. S. Dharmarajan, MD, AGSF
Department of Medicine
Division of Geriatrics
Our Lady of Mercy Medical Center
Bronx, NY
New York Medical College
Valhalla, NY
ACKNOWLEDGMENTS
Conflict of Interest: No financial support was provided for
this letter. The author has no real or apparent conflicts of
interest relating to the content presented in this publication.
Author Contributions: Dr. Dharmarajan is the sole
author of this paper.
Sponsor’s Role: None.
REFERENCES
1. Agnihotri P, Telfer M, Butt Z et al. Chronic anemia and fatigue in elderly
patients: Results of a randomized, double-blind, placebo-controlled, crossover
exploratory study with epoetin alfa. J Am Geriatr Soc 2007;55:1557–1565.
2. Guralnik JM, Eisenstadt RS, Ferrucci L et al. Prevalence of anemia is persons 65
and older in the United States: Evidence for a high rate of unexplained anemia.
Blood 2004;104:2263–2268.
3. Evaluation of anemia in CKD: Clinical practice guidelines and clinical prac-
ticeFrecommendations for anemia in CKD in adults. Am J Kidney Dis 2006;
47(Suppl 3):S11–S81.
4. Coresh J, Selvin E, Stevens LA et al. Prevalence of chronic kidney disease in the
United States. JAMA 2007;298:2038–2047.
5. Robinson B, Artz AS, Culleton B et al. Prevalence of anemia in the nursing home:
Contribution f chronic kidney disease. J Am Geriatr Soc 2007;55:1566–1570.
6. Alessandro Ble, Fink JC, Woodman RC et al. Renal function, erythropoietin and
anemia in older persons: The inChianti study. Arch Intern Med 2005;165:2222–
2227.
1575
FIVE TIMES SIT TO STAND TEST IS A PREDICTOR OF
RECURRENT FALLS IN HEALTHY COMMUNITY-
LIVING SUBJECTS AGED 65 AND OLDER
To the Editor: Falls are a leading cause of disability, injury,
and death in elderly people, occurring each year in more
than 30% and 50% of the population aged 65 and 80 older,
respectively.1 The use of several clinical balance tests has
been widely proposed in primary care to identify elderly
subjects with postural instability and at high risk of falling,
but the value of these tests in predicting falls remains un-
clear.
The aim of this prospective study was to investigate
whether standard clinical balance testsFOne-Leg Balance
(OLB), Timed ‘‘Up & Go’’ (TUG), and Five Times Sit to
Stand (FTSS)Fcombined with demographic and medical
data, predict risk of recurrent falls in community-living
subjects aged 65 and older.
METHODS
This population-based study included 2,735 consecutive
voluntary subjects aged 65 and older in an apparently good
state of health consulting for a medical examination2 be-
tween January 2004 and June 2005 at the Centre de
Médecine Préventive in Nancy, France.
During the medical examination, the subjects per-
formed the following clinical balance tests:
 . OLB test: Subjects were instructed to remain upright on
one leg without support for at least 5 seconds.3
 . TUG test: Subjects were observed and timed while ris-
ing from an arm chair, walking 3 m, turning, walking
back, and sitting down again (normal duration o12
seconds).4
 . FTSS test: Subjects were instructed to stand up from a
chair five times as quickly as possible without pushing
off.5 The seat height for the chair was 45 cm.
Falls were recorded using a self-questionnaire completed
18 to 36 months after the visit. Subjects were classified into
three groups: nonfallers, single fallers (1 fall), and recurrent
fallers (2 falls).
RESULTS
Information about falls was received from 1,958 subjects
(72% of the total sample, mean age 70
4; 978 women);
239 subjects (12.2%) reported one fall and 183 (9.3%) at
least two falls.
In univariate analysis, recurrent fallers were more
likely than nonfallers and single fallers to fail the TUG
(14% vs 7% and 7%) and FTSS (55% vs 35% and 38%)
tests. Eighteen percent of the single fallers and 16% of
the recurrent fallers failed the OLB test, versus 9% of
nonfallers.
A multivariable analysis was conducted using a Cox
proportional hazard regression model with time-indepen-
dent covariates. Of the three tests, only an FTSS time longer
than 15 seconds was independently associated with risk of
recurrent falls, after adjustment for four significant covari-
ates (history of fall, sex, number of medications, and living
alone) (risk ratio 5 1.74, 95% confidence interval 5 1.24–
2.45, Po.001). The optimal cutoff time for performing the
1576 LETTERS TO THE EDITOR AUGUST 2008–VOL. 56, NO. 8 JAGS

Vandoeuvre-lès-Nancy, France
Department of Geriatrics
University Hospital of Nancy
Vandoeuvre-lès-Nancy, France
Darko Miljkovic, MA
Centre d’Etudes et de Formation sur le Vieillissement
University Hospital of Nancy
University of Nancy
Vandoeuvre-lès-Nancy, France

Patrick Manckoundia, MD, PhD

Department of Geriatrics
University Hospital of Dijon
Dijon, France
Figure 1. Kaplan-Meier curves for prediction of recurrent falls
for subjects who took longer than 15 seconds (gray line) and 15 Rene Gueguen, PhD
seconds or less (black line) to complete the Five Times Sit-to- Patrick Miget, MD
Stand (FTSS). Centre de Médecine Préventive
Vandoeuvre-lès-Nancy, France

FTSS test in predicting recurrent fallers was 15 seconds Guy Vançon, MD

(sensitivity 55%, specificity 65%), which corresponds to Office d’Hygiène Sociale de Meurthe et Moselle Centre
the mean value of the time required to conduct this test in Jacques Parisot
the entire population. The Kaplan-Meier analysis illustrates Bainville-sur-Madon, France
the risk of recurrent falls during the follow-up period in
subjects with FTSS times longer than 15 seconds and 15 Philippe Perrin, MD, PhD
seconds or less (Figure 1). National Institute for Health and Medical Research
ERI 11 [EP]2R
DISCUSSION Faculty of Medicine
The FTSS has a significant predictive value for recurrent Vandoeuvre-lès-Nancy, France
falls in a population of community-living elderly subjects Department of Otolaryngology
aged 65 and older independently of the other main risk University Hospital of Nancy
factors, including history of falls, living alone, female sex, Vandoeuvre-lès-Nancy, France
and number of medications. Subjects who needed more
than 15 seconds to complete the test had a 74% greater risk Athanase Benetos, MD, PhD
of recurrent falls than those who took less time. Centre d’Etudes et de Formation sur le Vieillissement
Two prospective studies have shown that inability to University Hospital of Nancy
rise from chair is associated with risk of falls in older per- University of Nancy
sons.6,7 The current study shows, in a larger population than Vandoeuvre-lès-Nancy, France
in previous studies, that the threshold of 15 seconds for the Department of Geriatrics
FTSS test has been useful for the detection of elderly subjects University Hospital of Nancy
at higher risk of recurrent falls independent of the other main Vandoeuvre-lès-Nancy, France
risk factors for falls. The slower FTSS test time observed in
recurrent fallers could reflect postural balance disorders or ACKNOWLEDGMENTS
muscular weakness of the lower limbs in these individuals.5,8 The authors thank the Centre de Médecine Préventive,
The current study did not find a significant predictive Vandoeuvre-lés-Nancy, France. Sophie Rushton-Smith,
value for recurrent falls for the TUG and OLB tests. A pre- PhD, provided editorial assistance in the preparation of
vious study3 demonstrated that impaired performance on this manuscript.
the OLB test was the only significant independent predictor Conflict of Interest: The editor in chief has reviewed the
of injurious falls but not of all falls. In previous prospective conflict of interest checklist provided by the authors and has
studies, the TUG test did not predict risk of falls in a group determined that the authors have no financial or any other
of older healthy adults.9,10 kind of personal conflicts with this letter. This study was
The FTSS is easy to score and quick to administer, re- supported by grants from the Communauté Urbaine du
quires little space, and needs no special equipment. Con- Grand Nancy.
sequently clinicians could easily use it to identify people at Author Contributions:
high risk of recurrent falls and who are appropriate subjects Severine Buatois: study concept and design, subject
for preventive measures. recruitment, analysis and interpretation of data, writing
the manuscript.
Severine Buatois, PhD Darko Miljkovic: study concept and design, acquisition
Centre d’Etudes et de Formation sur le Vieillissement of data, interpretation of data, writing the manuscript.
University Hospital of Nancy Patrick Manckoundia: study concept and design,
University of Nancy contribution in manuscript preparation.
JAGS AUGUST 2008–VOL. 56, NO. 8
Rene Gueguen: acquisition of data, analysis and inter-
pretation of data, contribution in manuscript preparation.
Patrick Miget: study concept and design, subject recruit-
ment, realization of the clinical balance tests, interpretation of
data.
Guy Vançon: interpretation of data, contribution in
manuscript preparation.
Philippe Perrin: study concept and design, interpreta-
tion of data, contribution in manuscript preparation.
Athanase Benetos: chief investigator, study concept and
design, analysis and interpretation of data, writing the
manuscript.
Sponsor’s Role: ‘‘Communauté Urbaine du Grand
Nancy’’ had no role in the design, methods, subject
recruitment, data collection, analysis, or preparation of
this manuscript.
REFERENCES
1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly
persons living in the community. N Engl J Med 1988;319:1701–1707.
2. Manckoundia P, Buatois S, Gueguen R et al. Clinical determinants of failure in
balance tests in elderly subjects. Arch Gerontol Geriatr 2007 Sep 24 [Epub
ahead of print].
3. Vellas BJ, Wayne SJ, Romero L et al. One-leg balance is an important
predictor of injurious falls in older persons. J Am Geriatr Soc 1997;45:
735–738.
4. Podsiadlo D, Richardson S. The Timed ‘‘Up & Go’’: A test of basic functional
mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–148.
5. Whitney SL, Wrisley DM, Marchetti GF et al. Clinical measurement of sit-to-
stand performance in people with balance disorders: Validity of data for the
Five-Times-Sit-to-Stand test. Phys Ther 2005;85:1034–1045.
6. Nevitt MC, Cummings SR, Kidd S et al. Risk factors for recurrent nonsyncopal
falls. A prospective study. JAMA 1989;261:2663–2668.
7. 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–M117.
8. Schenkman M, Hughes MA, Samsa G et al. The relative importance of strength
and balance in chair rise by functionally impaired older individuals. J Am
Geriatr Soc 1996;44:1441–1446.
9. Boulgarides LK, McGinty SM, Willett JA et al. Use of clinical and impairment-
based tests to predict falls by community-dwelling older adults. Phys Ther
2003;83:328–339.
10. Buatois S, Gueguen R, Gauchard GC et al. Posturography and risk of recurrent
falls in healthy non-institutionalized persons aged over 65. Gerontology
2006;52:345–352.
ECONOMIC BURDEN OF INFORMAL CAREGIVERS
FOR ELDERLY CHINESE IN HONG KONG
To the Editor: In Hong Kong, the majority of elderly people
living in the community receive care from informal care-
givers.1 Informal caregivers form the backbone of caregiv-
ing and provide unpaid daily assistance, especially for
elderly people who are unable to afford paid caregivers.
They are vital for the maintenance of elderly people with
mental or functional limitations in the community, and
their support saves society a large amount of resources.
With the fast-growing elderly population, the extent and
amount of caregiving of elderly people can give rise to a
substantial economic burden on primary caregivers (PCGs).
The objectives of this study were to describe the economic
burden of PCGs for caring elderly people and to identify
predictors of high PCG economic burden in Hong Kong.
A cross-sectional telephone survey of the Hong Kong
Chinese adult population aged 35 and older was conducted
from January 2003 to July 2004.2 PCGs who provided un-
LETTERS TO THE EDITOR 1577
paid assistance to an elderly person in at least one activity of
daily living (ADL) or instrumental activity of daily living
(IADL) and spent at least 4 hours per week in caregiving
activities were identified. The care recipients were aged
65 and older and were household members, relatives, or
friends with functional or cognitive impairment requiring
assistance in ADLs or IADLs. Two hundred fifty-two PCGs
were interviewed; 169 (67.1%) were female, and 133
(52.8%) were aged 35 to 49, 91 (36.1%) were aged 50 to
64, and 28 (11.1%) were aged 65 and older.
The reported effect of caregiving on the work and fi-
nances of PCGs included income reduction (n 5 45,
17.9%), taking leave or absence from work (n 5 38,
15.1%), working part time (n 5 35, 13.9%), routinely
leaving work early (n 5 27, 10.7%), and early retirement
(n 5 22, 8.7%). Regarding self-reported monthly expenses
(not including income loss) on caregiving over the previous
12 months, 84 (33.3%) PCGs spent less than $64 (HKD
500), 47 (18.7%) spent $64 to $128 (HKD 500–1,000), 88
(34.9%) spent $128 to $641 (HKD 1,001–5,000), 21
(8.3%) spent $641 to $1,282 (HKD 5,001–10,000), and 12
(4.8%) spent $1,282 (HKD 10,001) or more. The PCGs
(n 5 114, 45%) and the Government Comprehensive Social
Security Assistance (n 5 42, 17%) were the most commonly
reported major sources of financial support for caregiving
to elderly people.
Associations between a number of factors and the
monthly expense of caregiving (o$128 (HKD 1,000) vs
 $128) were first evaluated using univariate analysis.
These factors included demographics, social characteristics,
tasks assisted by PCGs, duration and frequency of caregiv-
ing, the effect of caregiving on the work and finances of the
PCGs, and the major source of financial support for care-
giving. Approximately half of PCGs spent less than $128
and approximately half spent $128 or more, so the break-
point of $128 was selected. A P-value o.05 was considered
statistically significant.
Univariate analysis indicated that 10 factors were sig-
nificantly associated with monthly expenses of $128 or
more (Table 1). These factors were further analyzed using
stepwise multiple logistic regression analysis, which
showed that higher level of education, administration of
medications by the PCG, and reduced PCG income due to
caregiving were significantly associated with monthly ex-
penses of $128 or more.
The data showed that PCGs in Hong Kong were the
major source of financial support for caregiving to elderly
care recipients in more than 40% of the households
with elderly people. Nearly 50% of the PCGs claimed to
spend $128 or more monthly, approximately 10% of the
median monthly income in Hong Kong,3 although the
accuracy of the self-reported expenditure has not been
validated. More than half of the respondents also reported
various effects of caregiving on work and income. This is
consistent with findings that the financial effect of caregiv-
ing for elderly people was found in both income reduction
and out-of-pocket expenses.4 Our findings further suggest-
ed that PCGs who reported income reduction due to care-
giving for elderly people, provided assistance with
medication administration and those caregivers with high-
er education level had higher monthly out-of-pocket ex-
penses for caregiving.