prolonged serum levels exceeding 8-10 ,ug/ml. In cases 1 and 2 the immediate and dramatic changes occurred with levels greater than this. In case 3 lesser changes occurred even though the serum levels were in the "safe" range. The basal turn of the cochlea seems most vulnerable to both immediate and delayed effects, both of which may produce the dissociated pattern of AP response that is well recognised in high-tone sensory deafness of whatever cause.10The speed of onset of the observed effect suggests a direct action at a site in the cochlea, involving a temporary metabolic block-for example, interference with an energy requiring process or blocking of transport of cations across cell membranes. There is experimental and clinical evidence to show that aminoglycosides interfere with calcium metabolism (probably by binding).21-14 In the lateral line organ of the fish they may block potassium transport.15 Both these effects are rapid and may be reversed by administering the appropriate cation in solution. Other metabolic effects follow intoxication with aminoglycosides, although their speed of onset is not clearly established. Guinea-pigs treated with tobramycin sustain most outer hair cell damage in areas of the cochlea where there is the least amount and smallest granule size of glycogen-namely, the basal turn. The greatest oxygen consumption of the cochlea occurs in the basal turn, and is decreased by kanamycin.17 The adenosine triphosphatase hydrolysing system has been shown to be modified within the microstructures of the cochlea after the administration of aminoglycosides.'8 This may have an important effect on the function of the stria vascularis, which uses adenosine triphosphatase to support a sodium-potassium ion pump to maintain endolymphatic homoeostasis. The possibility that interference with protein synthesis caused of our observed changes is ruled out by their speed of onset.How our findings relate to long-term ototoxicity is not clear. Summary Two hundred and forty-three elderly people aged 60 to 96 years were questioned about their falls, and their sway was measured. For comparison sway was also measured in 63 younger subjects. Sway increased with age and was higher in women at all ages. There was no difference in sway between those with no history of falls and those who fell only because of tripping. In both sexes sway was significantly increased in people who fell because of loss of balance and in women whose falls were due to giddiness,

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The results consistently show excess mortality in patients treated with combined levodopa and selegiline. Revised diagnosis, autonomic or cardiovascular events, or drug interactions could not explain this finding, but falls and possible dementia were more common in arm 2. The results do not support combined treatment in patients with newly diagnosed Parkinson's disease. In more advanced disease, combined treatment should perhaps be avoided in patients with postural hypotension, frequent falls, confusion, or dementia.

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Falls, once thought to be an inevitable consequence of aging are now known to be the result of multiple pathological, psychological and social factors. Moreover, well-conducted research has shown that they can be prevented. Initially it appeared that multiple interventions by a multi-disciplinary team would be the most sensible and indeed the only effective approach. However, single interventions may sometimes be appropriate and on cost grounds would be preferable, provided that they are effective. This is clearly the case in the use of pacemakers for patients who are falling because of cardioinhibitory syncope. However, home modification, a seemingly obvious and intuitively correct intervention, has not been shown to prevent falls, although advice from an experienced occupational therapist can reduce falls, especially in those who have fallen previously. Whether balance training on its own is effective in reducing falls, or needs to be combined with muscle-strengthening exercises and other interventions, will be examined.

Sixty-two elderly in-patients suffering from insomnia were studied in a double-blind, double-dummy, placebo-controlled trial. Each group received either lormetazepam 1 mg, chlormethiazole 384 mg or placebo for 7 nights. Both lormetazepam and chlormethiazole significantly increased sleep duration, reduced sleep latency and improved quality of sleep and feelings on awakening. For both drugs, reaction times the next morning were unimpaired and there was no clinical evidence of accumulation after 7 nights continuous dosing. Lormetazepam and chlormethiazole in these doses are effective and safe hypnotics for frail elderly patients.

In an "incontinence clinic," a study of 309 elderly patients showed the most common causes of incontinence to be: unstable bladder (57 percent), outflow obstruction (13 percent), and atonic bladder (7 percent). Pure stress incontinence was rare (2 percent). One third of the patients improved, one third had to be catheterized, and one third did not improve. An individually designed program of bladder retraining for the patient, coupled with support and instruction for the relatives and for the professional care providers, offered the best chance of success.

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