Fall Prevention in the Elderly

Fall Prevention in the Elderly
Preventing Older People From Falling at Home

Many older people are at risk of falling in their own homes. Those that do have a serious fall, especially if they suffer a broken bone or other significant injury, do not ever completely recover. An accident of this kind can start an older person on a downward spiral which can include loss of independence, the need for of around-the-clock care or nursing home placement, and even death.

Falls and associated injuries are the number one cause of a person’s loss of ability to care for him or herself. A serious fall results in ten times the risk of nursing home placement.

Of adults older than 65 years who do not live in nursing homes or other institutions, more than a third fall every year. 10% of these falls are serious, with results such as fractures or head injuries. If an elderly person falls and cannot summon help, they can suffer other complications including dehydration.

Who as at risk for falls?

There are a number of factors that make older individuals unsteady and more likely to fall. The more medical problems, the more medications, and the more impairment a person has, the more likely they are to fall. Women are also more likely to fall than men.

The most common risk factors are a history of previous falls; problems with strength, walking and balance; and the use of multiple medications.

If you are wondering about a family member, these are things to look for:

  • Trouble with balance*
  • Weakness of muscles*
  • Difficulty with walking*
  • Complaints of dizziness or light-headedness
  • Poor eyesight
  • Having trouble with activities of daily living (called ADL)
  • Incontinence (inability to control urination)
  • Trouble with thinking and processing information (called cognitive impairment)

(*highest risk)

Specific medical problems associated with risk of falls include:

  • Pain or weakness* from any source
  • Parkinson’s disease
  • Alzheimer’s disease
  • Depression
  • Arthritis
  • Diabetes

(*highest risk)

Specific issues associated with increased risk of falls include:

  • A history of previous falls*
  • Taking multiple medications (four or more a day)*
  • Taking psychoactive medications (like sleeping pills or antidepressants)*
  • Living alone
  • Age over 80 years
  • Being very thin

(*highest risk)

What to do about looking at and reducing the risk of falls

Anyone at risk of falling needs to be evaluated by a physician, if possible, their regular doctor.

There are a wide variety of interventions that can help, from treating underlying medical issues to adjusting medications and enlisting the help of other personnel, like physical therapists. Most studies indicate that multiple interventions can reduce falling risk more than single interventions.

For example, if someone’s blood pressure is dropping too much when they stand up, lowering or eliminating medicine for high blood pressure may be necessary. Any medication that can cause sedation can also cloud an older person’s judgment and slow down reactions. Pain medication or sleep medication may need to be decreased.

Sometimes there are tradeoffs that have to be made, which is why it is important to consult with a doctor that is familiar with the needs of the elderly. If a person’s blood pressure is both high and low, depending on the circumstances, a doctor needs to decide which of these is the most dangerous, the highs or the lows. Similarly, a person with pain can fall because they have trouble bearing weight or moving due to pain. Continued pain may prevent them from exercising and lead to weaker muscles. Are they at greater risk because of pain, or because of pain medicine which may make them groggy?

A complete review of all of a person’s medical problems and medication is in order if there is any question about their safety and likelihood of falling.

For those with decreased vision because of cataracts, removing a cataract from one eye and correcting vision does decrease the risk of falling.

The role of physical therapy and home visits

Another type of healthcare professional who can both evaluate a person’s risk of falling as well as work on ways to help prevent falls is a physical therapist. A physical therapist can observe a person walk and do a number of assessments of their strength and stability. A therapist can suggest exercises to strengthen weak muscles. A physical therapist can also help pick any walking aids that might be useful, from a cane to a walker, and instruct the person in how to best use the aid.

Muscle strengthening and balance training, which can be supervised by physical therapists, both decrease the risk of falls.

An occupational therapist can make a home visit to evaluate the risks for falls within a person’s home, and make suggestions how to decrease those risks. These include things like:

  • Putting safety rails in showers and bathtubs
  • Removing throw rugs (to prevent someone from tripping on them)
  • Putting safety grips on slippery surfaces
  • Increasing lighting

What about osteoporosis?

If an older person has osteoporosis, which means thin, weak bones, a fall may lead to a broken bone. Things that lead to falls are similar to things that lead to fractures, and they have similarly undesirable outcomes. A badly broken hip, for example, will lead to a hospitalization and surgery. Even with treatment and physical therapy, the person may be even weaker and more unsteady after the fall.

In addition to try and reduce the chance of falls, doctors should make sure their older patients have as strong bones as possible. This means ensuring an adequate intake of both calcium and vitamin D. People age 50 years and older should be taking 1,200 mg of calcium a day and 600 to 800 IU of vitamin D.

Besides taking enough calcium and vitamin D, those with osteoporosis need to be treated, usually with medications called bisphosphonates, to try and improve bone strength. Bisphosphonates include, among others, Boniva® (once a month), Fosamax® (once a week) and Reclast® (by vein once a year). There are other types of medication that can be used.

In some studies, vitamin D has been found to decrease the risk of falling independently of its effect on bones.

In conclusion

Most internists and family physicians can treat older patients and evaluate their risk of falling. Some doctors have taken further training in geriatric medicine, which is the treatment of the elderly. You can look for someone with a credential in geriatric medicine if you do not believe the doctor you consult understands these problems sufficiently.

Many studies have shown that interventions can significantly reduce the risk of falling. Treating osteoporosis can also help reduce the risk of a fracture with a fall.

Since falls are so common in the elderly, and so frequently lead to a loss of independence and decline in health, prevention of falls is essential.

References

Buatois S., Perret-Guillaume C., Gueguen R., et al. A Simple Clinical Scale to Stratify Risk of Recurrent Falls in Community-Dwelling Adults Aged 65 Years and Older. Physical Therapy Journal 2010;90:550-560.

Ganz D.A., Bao Y., Shekelle P.G., Rubenstein L.Z. Will My Patient Fall? Journal of the American Medical Association 2007;297:77-86.

Sweet, MG, Sweet, JM, Jeremiah, MP, Galazka, SS. Diagnosis and Treatment of Osteoporosis. American Family Physician. 2009;79(3):193-200,201-202.

Tinetti M.E., Baker D.I., King M., et al. Effect of Dissemination of Evidence in Reducing Injuries from Falls. New England Journal of Medicine 2008;359:252-61.

Tinetti M.E., Kumar C. The Patient Who Falls. “It’s Always a Trade-off.” Journal of the American Medical Association 2010;303(3):258-266.



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Dr. Anna Kaplan

Dr. Anna Kaplan graduated with a BA in English literature from Pomona College in 1975. She received her MD from U.S.C. School of Medicine in 1979. A three-year residency (training period) in family practice followed, and she was certified by the American Board of Family Physicians in 1982. She recertified, a normal procedure, in 1988 and 1995. She retired from active practice after 15 years, but keeps up with medicine via continuing medical education.

Dr. Kaplan has written in the medical field for both consumers as well as professionals. She has also authored hundreds of articles on other subjects.

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