April 2017 - NON-MEDICATED LIFE
Preventing Falls in Older Adults
By Paul Lemanski
Medicines are a mainstay of American life and the healthcare system, not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death while others may reduce certain types of cancer.
In the first 75 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals, many, if not most of the benefits of medications in the prevention and treatment of chronic medical conditions. Moreover, as a medical intervention they may accomplish such benefits with fewer side effects, may reduce the number and amount of medication, and may allow actual discontinuation of medication.
The benefits of informed diet and lifestyle, importantly, also include a reduction in falls in older individuals. Reducing or eliminating medication that may adversely impact blood pressure, coordination, and balance has been shown to decrease fall risk and resulting serious medical problems in seniors. Moreover, the healthy lifestyle habits and exercise practiced to prevent falls may not only help to improve strength, coordination and balance, but also allow seniors a more active, engaged and independent life.
Falls are a serious medical problem for seniors. They are also all too common. In those over 65 years old, 27,000 die each year as a consequence of falls and 2.8 million are treated in emergency rooms. A fall resulting in a broken hip or brain injury may not simply involve a longer, more complicated recovery in a senior. It may rob them of their mobility, independence, and even require placement in a nursing home – at huge personal, family and societal cost.
Being able to identify those at higher risk for falling is an important first step in preventing falls. Those who have already fallen may be at highest risk and should bring any history of falls to the attention of their primary care physician. As seniors age muscle mass and muscle strength, especially in the legs generally becomes less. This loss together with arthritis limits the range of motion of joints and alters balance, coordination and gait. With age, vision may also become compromised, and cognition and judgment may degrade.
Finally, as seniors age, the number of medications prescribed generally increases. The use of four or more medications has been associated with an increased risk for falling. Additionally, certain classes of medications individually have been shown to increase the risk of falling. These include anti-hypertensive agents, diuretics, sedatives and hypnotics (including sleep medications), antidepressants, neuroleptics, benzodiazepines and narcotics. A discussion with your primary care physician, and a simple exam can help identify a senior at risk, and the degree of that risk.
Being able to identify living conditions that may contribute to falls is also an important step in fall prevention. For example, as outlined by the Centers for Disease Control and Prevention (cdc.gov/steadi), insuring a clear floor path for walking in each room is essential. Furniture may need to be moved; throw rugs may need to be removed or taped to the floor; books, papers, magazines, boxes and other floor objects need to be removed; lamp cords, telephone cords, extension cords may need to be rerouted; stairs should be cleared of all objects, should be in good repair, should be well lighted, and handrails should be present on both sides of the stairs; tubs should have a non-slip rubber mat and grab bars should be installed next to and inside the tub and next to the toilet; bedrooms should have lighting next to the bed and the path from bed to bathroom should be illuminated by night lights.
Once your primary care physician has assessed fall risk, she/he can make recommendations for interventions and risk reduction. As suggested by the CDC, low risk individuals will require education, vitamin D supplementation, if low, and possibly a referral for strength and balancing exercises in a program available in one’s community. The ancient Chinese exercise practice of Tai Chi may help in this regard. For those at moderate risk for falling, education and possible vitamin D supplementation remains important. Additionally, a review of medications and possible modifications should be made. A referral to physical therapy to improve gait, strength and balance would help, as would referral to a community-based fall prevention program.
Those determined to be at high fall risk, especially if there was a history of multiple falls, should undergo a more extensive physical exam. This will determine blood pressure changes with change in position and an assessment of visual acuity, cognition and adequacy of existing footwear for identified foot disorders. A detailed medication risk/benefit assessment should be made and a plan of care outlined.
Following CDC recommendations, high fall risk individuals should then undergo education, and vitamin D supplementation, as appropriate. They should be referred to physical therapy to improve gait, strength and balance, and should have modifications of and substitution for their current medication, as appropriate, to reduce fall risk. Foot disorders should be addressed and improved footwear/orthotics proposed. Finally, vision and home safety should be optimized and mobility aids (cane or quad cane, walker) ordered, as appropriate. High fall risk individuals should optimally follow up with their primary care physician within 30 days of initial evaluation to review the plan of care, have their physician assess and encourage fall risk mitigating behaviors, and discuss and address any barriers to adherence to the plan of care.
In clinical studies using approaches like the CDC, balance and gait training, and muscle strengthening may reduce the fall risk by as much as 27%. Discontinuing high fall risk medications may reduce risk by up to 39%. Comprehensive risk assessment with targeted management may reduce fall risk by as much as 39%.
In summary, the risk of falling is a serious and common medical problem for seniors. Falling may result in fracture of the hip that may have a profound impact on subsequent quality of life, mobility and independence. It may even require placement in a nursing home. By being aware of the consequences of falls, reporting falls to your physician, and undergoing an assessment, seniors may begin a process of fall risk mitigation. Simple clinically proven lifestyle interventions including strength and balance training, appropriate medication discontinuation, and home safety optimization – faithfully executed – may prevent falls and also allow seniors a more active, engaged and independent life.
Paul E. Lemanski, MD, MS, FACP (firstname.lastname@example.org) is a board certified internist at the Center for Preventive Medicine, CapitalCare Medical Group in Albany. He is medical director of the Department of Community Medicine and Population Health at CapitalCare Medical Group. Paul has a master’s degree in human nutrition. He is an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.