For Falling Victims, The Devil Is In The Details
People don't talk about falls the way they do heart disease or cancer, but this type of accident is among the leading causes of injury and death in the United States, especially for senior citizens. But falling is not just a mishap that happens to older adults — it's a sophisticated health issue, deeply intertwined with other medical and social challenges that come with increasing age. Not only do people face higher risks of falling as grow older, but falls also tend to precipitate or coincide with the onset of serious and even fatal health problems. And not all falls are alike.
Kathleen Walsh is a clinical assistant professor in the Department of Emergency Medicine at the University of Wisconsin School of Medicine and Public Health. She works at UW Health's Faint and Fall Clinic in Madison, specializing in understanding and treating patients who've experienced a fall. In an April 21, 2016 talk at the Capitol Lakes retirement community in downtown Madison, recorded for Wisconsin Public Television's University Place, she discussed the array of health factors and personal circumstances that surround every fall.
"The devil's in the details," Walsh said, again and again. She offered a few case studies to illustrate the different situations that can lead to falls, and detailed the kinds of questions doctors should ask patients who've experienced a fall.
Walsh pointed out that doctors themselves can contribute to a patient's fall risk by prescribing too much medication and not focusing enough on simple preventative measures, like making sure a patient is staying physically active. (She especially recommends tai chi for helping older patients stay healthy, active, and balanced.) Many other factors, ranging from the proper way to walk with a cane to the uncertainties of herbal medications, illustrate just how complex the problem of falling really is.
Walsh also discussed resources available to older patients looking to reduce their fall risk, many of them available through the Wisconsin Institute for Healthy Aging.
- Wisconsin has an aging population, and the highest concentrations of people 65 and older are in counties in northern Wisconsin. By 2030, the state's aging demographic will be even more pronounced.
- Among people ages 65 and older, 1 out of 3 people fall each year. The frequency of falls increases as people age on into their 70s and 80s.
- For an elderly person, a fall usually marks the beginning of a decline in health or the beginning of a serious new illness.
- Health concerns among older patients related to falls include being frail, delirium, syncope (passing out), dizziness and urinary incontinence.
- Bifocals, trifocals and progressive lenses can contribute to falls, especially when going up and down steps or walking over curbs.
- Vision, inner ear, proprioceptive sensing, strength and flexibility are the key elements of maintaining a person's balance.
- In 2014, the University of Wisconsin's statewide network of family medicine clinic surveyed patients about falls. About 70 percent of those patients responded, and of those respondents, 3,046 reported having a fall.
- Fall screening questionnaires ask patients about their history of falling, whether they've been advised to use a cane or similar device, what kinds of problems they have standing or walking, whether they experience incontinence problems, what kinds of medications they take, and whether or not they often feel sad or depressed.
- Different medical and circumstantial factors contribute to falls for different people, so doctors (ideally) ask patients a lot of questions about a fall. These can range from where the patient was at the time of the fall to what they were wearing to whether they'd been eating or drinking. Further assessments of a patient after a fall will include gathering vital signs, a walking test, and a cognitive screening. Doctors also look at factors that can be changed (medication, lifestyle choices), those that can't (pre-existing health problems), and how both types contribute to the risk of falling.
- A 2010 study found that Wisconsin had a high number of prescriptions per person for 30-day medications. However, Wisconsin has a relatively low concentration of people with prescriptions for high-risk medications. These medications, which can contribute to fall risks in people of any age, include Benzodiazepines, antidepressants, pain pills, Ambien (zolpidem), muscle relaxers, blood pressure medications, diuretics and herbal medications with side effects.
- An example of the "cascade effect" in medication prescribing can happen after a person falls. A doctor might have their patient take ibuprofen, which elevates the patient's blood pressure, leading to a prescription for blood pressure medication. The blood pressure medication can have a diuretic effect, which may lead a doctor to prescribe yet another medication to aid with bladder control.
- To prevent the "cascade" of over-prescribing, Walsh recommends only prescribing one new medication at a time, starting patients on a low doses and adjusting dosages slowly.
- Social factors can impact fall risk. For instance, if an older person moves to be close to an adult child, this can mean a loss of social connections, which can contribute to depression and isolation, which in turn can make falls more likely. Elderly people also need to watch out for factors in the home, like slick floor surfaces or chairs that can be difficult to get into or out of, and consider installing helpful features like grab bars.
- Regular movement and exercise, even as little as walking up and down a hall a few times a day, can help decrease people's risk of falls. Other lifestyle choices are important, such as moderating alcohol use, getting proper nutrition and maintaining hydration.
- On contributing factors to falls: "If you think about it, every time you fall, your balance was off. But the reason your balance is off is different for many, many people. That's what we have to tease out when someone comes to see us at the clinic or your doctor teases out when you go see him or her."
- On the problems that can impact an older patient's balance: "Some people have terrible peripheral neuropathy. They can't feel their feet, so then they're sensing is bad. Some people have bad vision or poor vision. ... Their hearing aids don't work or hearing aids don't work for them. This all contributes to balance. And if we can fix one of these four things, there's more, but these are the main, we'll make your balance better. You fell. The devil's in the details."
- On seeing how patients walk: "When a patient comes in from the waiting room back to a room in the emergency department, I watch them walk. They don't even know I'm watching them, but I watch them walk back to the room. I can tell a lot by how you're walking."
- On over-prescribing medications to older patients: "Less medication the better. Because what happens is when we get older and we keep adding medications, we get into what I call a medication madness, right? It's, like, why am I taking these? Do I really need to take them all? ...We call it the cascade effect. And then you get an increase in fall risk."
- On blood pressure medications: "When you start blood pressure medications in your 50s and 60s, a lot of times these are not looked after very often and when you get into your 80s and 90s, they probably need to be changed. Many people are on too much medication. Too much of the blood pressure pill."
- On the fear of falling: "Once you have fallen, this is what happens. This is what we see all the time. You need to touch or hold onto things walking around or even hold onto a friend. That's fine, but this is getting into the cycle of the fear of falling. You walk very slowly. You take small steps. Limited movement and you express a fear of falling. I don't wanna do that. I'm gonna fall. I'm gonna fall. We want to know that, though. We need to know that so we can help you. It's very normal."
- On preventative strategies: "This is what we ask patients to do. It's a kind of a mental activity and focus training. Think, think. Do you ever hear your mother say that? Just think about what you're doing. Right? Think before and after you stand, before you step, before you turn, before you reach. We ask patients just to slow down just a little bit and think what am I going to do? How am I gonna reach up there and get this? Is this a good idea? Is this really a good idea?"