Minimizing the risk of falls in elderly patients
Falls can cause a life-altering injury or even death in older people. Here are a number of practical steps you can take to help keep them upright.
Remember “Mrs. Fletcher,” who took a spill on the bathroom floor in that unforgettable TV commercial and uttered the immortal words “I’ve fallen…and I can’t get up”? She was speaking for millions of her fellow seniors; indeed, as many as 40% of adults over age 65 fall each year, and in people over age 75, falls cause 70% of all accidental deaths. Despite those sobering statistics, there is plenty primary-care clinicians can do to protect older patients from debilitating, possibly fatal falls. There are two broad types of fall risk factors: host-related and environmental.
Host-related factors, those clinicians must elicit by examining and interacting with patients, include:
Demographics: Factors linked to a higher fall risk include advancing age, white race, housebound status, and living alone.
Fall history: Find out when and where falls took place, what the circumstances were, and whether patients experienced symptoms, such as dizziness, in conjunction with falling. This will help you determine whether a patient’s falls are due to environmental or host factors.
Use of assistive devices: Make sure patients are using the appropriate device, e.g., cane or walker, and using it correctly; consider physical-therapy referral if training is needed.
Medical conditions: Ask patients about acute or chronic ailments, especially those that impair muscle strength, gait, or balance.
Medication use: Review all prescription and OTC drugs patients are taking; medications that increase the risk of falling include benzodiazepines, neuroleptics, antidepressants, anticonvulsants, and class I antiarrhythmics. Intake of four or more medications is an independent risk factor for falls. Decrease the number of medications if feasible, and screen for alcohol intake and overuse.
Evaluating body and mind
Recommended routine tests in individuals at risk for falling include complete blood count, serum electrolytes, blood urea nitrogen, creatinine, glucose, vitamin B12, and thyroid function. Consider neuroimaging in cases of head injury, new focal neurologic findings on physical examination, or suspected disruption in a central nervous system process.
In addition to the fall risk factors previously noted, many physical and psychological problems can increase patients’ chances of falling. Some of the most common include:
Depression and neurologic changes: Screen older patients for depression and provide treatment if warranted. Perform a neurologic exam targeting proprioception, cognition, cerebellar coordination, deep tendon reflexes, and muscle strength. To increase proprioceptive input, suggest that patients use assistive devices and wear low-heeled, thin-soled shoes that encase the foot. Reduce medications that impede cognition, and inform caregivers of cognitive deficits. Make referrals to physical therapists for gait, balance, and strength training.
Cardiovascular conditions: Check for carotid bruits and murmurs. Use ECGs to rule out arrhythmia and atrioventricular nodal blocks; ambulatory cardiac monitoring is indicated only if patients have a history of cardiac events or abnormal ECGs. Perform carotid massage under ECG monitoring to diagnose hypersensitive carotid sinus, which may require pacemaker placement.
Postural hypotension: Check patients’ BP after five minutes in the supine position, immediately after standing up, and again two minutes after that. Postural hypotension is defined as a drop >20 mm Hg in systolic BP with or without symptoms. Management includes diagnosis and treatment of underlying cause. Review and reduce medications.
Make sure patients are well hydrated, and modify salt restriction. Recommend pressure stockings and compensatory strategies (e.g., elevating the head of the bed, rising slowly, and performing dorsiflexion exercises). Prescribe medication if lifestyle measures fail.Visual problems: Recommend ample lighting without glare and avoidance of multifocal glasses while walking. Consider referral to an ophthalmologist.
Gait or balance problems: Use the “Get Up and Go” test as a screening tool. Have the patient get up from a chair without using his arms for support, walk 10 feet, turn and return to the chair, and sit down. If the patient needs more than 20 seconds, an in-depth evaluation is indicated.
Musculoskeletal disorders: Examine lower-extremity joints for arthritis and range-of-motion problems. Refer to a physical therapist to evaluate muscle strength and provide range-of-motion, gait, balance, and assistive-device training. Examine feet for calluses, bunions, and ulcers. Consider referral to a podiatrist.
Evaluation and management of environmental hazards are best handled by an occupational therapist. The CDC offers “Check for Safety: A Home Fall Prevention Checklist for Older Adults,” which includes a room-by-room list of hazards to look for and tips for reducing these hazards. It’s online in several languages at: www.cdc.gov/ncipc/duip/fallsmaterial.htm (accessed March 5, 2008).