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Richard W. Besdine, M.D. Headshot

Fear of Falling

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A month ago, I almost became the subject of one of my own medical school lectures, after an episode that illustrated one of the most serious health problems facing older adults and their doctors: falling.

To prepare medical students for their older patients' real-life challenges, I always teach the perils of falls, so when I fell myself on a patch of ice in my driveway, I knew what could happen. Mercifully, I broke nothing, although I had a softball-sized hematoma on my side for weeks. But I think I can thank decades of daily squash games for the bone density that probably saved me from breaking a hip and I returned to work the next day, sore but intact.

Many people aren't so lucky. More than 2 million people went to emergency rooms after a fall in 2010, and more than half a million had to be admitted to the hospital. And while most go home with fractures, cuts or bruises, more than 20,000 die from a fall each year. Falls are the leading cause of injury and of injury death for people over 65.

Fear of falling also haunts many older people, particularly those who have fallen already. (In a cruel twist, this fear actually increases their likelihood of falling again, as well as triggering a counterproductive reduction in exercise, and increasing isolation and depression.) Perhaps they know, or instinctively understand, that a bad fall represents the fastest ticket to disability, loss of independence and, often, the nursing home. Ninety percent of all hip fractures -- another of the dreaded events that can transform a life in the blink of an eye -- happen during a fall, and about a quarter of all hip fracture patients over age 50 die within a year.

Unpredictable, lightning fast and potentially deadly, falls pose a risk no older person can afford to ignore, on a par with other major health threats, according a world authority, my friend and colleague Mary Tinetti, M.D. of Yale Medical School. "Given their frequency and consequences, falls are as serious a health problem for older persons as heart attacks and strokes," she says.

While important, establishing the seriousness of falls was only part of Mary's contribution. More fundamentally, she put falling on the map, no longer to be seen as a tragic "accident," but as a treatable and preventable problem. By identifying a list of modifiable risk factors and then testing interventions, she proved that reducing those risks reduced subsequent falls, by as much as 30 percent. This is hugely important since, like many such problems, it is far better to prevent a fall than to try to recover from one.

Risk factors include:
  • Any previous falls;
  • cognitive impairment, such as Alzheimer's disease;
  • vision problems;
  • taking multiple medications, especially sedatives and hypotensive (blood pressure) drugs;
  • having multiple diseases;
  • having postural hypotension (a condition in which blood pressure drops upon standing up);
  • weakness in the legs and feet;
  • reduced proprioception (our awareness of the position of our body, in this case especially feet and legs);
  • balance problems;
  • abnormal gait (walking pattern);
  • use of a cane or other assistive device such as a walker;
  • unsafe footwear;
  • environmental hazards (such as loose rugs or uneven floors or sidewalks);
  • being over the age of 80;
  • history of fainting;
  • depression;
  • or other functional problems (trouble getting out of a chair, climbing steps).

While the simple fact of aging does not increase a person's risk of falling (at least until about age 80), it does tend to increase the number of risk factors. The more factors, the more a person's risk goes up until, with four or more, the likelihood of falling rises to about 80 percent in one year. Balance and walking problems, in particular, identify persons at high risk. Although not all risks are modifiable, most are, and are very much worth attention.

All primary care providers and their older patients should be discussing this but sadly, too many are not. Despite the growing body of knowledge about falls, many primary care doctors, nurse practitioners and emergency room personnel fail to see a fall for what it is: a golden opportunity to help their patients prevent something much worse.

In the office visit, all older patients should answer at least one question about whether they have fallen or are afraid of falling. Older adults within the risk profile should be given the "get up and go" test. If they can't rise from a chair, walk 10 feet, and sit back down in less than 10 seconds, they need further evaluation.

Community-based programs to help people improve their balance, muscle strength and sometimes confidence can also help, and providers should make such referrals. The Centers for Disease Control and Prevention (CDC) has compiled excellent lists of programs offering exercise interventions -- such as Stay Safe, Stay Active and tai ch'i courses -- as well as home modifications and multi-faceted programs such as the NoFalls Intervention and Stepping On.

Anyone who cares for older adults should also be aware of the new falls guidelines from the American Geriatrics Society, which include evaluation and counseling, medication review, home modifications, exercise and/or physical therapy and appropriate use of canes and walkers.

In Connecticut, Dr. Tinetti forges ahead, and recently showed that increased health care provider (including physicians, nurses, physical therapists, pharmacists and others) awareness of intervening on risks led to statistically significant reduction in serious fall injuries such as hip fractures and lower costs among their patients, compared to a control group. Continuing to educate the doctors and other health care providers is proving as important as educating the public.

Sadly, increased awareness often spikes only after something awful happens. Last summer, Nancy Reagan stumbled and appeared to come close to suffering serious injury, on television and on the arm of a U.S. senator, no less. Let's hope that her near-miss and the resulting media attention, as well as more conversations in doctors' offices, senior centers and around family dinner tables, will save many more people from the fear of falling.

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