09/20/2012 12:42 pm ET Updated Nov 20, 2012

Fear of Falling: Breaking the Dangerous Downward Cycle

"There are always options for moving." -- Gretchen Reynolds
New York Times Phys Ed columnist
Author of The First 20 Minutes

For Mrs. P., the second fall was one fall too many. Once an active octogenarian, she had fallen and broken her hip, undergone rehabilitation, learned to manage a walker, but still, she had another fall. "That was it for her," recalls physical therapist Sonia Rapaport. "By the time she became my patient, she flat out refused to walk anymore. She was one stubborn lady."

Bed- and wheelchair-bound, Mrs. P. rapidly lost abdominal strength, her legs atrophied, and soon her refusal to get on her feet became her reality. She could no longer walk.

A physical therapist for more than 30 years, Sonia has seen several downward spirals precipitated by a fall. "Older people can become less active, then weaker, and then they fall," she says, her voice taking on a chant-like quality that suggests this story is all too familiar. "Once they fall, they develop a fear of falling, so they become even less active. That leads to less socialization, loss of appetite and depression. They become even weaker, which increases their chance of falling again. It's a vicious cycle."

Sonia is a passionate advocate for preventing falls and teaches the topic to home health aides in training at Partners in Care. In advance of national Falls Prevention Awareness Day on Sept. 22, I spoke with her about ways to help patients and training caregivers break this cycle. The issue is of vital importance as our population ages: Each year, one in every three Americans aged 65 and older -- or 11 million people -- suffers a fall.

Get Off the Couch

The first step in breaking the cycle is, well, taking the first step. Physical activity and maintaining strength play a critical role in staying on your feet. Studies show that for those who are normally inactive, even a small amount of physical activity can make a big difference in a person's health. "The greatest health benefit from exercise comes from getting up off the couch," exercise researcher Timothy Church says in the book The First 20 Minutes.

With a caveat that seniors and anyone with health concerns should clear physical activity with their physician, supervising nurse or rehabilitation therapist, Sonia outlines a few first steps she undertakes to help patients gain the stability and confidence to get up off the couch. After making sure the environment is uncluttered and safe, with a chair directly behind the patient and Sonia right next to them for stability, she works with patients to help them:

  1. Stand. Feel the feet rooted firmly to the floor. Shift weight from foot to foot without lifting feet off the ground.
  2. March in place. With weight shifting mastered, slowly lifting up one leg, then the other. Get a beat going (music can help).
  3. Visualize. "They've spent 60, 70, 80 years walking, and it helps to picture themselves doing it," says Sonia, noting that it builds confidence.
  4. Take it one step at a time. That first step proves they can do it. Then three steps from the couch to the chair. Then across the living room, to the kitchen, or maybe down the hall.

The ultimate finish line depends on each patient's physical and cognitive abilities and personal health care goals -- which should be both challenging and achievable. Desire to walk a beloved pet or see friends at church can be a strong mobility motivator.

Attention to safety is paramount. For those with dementia or who otherwise need close attention when they are not seated or in bed, Sonia recommends a pressure-sensing mat alarm that can be placed under a chair cushion or mattress and sounds when the patients gets out of the chair or bed. That way, if the caregiver is in another room, she can quickly return to attend to the now-mobile patient.

Tucking Exercise into Daily Life

Sonia teaches aides-in-training to always look for opportunities to get a client moving. "Have them come with you when you do the laundry," she advises. "Just because a person has dementia, doesn't mean she can't help fold the clothes." In fact, Sonia notes, the rhythm, repetition and companionship can be comforting for someone with dementia, and the walking, standing and fine-motor act of folding are good exercise.

Here are five more ways to include physical activity in activities of daily living:

  1. Just Say Yes. Rather than declining the offer when your elderly mother with diabetes and hypertension wants to help in the kitchen, accept. Let her wash or dry the pans, put away the leftovers, or other safe activities (standing near the counter, for example, and not handling sharp knives or delicate glass). Explains Sonia, "When you say, 'Sit down, Mom, I've got this,' you think you're doing Mom a favor. But letting her help is a bigger favor in the long run."
  2. Commercial Break = Exercise Break. Sonia teaches aides to introduce exercise into the lives of even the most inactive clients, who spend the bulk of the day watching television. During commercial breaks, have the client stand for a minute or two, perform arm exercises, move the legs back and forth, kick a ball across the floor, or toss and catch a ball with the caregiver. The frequency (and inevitability) of commercial breaks provides a surprisingly good ritualized structure for exercise.
  3. Exercise Loves Company. Sonia still smiles, remembering a home health aide in her mid-60s who, after making sure her 80-something client completed the exercise plan, would then perform the routine herself -- to the delight of her client. "They giggled about it all the time," Sonia remembers. "They really enjoyed watching and helping each other do the exercises. The home health aide, who was older and not so speedy herself, said she felt stronger, peppier, better in general after doing the exercises."
  4. Mind Wanders, Body Follows. "Patients with dementia often have tons of energy," Sonia notes. Wandering unsupervised can pose safety problems, but preventing a person with dementia from getting exercise also poses problems. "It's a mistake not to let them walk," she says. "They'll only get weaker." (See my previous column for safety and other tips on caring for someone with dementia.)
  5. Remember: A Little Activity Goes a Long Way. You don't need to run a marathon to reap the benefit of physical activity. There is a distinction between fitness and health. For an 85-year-old great-grandfather with multiple chronic conditions, walking to the end of the corridor to take out a small bag of recycling pays great dividends. For the 78-year-old former dancer now afraid to get out of her chair, standing for one minute whenever the cuckoo clock chirps on the hour can help break a downward spiral into weakness and depression.

More to Preventing Falls

Remaining physically active is essential, but it is only one part of a larger fall-prevention picture, which also includes medication management, vision upkeep, proper footwear and a safe home environment. You can see more fall-prevention tips here, from our affiliate organization, the Visiting Nurse Service of New York. VNSNY's customized falls prevention program, Strong Foundations, helps at-risk New Yorkers and their families and caregivers reduce the risk of falling -- and prevent the "vicious cycle" that a fall can set in motion.

For more by Marki Flannery, click here.

For more on caregiving, click here.