Find the reason, then prevent the fall
■ A column about treating a growing demographic
By Beatriz Korc, MD — is a practicing geriatrician and director of clinical services in the Dept. of Geriatrics and Adult Development at the Mt. Sinai School of Medicine in New York. Posted Dec. 22, 2008.
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The daughter of an 85-year-old woman called your office because her mother had fallen twice in the last month. Both times, the older woman was home alone. The first time, she was able to get up, walk to the phone in the living room and call her daughter. In the second instance, however, she fell in the morning on her way from the bedroom to the bathroom and was unable to get up until her home attendant arrived an hour later. The patient refused to go to the emergency department but agreed to come see you.
Your history and physical show a bright and talkative but frail woman. She has an extensive medical history of diabetes mellitus, coronary artery disease, hypertension and moderate renal insufficiency. She complains of insomnia and dizziness that occurs mainly when she gets out of bed in the morning. She reports some numbness -- although not worsening -- in her big toes, and says it has been happening "forever." Her medications include glyburide, lisinopril, aspirin and metoprolol. She recently bought Tylenol PM to treat herself for insomnia, aches and pains.
Her vitals were normal, and the exam was within normal limits, with the exception of chronic changes of osteoarthritis and mildly decreased (1+) pedal pulses bilaterally.
This case offers an important teachable moment in which a physician can discuss a whole range of strategies about fall prevention with the patient. After all, one in three adults 65 and older falls each year, making this problem a leading cause of injury deaths for this demographic. Falls also are the most common cause of nonfatal injuries and hospital trauma admissions.
In 2005, 15,800 people 65 and older died from injuries related to unintentional falls, and about 1.8 million were treated in hospital emergency departments. More than 433,000 of these patients were hospitalized, according to Centers for Disease Control and Prevention statistics.
These injuries -- hip fractures are among the most common -- are major determinants of functional decline. One in four seniors who breaks a hip stays in a nursing home for at least a year after the injury. Also, about one out of five hip fracture patients dies within that time period. Even those patients not seriously hurt often develop a fear of falling, which may lead them to limit their daily activities and decrease their independence. From this point, mobility and physical fitness diminish, and the actual risk of falling increases.
Geriatricians place a high priority on issues of gait stability and fall prevention. The etiology of falls is usually multifactorial, and all potential causes need to be addressed. Many times, a fall is a nonspecific sign of an ongoing acute illness. Therefore, during the patient encounter, it is important to investigate the circumstances of this fall and previous ones, any associated symptoms and other related medical conditions.
In the exam room, for instance, the physician needs to analyze a patient's gait and balance. If a problem -- tremor, weakness, instability -- is detected, underlying conditions need to be considered, and the patient may need to be referred for physical therapy. Recommending increased exercise also can help minimize the patient's risk. Checking the patient's medications is a necessity. Side effects of many seemingly harmless prescription and over-the-counter drugs often include dizziness or unsteadiness and can lead to increased chances of falling. The patient also can be urged to sign up for a call system or alert so they have access to help immediately if necessary.
Another critical undertaking is to urge patients to have an in-home evaluation done by a trained professional -- for instance, a physical therapist or visiting nurse. This effort can lead to the detection of specific hazards, such as rugs, furniture placement, clutter or poor lighting. Additionally, the assessment can generate suggestions such as installing grab bars to aid the patient in navigating living areas. Other insights could emerge that involve basic habits, such as the type of shoes or slippers the patient wears.
Office staff can help, too. They should have easily accessible lists of the appropriate service providers for referrals. Also, while taking histories and vital signs, nurses can ask patients in this at-risk category whether they have fallen in recent months. If a patient responds affirmatively, he or she can be given a list of fall-prevention tips, including exercise information and nutrition supplementation with calcium and vitamin D. Another approach could be to hold periodic, in-office patient education meetings.
Overall, this particular patient's case demonstrates why it is necessary to look at the whole picture rather than stop with the first answer. Here, initial consideration would point to the patient's use of Tylenol PM as the culprit. Since she had only recently starting taking this medication, it could have been the trigger. But the physician also should assess her antihypertensive medications, her gait, her vision and her footwear, as well as encourage an examination of her home. After all, her problem may be the sleep aid, but it also could be the neuropathy of her feet, something in the distance she walks between her bedroom and bathroom, another issue or a combination thereof.
Beatriz Korc, MD is a practicing geriatrician and director of clinical services in the Dept. of Geriatrics and Adult Development at the Mt. Sinai School of Medicine in New York.