Standing Tall Against a Fall


Dear Readers,

Joan Rees was an active, independent 79-year-old with few physical problems except balky knees from arthritis. One day she took a misstep and fell, fracturing her pelvis. The incident was excruciatingly painful, disruptive and required months and months of rehabilitation and lifestyle adjustments before she could resume anything resembling her old life.

Rees’ story, recounted in “A Tiny Stumble, a Life Upended” in The New York Times, is a cautionary tale about the consequences of a fall for older people. Even though Rees is back on her own, her accident drew the line where, as the story explained, “the roles of parent and child began to reverse.”

This month, I look at why falling is so dangerous for older people, and what they can do to minimize their risks of this potentially life-changing event.

Aging and Accidents

Although generally healthy, Rees was, as The Times said, “a textbook case of a serious injury waiting to happen” because she had fallen before (although without serious complication), her balance was impaired and she had arthritis in her knees. In other words, hardly unique.

In a recent 12-year span, according to a study in JAMA Internal Medicine, the prevalence of self-reported falls among older adults appeared to be on the rise. Falling is the most frequent cause of injury among older adults; almost 1 in 3 adults 65 and older fall each year.

The study was interesting because although falling is a common cause of injury among older adults, and their risk of falling might be higher than it has ever been, the researchers, from the University of Michigan, found that the increase in falls wasn’t due to our aging population; in fact, all age groups seemed to be experiencing more falls over a 12-year period.

But because falling is more often life-threatening to older people, it’s especially important for them to avoid it. Further research is needed to figure out why everybody, not just the elderly, is taking a tumble more frequently. But the University of Michigan is one of 10 U.S. clinical trial sites engaged in a major study on preventing fall injuries among the elderly to find effective, evidence-based strategies to address the personal and public health burden of falls.

“[I]f the prevalence of falls is actually increasing as much as it seems to be, we need to do more work to identify possible factors and how we can address what we know to be a high risk among a vulnerable group,” said one of the study’s researchers.

Bones lose density as we age, which can lead to osteoporosis, which makes them fragile. Even healthy bones break in bad accidents, but they should be able to withstand most falls. Bones weakened by osteoporosis, though, are more likely to break. Women, particularly, are prone to early osteoporosis after menopause when estrogen levels drop.

According to the National Institutes of Health (NIH), more than 10 million people nationwide have osteoporosis.  And the NIH estimates that more than 2 million “fragility fractures” (those due to abnormally weak bones) occur nationwide each year.

Wrist fractures are common when someone falls forward or backward, and extends an arm to break the fall. Hip fractures often occur when someone falls to the side. “Your hip may be strong enough to handle weight that goes up and down,” according to the NIH, “but not an impact from another direction.”

Other risk factors for falls are diminishing muscle mass, which contributes to a compromised sense of balance, and certain medications, many of which are disproportionately consumed by older people, because they can make you dizzy. And some meds promote osteoporosis.

Many households and public areas present trip hazards, so danger isn’t just a matter of physical health and fitness, it’s also about environment.


Heading for a Fall

Weakness or a lack of physical fitness are clear fall risk factors, but the effects of medication might be less obvious.

According to research recently published in JAMA Internal Medicine,certain antipsychotic medicines are associated with more serious falls and more fractures.

Adults in this study 65 and older who received a new prescription had a 53% increased risk of falling. The medication researchers focused on was considered “atypical” — that is, prescribed “off-label,” for reasons other than those approved by the FDA. Doctors are permitted to prescribe off-label meds, but drug manufacturers may not promote them for those purposes.

The study’s “findings call into question the widespread off-label use of atypical antipsychotic medications and support increasing evidence of safety concerns regarding their use in older adults.”

The drugs studied for off-label use were quetiapine (Seroquel), which treats depression and bipolar disorder, risperidone (Risperdal) and olanzapine (Zyprexa), both of which are used for for schizophrenia and bipolar disorder.

Many of these drugs present a risk even when prescribed as promoted. Other studies have indicated increased fracture risk with the use of antipsychotics because their sedative and low blood pressure effects and can make you dizzy and affect your gait.

A lot of older people take blood pressure medicines. Another study inJAMA Internal Medicine found that people older than 70 who were taking antihypertensive drugs were more likely to suffer a fall that resulted in serious injuries. And that risk doubled if they had been injured previously in a fall. More than 8 in 10 of the study participants had been taking some kind of antihypertension drug.

“The potential harms vs benefits of antihypertensive medications,” the researchers concluded, ” should be weighed in deciding to continue treatment with antihypertensive medications in older adults with multiple chronic conditions.”

Patrick’s Patient Safety website has blogged about the dangers of certain drugs for older people; see “Doctors Overprescribe Dangerous Drugs to Medicare Patients” and “Seniors, Be Aware of Drugs That Present a Fall Hazard.”


Prevent Falls by Minding Your Meds

Discuss the risks and benefits with your doctor of all the drugs you take, especially antidepressants, antipsychotics, benzodiazepines (Valium, Xanax and others) and blood pressure meds.

Always get up slowly from a prone or sitting position, and use a cane or walker if you’re regularly dizzy or your balance isn’t good.

Some drugs promote osteoporosis, including steroid hormones like prednisone, some breast and prostate cancer drugs, some diuretics and some drugs that treat acid reflux disease. So always be clear why your doctor prescribes them, if there are suitable alternatives, what the side effects are and how to minimize them.

Nicotine and other toxins in cigarettes promote also bone loss, so don’t smoke.

You might have no choice but to take some drugs that contribute to fall risk, but you can develop coping strategies if you understand their effects.


Prevent Falls by Exercising

Because you’re less likely to fall if you’re in good physical condition, and less likely to be injured seriously if you do fall, regular exercise is a key preventive measure.

Weight-bearing exercise builds bone. If you’re fit enough, lift weights, jog, walk, play tennis, go dancing — anything that has an impact on the ground (swimming and cycling aren’t as efficient at building bone mass). Engaging muscles by making them bear weight signals bones to maintain dense tissue.

Many exercise programs offer classes specifically for older people that include balance drills such as standing on one foot, or using a Bosu ball or other squishy surface that forces you to engage muscles to maintain balance.

Some disciplines such as yoga and tai chi also promote muscle strength and balance.

But you don’t need a fancy program to sharpen your physical skills. Try these exercises:

  • Walk the length of the driveway, putting one foot in front of the other.
  • Stand on one leg at a time for a minute and slowly increase the time. Try to balance with your eyes closed or without holding on.
  • Stand on your toes for a count of 10, and then rock back on your heels for a count of 10.
  • Move your hips in a big circle to the left, and then to the right. Do not move your shoulders or feet. Repeat 5 times.

Prevent Falls by Smart Home Design

Make sure your environment is as safe as you can make it.

  • Keep rooms free of clutter, especially on floors.
  • Don’t walk in socks, stockings or slippers.
  • Be sure rugs have skid-proof backs or are tacked to the floor.
  • Keep a flashlight next to your bed to guide you in the dark.

The Harvard School of Medicine newsletter offers additional advice on how to adapt your home to reduce fall and other hazards. For example, lower things you store in the kitchen so that you’re not reaching or standing on stools to retrieve something.

Slippery bathrooms are a huge fall threat. Use nonstick mats and treads on tile and other smooth surfaces. Grab bars are good for people with shaky balance. You might consider replacing a bath tub with a walk-in shower and a standard toilet with an elevated model that makes it to sit and stand up.


Prevent Falls by Eating Well

Vitamin D, according the several studies and the NIH, can improve muscle strength and balance, so make sure you’re not deficient in that nutrient. ( See our blog, “How to Get the Right Amount of Vitamin D.”) As we age, we need more vitamin D, which is converted from sunlight.

Certain foods are rich in the vitamin, including milk, eggs, fatty fish and fortified cereals. But getting too much can cause problems, so don’t take supplements until you discuss it with your doctor.

Vitamin D also helps your body absorb calcium, a mineral critical to bone strength. Good sources of calcium include milk and milk products, dark green leafy vegetables like kale and collard greens. NIH guidelines recommend that women older than 50 get 1,200 mg of calcium a day, and that men get 1,000 mg a day at ages 51 to 70, and 1,200 mg a day after that.

Drink water. Good hydration is important for balance, especially on hot days and for people at risk of low blood pressure.


A Sense of Control

Joan Rees, according to The Times story, considers herself nearly fully recovered. She regained her optimistic outlook, and takes long walks around her neighborhood. Her life isn’t quite the same, but it’s very good and she learned her lesson well. She’s more aware of her surroundings and the health factors that literally can trip her up.

Falling doesn’t have to be a dire event. But it’s best if you can make it a never event.


Here’s to a healthful 2015!

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Patrick Malone
Patrick Malone & Associates