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Fall down six times
Get up seven
    - Buddha

"I've fallen down and can't get up." How many times have you heard this phrase in a commercial or a funny skit on the comedy channel? It is not a laughing matter for an elderly person living alone today.

For people over the age of 65, falls are the leading cause of accidental deaths and injury-related visits to the ER. One in three persons over 65 will fall at least once per year increasing to one in two by age 80. Falls are the 7th leading cause of death in individuals 75 or older and associated with 9500 deaths annually.

Serious injuries including head trauma, soft tissue injuries, fractures and dislocation occur in 5 to 15 % of elderly fall victims. Hip fractures account for 90% of fall fractures in the elderly and are the leading cause of extended hospitalization and loss of mobility. A shoulder or wrist fracture is painful but a hip fracture can often result in permanent disability or nursing home placement when the victim is unable to care for themselves. Picture your grandmother hopping around on a pair of crutches; ludicrous and unsafe. Even with a walker, many elderly people lack the upper body strength to effectively use their arms and walk non-weight bearing on the affected limb.

Etiology

Accidental falls can often occur in the home or community without significant injury other than a few scrapes or a bruised ego to most of us. An older person who falls, even without injury, may self-limit his mobility and activities to prevent future falls. A deep seated "fear of falls" becomes the modus operandi. Physical strength, endurance and flexibility correspondingly decrease with decreased activity.

Normal physiological changes accompany increasing age and can lead to decreased balance and increased risk for falls. Other physiological changes are NOT normal consequences of aging but result from certain disease processes and are considered pathological.

Age related changes include:

  • Decreased range of motion (ROM) and flexibility – especially in the lower extremities(LE) and spine
  • Weakness – LE strength can decrease up to 40% from ages 30 to 80
  • Increased postural sway and thoracic kyphosis
  • Decreased step length – i.e. short shuffling steps
  • Balance deficits from changes in the three sensory systems which coordinate to provide postural control
        -Vestibular – Decreased hair cells in the semicircular canals affect vestibular control
        -Visual – Decrease in acuity, depth perception, cone cells and accommodation
        -Somatosensory – Increased threshold of excitability for sensory receptors results in decreased reaction time

Pathological diseases which affect balance include:

Risk Factors

The causes of falls in the elderly are multifactorial and additive including environmental, physiological and psychological factors. Risk factors are divided into two categories: Intrinsic and Extrinsic.

Intrinsic risk factors are inherent to each individual and concern the person's age, gene's, physiological and psychosocial condition.

Intrinsic factors include:

  • Postural instability
  • Orthostatic hypotension
  • Sensory deficits
  • Foot problems – toenail length, callouses, bunions, deformities
  • limited ROM
  • Cognitive deficits
  • Depression
  • Acute illness – dizziness, syncope
  • Muscle weakness/deconditioning

Extrinsic risk factors arise from external forces acting upon the individual.

Extrinsic factors include:

  • Environmental hazards
  •    -Cluttered hallways and stairways
       -Loose rugs
       -Poor lighting
       -Wet surfaces
       -Small pets
  • Prescription Medications – use of 4 or more is a red flag
  • Alcohol or mind altering drugs

Fall prevention

The single most predicative factor for falls is a previous history of falls. Every elderly person should have a thorough physical exam by a physician schooled in fall prevention including a detailed history of the last 6 months of activities. Many Senior health centers are opening around the country with Geriatric specialists who can help a great deal in keeping our elderly safe and in good health. When appropriate, a referral to a physical therapist for strengthening, balance and advanced gait training can help prevent falls.

Other steps to reduce fall risk include:
  • Medication modification
  • Family education on risks and fall prevention
  • Home safety inspection with modifications where needed – installing grab bars, use of non-slip mats in tubs and showers, elevated toilet seats, removal of clutter or throw rugs
  • Use of an assistive device when appropriate

However the best prevention for falls in the elderly remains an active lifestyle. Maintaining strength and flexibility with a good exercise program will carry you through the twilight years able to enjoy the things you love.

Sources:


Falls in the Elderly ,George F. Fuller, COL, MC, USA http://www.aafp.org/afp/20000401/2159.html
Preventing Falls and Reducing Injuries,Mary E. Watson, MSN,RN,CS,clinical seminar
Predicting the probability for falls in Community-dwelling older adults.Shumway-Cook a, Baldwin M, Polissar NL, et al. Phys Ther 1997;77:812-819.
Falls in the elderly: part II, balance, strength and flexibility. Gehlson GM, Whaley MH. Arch Phys Med Rehabil.1990;71:739-41.

Do you know why life insurance costs more for men than it does women? Actuaries and underwriters will give you a myriad of answers to this question, but it all boils down to this: Women outlive men to such a statistical rate that you could make a fortune on the dead pools if you could bet small amounts on thousands of cases of regular folks on a split-the-sex one-on-one parlay.

Take my mom and dad. Like most male members of this Germanic-Irish-English (and whatever other Caucasian European nation you want to throw in the mix) brood, he did his manly duty and died of heart disease at the somewhat suggestive age of 69. That was several years later than his dad or his father-in-law or any of his brothers, uncles, male cousins, etc. The old joke for the men in my family was this:

"You may see many miracles during your life, son, but there's one thing you'll never see."
Young man: "What's that?"
Wise elders: "Seventy."

Now, thanks to the miracles of modern science and the greedy pharmaceuticals (praise be to God for both), I may be the first of the brood to change that prognostication. If not me, I bet I have a male cousin or two out there who drinks less and will.

Compare this testosterone-laden predicament for the men in my family to the lifespan of my mom. She'll be 81 years old in May, and my wife is firmly convinced that even though the old broad smokes at least a pack of cigarettes a day, she'll outlive me. She's been experiencing bouts of vertigo where she'll lose her balance for no good reason and fall. (I suspect the reason is somewhat due to the fact that she's got a lit cigarette hanging out of the side of her mouth when it happens, but she won't admit this to be the case.) She lives about four hours drive from us and now that she's getting to the point where a broken hip from one of these falls would be a disaster, we've tried to convince her to sell her house and land and move over here where we could keep an eye on her. If you think that's about to happen, you do not even begin to realize what a stubborn old battleaxe birthed this user.

I've tried to get her to buy and learn how to use a computer so that we could communicate some other way than the telephone. I've explained to her the concept of "the internet" and "email" but I might as well have been explaining plate tectonics to a rock. Even though the phenomenon would be going on all around the rock, it would be hard to expect the rock to understand the significance of it all. Thus, there will be no computer in my mom's house. In fact, every time we visit, I have to reset the clock on her TV and VCR. She only uses the VCR to replay one religious tape she has. When she wants to see this tape, she'll call me to ask, "Which channel do I have to set the TV to in order to see my tape?" She's never attempted anything as risky as "record."

It's not that she's a stupid woman. She is actually quite bright and well-spoken. But the age of technology has totally passed her by and she has no desire to attempt to catch up. I would venture to bet that there are millions of elderly folks just like her in developed countries all over the world. Regardless, we tried to talk her into checking out the Lifeline program where she would have one of those devices to carry around which would call for help if she had "fallen and couldn't get up." She finally did check into that and it was very expensive. She could afford it, but she's a frugal woman and even I had to agree that the cost sounded exorbitant for the service provided. I said, "Why don't you just get a little cell phone which you could carry around with you?" She liked that idea and finally did so. Little did I know that it would turn into an episode of Mama's Family trying to help her learn how to use the damn thing.

She called me yesterday on her regular phone and excitedly said, "I got a cell phone today. Here's the number. Call it and let me see if it works."

So I dial the number and the phone rings several times. Finally, I get the, "The customer you are trying to call is not…" blah blah blah. I called her land line and said, "Did the phone not ring?" She said, "No. It just sat here and vibrated."

After trying to explain to her that the vibration was the ring and attempting to find menu options on a phone I've never seen in order to help her change the vibration option to a ring tone option, I gave up. I told her to take the phone back where she bought it (Cingular) and tell the folks who sold it to her to show her how it works.

I had told her a friend of mine was going to be on Jeopardy! today and that she should make sure she saw it. She seldom misses Jeopardy! (nor do I) but I wanted to make sure she caught Kyle's appearance just in case he won. (What would be the chances of that, in a Tournament of Champions with the dreaded Adults with so many more years of life experience?) So she calls me after the show and says she saw my friend and how much she enjoyed it. I said, "Are you calling from your cell phone?"

She says, "No. I don't think that thing likes me."

"Electronic devices do not have feelings."

"Then why does it say 'Quit roaming'? Why does it want to talk to me like that?"

"Did you take it back to the store?"

She says, "Yes. And the girl was real nice. She helped me with it."

"OK, I'll call you on it and let's see if it works now." I dial the number and it rings and rings and rings. Finally, I call the land line and say, "Did the phone not ring?"

"NO!! All it did was start playing this annoying music."

I am through trying to help her with this over the phone. If she doesn't figure it out by the next time I visit, I suspect the cell phone will be part of a wind chime on the front porch.

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