Q: How to prevent falls in older adults?
A: Currently, the “Welcome to Medicare” prevention visit as well as the Medicare annual wellness visit with your generalist includes a brief screening for risk of falls. This is not a thorough examination. Older adults worried about falling are usually told by their primary care doctors to exercise or see a physical therapist, to see a podiatrist, to get vision checked, and to install grab bars. Sometimes medications that can cause somnolence or blood pressure drop are adjusted. Unfortunately, this is just not working... (1).
Again, what should you do to help prevent falls in older adults? The items listed below will give you some ideas of what is commonly done. Will it work if you do just this? Usually not... Read on to learn more...
Talk to Your Doctor: Ask your doctor or healthcare provider to evaluate your risk for falling and talk with them about specific things you can do. Ask your doctor or pharmacist to review your medicines to see if any might make you dizzy or sleepy. This should include prescription medicines and over-the counter medicines. Ask your doctor or healthcare provider about your bone health. If you, your loved ones or your doctor or healthcare provider are concerned about your risk of falls see physician expert in human biomechanics to assess your gait and balance.
Have Your Eyes Checked: Have your eyes checked by an eye doctor at least once a year, and be sure to update your eyeglasses if needed. If you have bifocal or progressive lenses, you may want to get a pair of glasses with only your distance prescription for outdoor activities, such as walking. Sometimes these types of lenses can make things seem closer or farther away than they really are.
Make Your Home Safer: Get rid of things you could trip over. Add grab bars inside and outside your tub or shower and next to the toilet. Put railings on both sides of stairs. Make sure your home has lots of light by adding more or brighter light bulbs.
Do Strength and Balance Exercises: Do exercises that make your legs stronger and improve your balance
Q: How Common Are Falls?
A: One in four older adults falls every year. Falls are more common as we age. Women are more commonly affected than men.
Q: What are some of the common effects of falls?
A: Those who fell are twice more likely to fall again. Falls also cause fear of future falls and reduced social involvement making many patients feel lonely and isolated. Over 95% of hip fractures and 60% of traumatic brain injuries in older adults are caused by falls. 2.8 million emergency room visits a year are due to fall related injuries (and no one likes to wait in the emergency room ☹). Many patients after hospitalization end up staying several months in nursing homes for continual rehabilitation. Falls are a number one cause of mortal injury in older adults. Every twenty minutes an older adult dies from a fall.
Q: Are falls a normal part of aging?
A: No, falls are preventable. We can diagnose and treat conditions that contribute to falls, even with patients with significant memory and cognitive deficits.
OK, let's take a dipper dive to learn about fall prevention...
Rate of falls in older adults (65 years old and older) in the United States is high: one in three to one in four older adults experience a fall (2, 3). Falls are the number one cause of injury-related death in older adults as well as non-fatal injury leading to emergency room visits (4). On the average one in five falls result in serious injury like brain trauma and hip fracture. Other common fractures include wrist fracture and shoulder fracture.
Unfortunately, fall prevention as a science is not currently taught in medical school curriculum. The subject matter is likely considered too complex as there is limited evidence of any algorithmic approach yielding good improvement in patient outcomes.
The Centers for Disease Control and Prevention has developed an algorithmic approach for identifying, risk stratifying and managing older adults at risk of falls: Stopping Elderly Accidents, Deaths & Injuries (STEADI) (5). The STEADI algorithm i) screens patients for risk of falls: “Do you feel unsteady when standing or walking? Are you worried about falling? Have you fallen in past year?”; ii) stratifies patients by their risk of falls, e.g. those with one traumatic fall or two non-traumatic falls a year with gait and balance deficits (e.g. Timed Up and Go test score at of least 12 sec to screens positive for future falls); and iii) recommends a multi-factorial assessing for balance and gait deficits, vision deficits, polypharmacy, somatosensory deficits, foot and ankle problems and vitamin D deficiency. There is even a study showing that this algorithm can reduce fall related hospitalizations, however the study methodology is very limited, for one this is not a randomized controlled study, results varied from clinic to clinic, fall prevention recommendations were inconsistent, patient engagement was poorly documented, and data was only collected from one healthcare system (6).
OK, so what does work? How should we approach fall prevention in our loved ones?
First of fall, we recommend differentiating between the acute cause of falls and the chronic predisposing conditions. For instance, you may have heard of someone tripping on a stair and falling. Some others fall tripping over a curb. Some loose balance while reaching for something in a kitchen or bathroom. Others fall after a slip. All of these are acute triggers of falls.
Most older adults and their physicians forget that there is usually an underlying biomechanical reason for the falls. For instance, there may be an underdiagnosed problem with the sense of proprioception (ability of your body to tell you where you are in space), or a the inner ear problem (the vestibular system, much more rarely). See, G-d designed us in such a way that we can sense the ground and move around the world even with eyes closed. Seeing just helps us identify barriers that are ahead of us. The sense of proprioception helps us sense where the foot is in space relative to the ground, so that we can walk around safely. This information travels from foot all the way up the spine to the brain. There are several reflexes that are involved and many times someone who tripped ends up catching him or herself. We affectionately call it having "good reflexes." What happens is that as we age we notice that our reflexes are just not as good. Many of us believe that this is normal part of aging, which of course it is not.
The exciting news is that we can identify the problems with proprioception and using several neuro-muscular re-education techniques help improve the underlying problem.
Let's see how the underlying proprioception problem contributes to falls. Why did Joe Smith trip over the stair? His central nervous system (brain and spine) got poor signals about the location of the stair relative to the foot, therefore the automatic calculations about how to safely step over the stair were mistaken and Joe tripped over the stair. How did Sally Jones loose balance in the kitchen? See the sense of proprioception helps us balance safely when we stand walk or reach forward. Sally reached over to the bottom of the fridge but her sense of balance was impaired and she fell. In both cases we found the acute reasons: stair, reaching over as well as the chronic impairment contributing to the fall. Unfortunately, many people call these types of falls mechanical falls, which implies that falls are due to external factors, but this is a mistake. External factor e.g. the stairs, were the acute cause, but the underdiagnosed biomechanical problem was not identified.
OK, you tell me but what about the UTIs, pneumonias and drugs that cause falls? Same problem, UTI, pneumonia or medications are causing a temporary sense of altered brain function either due to medication side effects or due to illness. This is an acute factor! What we find in our experience is that underlying biomechanical factors contributing to the falls are often missed...
How do we know that biomechanical causes of falls are so important? A high profile article on fall prevention in older adults lists multiple different reasons why older adults fall and multiple different interventions supported by evidence to help reduce falls (6). Yes, there is some evidence for many different interventions, but the strongest evidence supports interventions targeting biomechanical deficits in gait and balance function.
So, hold on there, are we saying that basically go to physical therapy and you are good? Is that the solution for fall prevention in older adults? Unfortunately, this is not so simple. Most of our patients had been going to physical therapy for several years already and did not get better, this is how they hear about Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute. What is our secret?
A thorough fall prevention examination needs specialized training in human biomechanics of gait and balance, as well as expertise with various vestibular, vision, neurological, cardiological, and orthopedic conditions. Unfortunately, no medical specialty currently offers all of this training in one package.
This is why, when Dr Atanelov was working at Johns Hopkins, he was charged with developing a comprehensive fall prevention approach that casts a wide net to include multiple different diagnoses yet provides a specific and concrete personalized fall prevention plan. After developing a successful protocol, Dr Atanelov left Johns Hopkins to start the nation’s first comprehensive fall prevention medical institute, Steady Strides. Dr Atanelov has also continued to be actively involved with research, clinical care, and public health initiatives.
Q: What is missing in current fall prevention medical paradigm practiced in most medical offices?
A: A thorough fall prevention examination needs specialized training in human biomechanics of gait and balance, as well as expertise with various vestibular, vision, neurological, cardiological and orthopedic conditions. Unfortunately, currently no medical specialty offers all of this training in one package to help arrive to the right diagnosis.
Q: Is having the right diagnosis enough to prevent falls?
A: Diagnosis is just the first step. Next, we need to help prioritize which of the many risk factors for falls to focus on. This would normally require several specialist physicians to seat together and discuss the various contributions of various medical conditions to each patient, one patient at a time. Unfortunately, this is not the norm, and even the general practitioner is not equipped generally to help prioritize these diagnoses.
Q: Is prioritizing the diagnoses the final step?
A: No, after we have arrived to the prioritized set of most important conditions contributing to falls for the patient at hand, we need to provide a tailor-made medical and rehabilitation treatment approach taking into account all of the patients’ medical and social conditions.
Q: How is Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute different in preventing falls?
A: Steady Strides: Fall Prevention and Stroke Rehabilitation Medical Institute is nation’s only comprehensive medical fall prevention program. Dr Atanelov developed his comprehensive medical fall prevention program while working at Johns Hopkins where he served as Medical Director of the Fall Prevention Medical Clinic. He uses human biomechanics and additional training in other medical specialties (e.g. vestibular, endocrine, vision, neurological, cardiological and orthopedic) to provide a one-stop-shop to help diagnose and prioritize medical conditions contributing to falls. Dr Atanelov works with in house physical and occupational therapists to provide a tailor-made team based, concrete, goal-directed fall prevention medical and rehabilitation plan of care.
Q: Is care at Steady Strides covered by insurance?
A: Yes.
References:
1. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 2001 May;49(5):664-72. PMID: 11380764 https://pubmed.ncbi.nlm.nih.gov/11380764/
2. O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993 Feb 1;137(3):342-54. doi: 10.1093/oxfordjournals.aje.a116681. PMID: 8452142. https://academic.oup.com/aje/article-abstract/137/3/342/168819?redirectedFrom=fulltext
3. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years - United States, 2014. MMWR Morb Mortal Wkly Rep. 2016 Sep 23;65(37):993-998. doi: 10.15585/mmwr.mm6537a2. PMID: 27656914 https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm
4. Data searches available at the National Center for Health Statistics (NCHS), National Vital Statistics System. Accessed from Centers for Disease Control and Prevention (CDC) Web-based Inquiry Statistics Query and Reporting System (WISQARS) at https://www.cdc.gov/injury/wisqars. Retrieved on May 8, 2020
5. The Centers for Disease Control and Prevention’s (CDC) had created a general algorithm for medical providers-Stopping Elderly Accidents, Deaths and Injuries (STEADI). Accessed on May 18, 2020 at https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf
6.Johnston YA, Bergen G, Bauer M, Parker EM, Wentworth L, McFadden M, Reome C, Garnett M. Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An Outcome Evaluation. Gerontologist. 2019 Nov 16;59(6):1182-1191. doi: 10.1093/geront/gny101. PMID: 30239774; PMCID: PMC6625936. https://academic.oup.com/gerontologist/article/59/6/1182/5103473
6. Ganz DA, Latham NK. Prevention of Falls in Community-Dwelling Older Adults. N Engl J Med. 2020 Feb 20;382(8):734-743. doi: 10.1056/NEJMcp1903252. PMID: 32074420. https://www.nejm.org/doi/full/10.1056/NEJMcp1903252?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed