As we age, our risk of falling increases. Our feet may catch on a well-worn rug or we may miss a step going downstairs to the kitchen at night. We lose balance, strength and agility; medications may make us drowsy; or we may become dizzy after getting up from a chair as our blood pressure plummets.
No one has done more to highlight the medical significance of this issue than Dr. Mary Tinetti of Yale University. The recipient of a 2009 MacArthur Foundation “genius” grant, Tinetti has spent almost two decades exploring why seniors fall. Most recently, she co-chaired a committee of American and British experts that helped prepare new guidelines for preventing falls.
Tinetti spoke at length about the guidelines, which were published in January in the Journal of the American Geriatrics Society. An edited version of our discussion follows.
Q Tell me about the guidelines.
A A key finding is that we can identify a subset of older people who are at sufficient risk of falling that they would benefit from attention to fall prevention.
Q What characterizes this subset?
A People who have had two or more falls in the past year, one or more falls that resulted in an injury, or who are unsteady when they walk.
Q Once identified, what should happen next?
A What allows us to walk upright safely is an intricate system of balance that involves many components — the brain, our vision, our inner ear and our muscular skeletal, nervous and cardiovascular systems. We know that people are at increased risk of falling when multiple systems aren’t working correctly.
The guidelines recommend that clinicians identify as many risk factors as possible and improve as many as possible instead of focusing on one system at a time.
Q You recommend fall assessments for people at risk. What would that involve?
A Ideally, you’d want a team of professionals working together. A physical therapist would look at an older person’s balance and gait and then prescribe appropriate exercises. A physician would focus on blood pressure drops when the patient stands up. Right now, doctors are interested if blood pressure is too high, not too low.
Also, a doctor would review all the medications the person is taking and stop or reduce the dose of potentially offending ones. The home care nurse or physical or occupational therapist would look at the environment to make sure it’s as safe as possible. The way health care is currently set up, it is difficult for these different health professionals to work together and coordinate their roles, but it is possible.
Q How do these recommendations differ from previous guidelines?
A We’re more specific for what we’re recommending for exercise. The evidence shows us that exercise should include both balance and strength components. We now say the balance part can be done either through tai chi or physical therapy or other exercise programs.
The other piece that’s new is a much greater focus on reviewing and reducing all medications, if possible.
Q Tell me more about that.
A The problem is that as people get older, they have multiple conditions. But the way we look at people is one disease at a time. What should happen is more consideration of the impact of all the medications someone is taking and the trade-offs — not just will these medications help your blood pressure or diabetes, but will they overall do you more good than harm? That’s a new way of thinking.
Q What needs to happen going forward?
A For seniors, they need to start asking their doctors and nurses about what they can do to prevent falls. Every time someone wants to start a medication, ask “is this going to help me with my balance, my mobility and my functioning as well as my disease or at least not hurt my balance, mobility and functioning?”
Doctors today need to refer patients more than they do to physical therapy so they can improve their balance and their gait. And discharge planners in hospitals need to look at how to help mitigate risk factors for falls for patients returning home from the hospital. Medicare has said it’s not going to pay for complications associated with falls that take place in hospitals but that doesn’t go far enough.
The impact of falls and how to avoid them
More than 2 million older adults fall each year, breaking their arms, legs or hips or suffering brain injuries, according to the U.S. Centers for Disease Control and Prevention. The accidents lead to more than 580,000 hospitalizations and 18,000 deaths annually.
Even when tumbles are less serious, 20 percent to 30 percent of seniors find it harder to get around or live independently after a fall, increasing their risk of going to a nursing home or dying early, the CDC notes.
Yet evidence shows that many falls can be prevented with foresight. Professionals recommend:
Get regular exercise that helps you increase your strength and improve your balance. Tai chi programs are a good option.
Make sure your home environment is safe. Get rid of loose rugs, install grab bars in the bathroom and install handrails on staircases. Stop using that step stool if you’re not steady.
Have your doctor review all the medications you’re taking, eliminate those no longer necessary, and, if possible, reduce doses for drugs that might make you dizzy or drowsy.
Get your vision tested regularly and make sure house lighting is adequate. As we age, we need brighter lights to see well. Use night lights.
