Fall proofing ME: What Can I Do?
The media is awash with stories about older adults falling and hurting themselves, and these reports usually mention that each year one in three of those over 65 will fall, and two million will be treated in emergency departments for fall-related injuries (1). For older adults reading these reports there are two common questions. Are falls really a big deal for me? And if so, what can I do to make it less likely I will fall and hurt myself?
This article is about what you can do to make falls less likely, and includes a personalized approach to fall prevention and fall risk reduction.
In our companion article (Am I at Risk for Falls?), you can learn whether your personal risk of falling is big enough to make it something more important to worry about than all the other things you might concern yourself with (such as cholesterol, blood pressure, or brain health).
Here are the key things to focus on to make your personal fall risk as low as possible:
- Exercise, Balance and Gait
- Vision (and Hearing)
- Hazards at home
- Bathroom visits
- Lifestyle issues
How Can I Reduce MY Fall Risk?
The good news is that a lot of intellectual horsepower has gone into answering this question, much of it summarized in a series of resources on the website of the CDC (Center for Disease Control and Prevention (USA) (1). And, it turns out there are definitely some things you can do that should make a fall-related trip to the emergency room less likely.
Below is a brochure published by the CDC describing four actions you can take to prevent falls. The actions relate to exercise, medications, vision, and fall-proofing your home. It seems the most effective interventions to reduce falls include a focus on all of these factors.
Four things you can do to prevent falls
Attribution: CDC: What you can do to prevent falls
Exercise seems to be an absolutely critical part of any effort to reduce one's fall risk. But as we dig into this topic we find that not just any old exercise program will do, if the goal is fall risk reduction. For example, just taking the local spinning class, designed for 20 year olds, is probably not the most effective approach to reducing your risk of falling.
The CDC Compendium of Effective Fall Interventions (4) identifies 15 separate studies demonstrating the effectiveness of various types of single intervention exercise programs for reducing fall risk. The results of these studies are pretty impressive, with reductions in fall risk as a result of these programs varying from 22% to 66% in the different studies. There are an additional 12 multifactorial falls prevention studies identified in the CDC Compendium, all of which include exercise as a critical component.
The studies typically focus on improving some or all of the following:
- balance & gait;
- reaction time;
- aerobic capacity;
The obvious question is "Which sort of exercise program is right for ME? How do I find a good program?" Stay tuned for an upcoming article on this topic.
Exercise can improve our functional level
There is an especially important point to make here. Many of us think of exercise as something young people do. Or at any rate something "we did before we got frail". But exercise actually has the potential to restore lost functionality in some cases.
Dr. Mindy Renfro comments on this topic:
Yes, aging gives us greater barriers to strength, balance and overall fitness levels – but it does NOT prevent us from improving our functional level (in the absence of serious illness or injury). The muscle mass we have left has the same potential to gain strength as anyone else’s muscle mass… we just have fewer muscle fibers or less mass to engage.
If one finds that they need a cane or walker then they also need a physical therapy referral followed by a lifelong fitness plan that is tailored to them by a PT who understands aging. The PT’s name should be followed by the credentials “PT, DPT, GCS” or "PT, NCS”. The Geriatric certified specialist or the Neuro certified specialist has better training to meet their needs.
If PT causes pain, it is not the right therapist. No pain – no gain is simple nonsense and for an aging adult is even dangerous. Temporary use of a cane or walker may be alleviated and/or forestalled by PT in many (not all) cases.
Some types of medications (or combinations of medications) can have side effects like dizziness or drowsiness or low blood pressure that make falls more likely, and sometimes adjusting the list of medications can reduce one's fall risk. Obviously, this is something that needs to be done by a clinician.
However, this is not always something the average primary care practitioner has time to focus on, and unless you have a personal geriatrician well versed in fall avoidance topics, it may be prudent to visit the doctor equipped with a checklist of what exactly to ask about.
Below is a guide from the American Geriatrics Society which lists 10 medications older adults should use with caution. Some of the drugs they mention have side effects that can increase fall risk, and this would be a useful document to take along to your next doctor visit to discuss with your physician.
Attribution: American Geriatrics Society. Downoad this guidance document here as PDF .
In addition, the CDC has a more specific set of suggestions for medication management to reduce fall risk. It is targeted at clinicians, but you can download it here (as a PDF).
Interventions and Medications and Falls
The CDC Fall Intervention Compendium (4) highlights some interesting study results relating to medication and falls.
- 64% reduction in fall likelihood after withdrawal of psychotropic medication (Psychotropic Medication Withdrawal, New Zealand);
- 38% fewer falls in women taking active Vitamin D supplementation vs those not taking it (Active Vitamin D (Calcitriol) as a Falls Intervention, USA);
- 52% fall reduction in women taking Vitamin D supplements (Vitamin D to Prevent Falls After Hip Fracture, UK);
- 39% reduction in fall probability on adults undergoing Vitamin D supplementation (Study of 1000 IU Vitamin D Daily for One Year, Germany).
Of course, caution is warranted in interpreting these results, as the details of the studies, and the target populations and the exact intervention details all need to be considered before deciding whether these results have implications for you. This is where your doctor comes in.
But it is certainly worth asking if Vitamin D might help your fall risk, and whether you could do without that psychotropic medication (benzodiazepine or other hypnotic drug, antidepressant, or major tranquilizer)?
The basic problem here is that if you can't see well, it is easy to trip over something or lose one's footing. And good vision plays an important role in balance as well.
There are several important factors. You want good glasses with the right prescription. And common ophthalmic conditions of the older adult should be well managed (glaucoma, cataracts, macular degeneration etc). Hence the recommendation of regular eye checkups.
And you want good lighting in places where you commonly go and where you live. This is dealt with further in the checklists for fall proofing your living environment (below).
But an additional thing to think about here is that you want to be careful about venturing into poorly lit environments if you are at risk of falling. So when you go out at night, maybe it makes sense to stick to well lighted places. Or to carry a flashlight with you.
Some of the members of our discussion circles have recently got interested in a series of canes with attached lights that we have been investigating. You can see a number of discussions of what to do to make venturing out at night safe in the Explorer Discussions section of this website.
Attribution: Longevity Explorers, Tech-enhanced Life, PBC.
Falls and Cataracts
In the CDC Falls Intervention Compendium (4), they reference an interesting study evaluating the effectiveness of first eye cataract surgery in reducing falls compared with a control group who were awaiting surgery.
- After 12 months, participants in the intervention group had experienced 34 percent fewer falls than those who did not have cataract surgery (Cataract Surgery, UK).
This suggests that waiting as long as possible for that cataract operation might not always be such a good idea, as it might increase your risk of falling.
There are professionals who will come to your house and do a fall hazard assessment, and make recommendations about a variety of home improvements, including grab bars in the shower, removing rugs that may be trip hazards, getting adequate lighting in various places, reducing clutter and the like.
Interventions and Fall Hazard Assessments
In the CDC Fall Intervention compendium (4), the authors identify four separate studies, each looking at whether interventions that involved this type of professional-led home hazard mitigation could actually reduce the probability of falls. Each of these studies demonstrated substantial reduction in fall risk:
- 44% fewer injuries (VIP trial, New Zealand);
- Fall rates reduced by one third, but only among those who had a fall in the year prior to the study (Home Visits by an Occupational Therapist, Australia);
- Fall rate reduced by 31% (Falls-HIT, Germany);
- Fall rate reduced by 46% when assessment performed by OT, but unsuccessful when performed by a "Home Care Worker" (Home Assessment & Modification, Yorkshire).
Results seemed particularly good when the population was one that had fallen in the past. The takeaway message seems to be that this type of home assessment and remediation would be well worth doing, expecially if one were at high risk of falling. But it seems as if the skill of the assessor is key, and one would want a well qualified assessor (perhaps an Occupational Therapist trained in this type of work).
Fall Hazard Check Lists
There are numerous "Fall Hazard Check Lists" on the Internet. These are helpful guides to check the work of these professionals, or to do a quick assessment of your parent's house to see if it is time to call in the professional to make some recommendations.
Here are some examples.
A. This Checklist for Reducing Fall Risk was developed by a member of our expert falls panel, in collaboration with a group of older adults living in Marin, CA, USA.
B. The "Home Fall Prevention Checklist" below is available on the CDC website, and made available here as well for convenience.
Attribution: CDC: Check for Safety Program.
In addition to the factors above, one that keeps coming up when talking to people who work in aged care settings is the correlation between trips to the bathroom and falls. I think the typical scenario is: you wake up, need to go urgently, stumble out of bed half asleep, ... and fall.
Here is Nurse Administrator Pam Sharkey's observation on this topic:
A common scenario involves falls in the elderly who need to use the restroom. All of us were potty trained between the ages of 2-3 years old and the urge to use the bathroom is the major trigger to get up and go to the bathroom. Often times the elderly take medications to increase the use of the bathroom (diuretics) to treat a medical condition which also causes an increase urge to need to use the restroom which can cause a fall.
For the elderly who are ambulatory, a regular "restroom schedule" would be helpful. For those who are not ambulatory independently, a bathroom schedule for a caregiver or family member would be helpful to prevent the elderly getting up to use the bathroom urgently.
Food for thought.
In reading the sources described below in the reference section, one comes away with several additional recommendations, we think of as "lifestyle" recommendations.
Shoes: Wearing the right shoes is strongly recommended by various sources, as the "wrong" shoes lead to increased likelihood of tripping. When we published this article the NIH had a nice explanation of what a "good" shoe looked like, but that useful resource is no longer online.
Alcohol: I guess we all know alcohol can affect balance.
Sleep: Several of the references make the point that lack of sleep can contribute to increased risk of falling.
Stand up slowly: If you are prone to low blood pressure, or to light headedness when standing up, then standing slowly makes dizziness (and then falling) less likely.
Mobility aids: If you are unsteady on your feet, mobility aids like a walker or cane may help make falling less likely. This is a topic to discuss with your clinician.
Fall Prevention Programs: Multi-factorial Interventions
It seems the most effective approach to reducing our risk of falling is to attack all the above factors in parallel. A good way to do that is to take one of the numerous "Fall Prevention Programs" that are available through governments, and a variety of entities in the aging services ecosystem.
At their best, these programs are carefully designed, evidence-based, "Multi-factorial interventions" (ie they attack multiple factors at once - exercise, home hazards, medication, vision), run by well trained professionals.
However, not all programs offered in the community are equally effective. We found ourselves asking "What should I look for in an exercise program or a fall prevention program if I am at risk of falling?". See our follow-on article: The Best Fall Prevention Program.
Learn More about Falls in Older Adults
If you want to learn more about this topic, here are some resources we found especially useful, in addition to references already mentioned above.
National Library of Medicine's Medline Plus section on Falls (6)
This reference (6) is a thorough learning resource on the topic of falls in older adults, assembled by an organization with great credibility. It includes links to:
- National Institute on Aging page on Falls (Nice overview and tips on how to prevent falls)
- Ways to prevent falls and fractures (NIH Osteoporosis and realted Diseases resource Center)
References and background and further reading:
(1) The Centers for Disease Control and Prevention National Center for Injury Prevention and Control (NCIPC):
Falls - Older Adults.
(3) Blood pressure medications linked to serious falls: What you can do, by Dr. Leslie Kernisan (San Francisco-based Geriatrician and blogger on the topic of Geriatrics for Caregivers)
(4) CDC Falls Compendium (Summary of evidence based falls prevention program literature). This document describes a series of interventions that have been shown in peer reviewed studies to be effective. It is the background for some of the discussion in this article.
(8) NIH Senior Health: Falls and Older Adults (the government unfortunately took down this useful resource).
(9) Frequently asked Questions on Falls (Intellihealth) (Link disappeared from Internet)
(10) Ways to prevent falls and fractures (NIH Osteoporosis and realted Diseases resource Center)
Lead authors: Richard Caro and John Milford