Seniors who fall -- it's a common problem -- can face a challenging recovery
[00:00:00] Host Amber Smith: From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Falls can cause serious injuries, especially in people over age 65. The Centers for Disease Control and Prevention says one in four older people fall each year, with fewer than half telling their doctor about their fall.
[00:00:21] Host Amber Smith: I'm talking today with Dr. Andrea Berg. She specializes in geriatric medicine at Upstate. Welcome back to "HealthLink on Air," Dr. Berg, and thank you for your time.
[00:00:30] Andrea Berg, MD: Thank you for having me.
[00:00:32] Host Amber Smith: Now, how big of an issue are falls among the patients that your practice sees?
[00:00:37] Andrea Berg, MD: Falls is really one of the most common events, and it's significant because it's an event that threatens the independence of our older adults.
[00:00:45] Andrea Berg, MD: So it's a huge issue for us.
[00:00:48] Host Amber Smith: What types of injuries do you commonly see in someone who falls? Is it true that 95% of hip fractures happen in falls?
[00:00:55] Andrea Berg, MD: That's true. Over 90% of hip fractures are a result of the fall. Almost a third of those who fall may need medical attention relating to that fall. Unfortunately, most of those will all have some restriction on their activity for at least some time.
[00:01:08] Andrea Berg, MD: The injuries vary; most falls will result in just minor soft-tissue injuries, but five% to 10% result in a fracture or a more serious soft-tissue injury or head injury. But the hip fractures really are a major concern and an issue if they have them.
[00:01:26] Host Amber Smith: Is it always lower extremity, or do you see upper extremity fractures as well?
[00:01:33] Andrea Berg, MD: I certainly see an upper-extremity as well, depending upon how the fall happened. You can have wrist or shoulder injuries. You can have rib fractures as well, depending upon sort of the situation that ended up with the fall. There's some groups that are higher risk, you know, women in nursing-home settings, and if they have other medical conditions like dementia, they tend to be the highest risk, and we'll see them more often with the hip fractures.
[00:01:59] Host Amber Smith: So let's talk about what recovery is like. If someone over age 65 breaks a bone, what is recovery like for them?
[00:02:08] Andrea Berg, MD: Well, for a fracture, you know, medical management tries to first relieve pain, and ideally to restore bone alignment and allow fractures to heal ,for if in the setting of a hip fracture for a medically stable person, with a hip fracture a surgical repair is recommended, and ideally early, within that first 24-to-72-hour period after the fracture, because earlier repair is linked with a lower chance of complications. But then after that, there's rehab, and rehab after, say, a hip fracture, will continue to include pain management, trying to mobilize people.
[00:02:42] Andrea Berg, MD: And then again, to prevent complications from happening.
[00:02:46] Host Amber Smith: So to start out with, they may be immobilized for a while before they can get up and do the physical therapy?
[00:02:53] Andrea Berg, MD: Yes. And that opens you up to a whole bunch of other problems, the complications, right, as you quickly can have a loss of strength, and you can set yourself up to things like pressure ulcers.
[00:03:06] Andrea Berg, MD: If you're in a sort of an immobilized state, people could get delirious, they can get blood clots, they could get lung issues. So those are the complications that we're really, really trying to avoid.
[00:03:21] Host Amber Smith: So, with a fractured hip, because that one seems pretty common, is there casting involved?
[00:03:26] Andrea Berg, MD: Yeah. There's a wide variety, depending upon where it is, if it's a place where they often can just be pinned, so there's a lot of different surgical options where they might have to go in and have a pin, but again, it's not necessarily a cast, a brace, but, for older folks, rehab isn't necessarily so easy, and working around pain and some of the limitations, that's where restoring function isn't always perfect.
[00:03:51] Andrea Berg, MD: You know, about 75% of hip fracture survivors will return to their prior level of function, but their overall mobility is going to be more limited. Now, half of them will need an assist device like a cane or a walker, and a half of patients will have a need for a stay in a long-term care rehab, but only some of those might not ever return to home. You know, 25% of those might still be in long-term care a year later. So, that's where the functional changes happen in folks that survive these hip fractures. And to note: (with) the hip () fractures themselves, there's a mortality rate. People do die from the fall itself, 5% during that initial hospitalization and some of our frailer folks, but a year out, 25% can die, just because of complications from the fractures.
[00:04:41] Andrea Berg, MD: So that's why we take these falls really seriously, because they can have real impacts on people's survival.
[00:04:48] Host Amber Smith: It sounds like recovery can be very challenging.
[00:04:53] Andrea Berg, MD: Yeah. That's why we try to prevent them if possible.
[00:04:55] Host Amber Smith: You mentioned this can threaten someone's independence. So even if someone, if all they break is a wrist or an ankle, can an older person live alone and have a healthy recovery without assistance for an injury like that?
[00:05:10] Andrea Berg, MD: It's hard to make broad blanket (statements), but even those that don't experience physical injury, you know, falls definitely are associated with declines in their functional status and that they have an increased likelihood that they're going to need more supports either in their home or, God forbid, having to leave their home and transition into like a skilled nursing placement.
[00:05:30] Andrea Berg, MD: In general, people are going to have an increased need for medical services, and the bigger concern, too, is that they might develop a fear of falling, which unto itself set them up for a negative impact on their quality of life and a higher risk of falling again.
[00:05:46] Host Amber Smith: You're listening to Upstate's "HealthLink on Air." This is your host, Amber Smith, talking with geriatric specialist Dr. Andrea Berg.
[00:05:54] Host Amber Smith: Let's talk about some of the typical reasons that someone who is older might fall. What do you typically see?
[00:06:00] Andrea Berg, MD: Falls, like many things, in geriatrics, are rarely one thing, you know, it's often accumulation of a lot of little things that can add up.
[00:06:09] Andrea Berg, MD: But there are some age-related changes that could set people up for a fall, you know, changes in strength, balance, our nervous system. Those are normal age changes that might increase people's risk of falling, but then there's medical causes, too, that you layer on to those changes and they could really increase people's risk, and that's really varied, and changes in vision, changes in cognition, dementia, Parkinson's (disease) or stroke, or blood pressure, almost anything you can see how arthritis (or) these common conditions that have been as we get older can cumulatively increase somebody's risk of falling. So it's really important that, in working with your medical providers, you try to optimize your medical therapy, monitoring for disease progression, so that we're always avoiding things like that, that we choose our medications appropriately, we could maybe avoid people being at an increased risk of falls.
[00:07:04] Host Amber Smith: You mentioned medications. I mean, there's some of them that leave a person feeling a bit dizzy. I can imagine that might make someone more prone to falling, right?
[00:07:15] Andrea Berg, MD: Absolutely. There's a bunch of high-risk meds. A lot of them have to do with sleeping. A lot of our hypnotics that people take a lot of medications for sleeping, trying to make them feel a little sedated is their goal. But unfortunately that could cloud people's thinking, it could impair their balance.
[00:07:30] Andrea Berg, MD: And that group is really high risk for setting up people for falls. Some of the mood medications as well, and that's for anxiety or depression, like benzodiazepines in particular, we really try to avoid as people get older because they have been shown to significantly increase people's risk of falling. But even blood pressure medicines, if they're medicines like diuretics that could lower people's blood pressure perhaps too much, or set them up for being a little dehydrated, that could increase people's risk for falling.
[00:08:01] Andrea Berg, MD: So in general, we try real hard to just limit the medications to those that we really need, you know, less is more, and that's something that we frequently will be doing in our office is, looking through and saying, are there safer options? Can we use the lowest effective dose possible? And the fewest meds (medicines).
[00:08:20] Host Amber Smith: I'm assuming in Central New York fall hazards increase during the winter months Do you see more patients who've slipped on the ice?
[00:08:27] Andrea Berg, MD: Absolutely. But you know, the summer months have their own challenges as well, when it comes to high temperatures and hydration, but definitely slipping on the ice or just uneven and slippery surfaces, come with their risks.
[00:08:41] Host Amber Smith: Now, I've heard that a person who falls once has a really good chance of falling again, but I don't understand the reasons for that.
[00:08:51] Andrea Berg, MD: That's absolutely true. And that's a screen that we do in the office if someone's coming in with an initial fall, then we'll look into it, but a history of falls puts them in a different category, where we have to think a little bit more holistically on how can we prevent them in a broader approach.
[00:09:07] Andrea Berg, MD: I think fear of falling plays into that repeated fall, though. A fear of falling can lead people to kind of play it safe too much. They might restrict what they're doing and then that's negative for their quality of life. They're not interacting as much, they're less social, but also it could lead to poor balance.
[00:09:25] Andrea Berg, MD: They might change the way they're walking, even as the fear limits their natural stride. And that becomes a risk factor for future falls.
[00:09:33] Host Amber Smith: What do you say to a patient who has survived a bad fall and now is petrified of falling again?
[00:09:40] Andrea Berg, MD: You know, there's actually a whole group of therapy, cognitive behavioral therapy, that has been shown to be very helpful in this. They aim to change sort of how the person thinks; that's the cognitive part, and then how they act, that's the behavior. And looking to kind of overcome that fear of falling by shifting their focus away from more pessimistic thoughts and (toward) things that they could do, like exercise to promote their balance and their safety.
[00:10:05] Host Amber Smith: Well, let's talk about some of the ways that family members can help reduce the chance of their older loved ones falling. What do you recommend?
[00:10:18] Andrea Berg, MD: One of the first things you look at is the home environment. And that's sort of hard sometimes for us in an office to get a sense of what's the reality of people day to day.
[00:10:26] Andrea Berg, MD: So they're real basic things, like making sure the lighting is adequate. And particularly at night, removing things around the house, on the floor that might be a hazard. If there are things like door jambs, accounting for them, looking for loose carpeting or throw rugs, looking at the furniture, maybe replacing some of the existing furniture with safer, more stable and more appropriate height options.
[00:10:51] Andrea Berg, MD: Support structures. Sometimes we, even for folks that are repeated fallers partner with our physical therapy colleagues, and they do home safety assessments, and they'll look at high-risk areas like the bathrooms and make some suggestions on where some grab bars should be installed or elevated toilet seats, very basic functional things to set people up to succeed -- non-slip bath mats or a bedside commode to avoid people having to use the restroom a lot in the evening. So, those are some things that families can do if we're worried, to avoid falls or, if somebody has fallen, to avoid future falls. But then also very basic things like footwear, making sure that the shoes that people are wearing are not only fashionable but functional as well, that they are a good fit, that they're non-slip, that they're not high heeled and that they have a really good surface area contact ratio. So, those are some things that family members, I think, can be helpful with to prevent falls.
[00:11:53] Host Amber Smith: I noticed you said footwear. You're not talking about just wearing socks in the house because socks are slippery, right?
[00:12:00] Andrea Berg, MD: Absolutely, yeah.
[00:12:01] Host Amber Smith: Is it a good idea to go barefoot?
[00:12:04] Andrea Berg, MD: You know, in your own house, I think that for people, if they're at a higher risk of falls, I think it's better to have supportive footwear.
[00:12:11] Andrea Berg, MD: They have a little bit more of a tread, and that'll give more balance and stability for folks. There's a lot of reasons, like you said before that people have medical conditions that might impair their ability to feel on the bottom of their feet, and so you want to set them up for success that they're not in an unsteady place that they could trip.
[00:12:31] Andrea Berg, MD: So if they're a high-risk faller,I would wear supportive footwear instead of certainly not socks and bare feet.
[00:12:38] Host Amber Smith: Now, does vitamin D play a role in preventing falls?
[00:12:42] Andrea Berg, MD: Yeah, that's interesting. So if people are deficient, if they're low in vitamin D, there's certainly a role in falls, but it hasn't been shown. For awhile, there were thoughts of "We'll give D to everybody," but it hasn't been shown that just giving vitamin D to people that don't have low vitamin D levels improves fall risk. But certainly it's something we check for. And if somebody is low in vitamin D, and by that, it's usually agreed upon that like a total D level of less than 30 (nanograms per milliliter, abbreviated ng/mL), we should supplement them appropriately with pills, with daily supplements, because that has been shown to improve muscle strength as well as bone health.
[00:13:19] Host Amber Smith: How do geriatricians like yourself evaluate an individual's risk for falling? If you have a new patient coming in, what sorts of questions would you ask them?
[00:13:32] Andrea Berg, MD: Well, we have to ask explicitly if they've fallen, because often people don't necessarily report falls, on their own. So, asking about if they have a history of falls or for falling recently, and a little bit about the setting around the falls, if they come in with a fall, it's really important.
[00:13:49] Andrea Berg, MD: But other things as well -- just asking about any difficulty people are having with walking or with balance, if they're having trouble getting up from a chair, they're having a false start where they have to do a couple of tries to get up, before they're able to stand, they're having dizziness when they stand or problems with their eyes, any weakness or sort of numbness. Those are all red flags, that would make me concerned about safety involved. And those are definitely screening questions that we ask.
[00:14:20] Host Amber Smith: If you identify someone who has a fall risk, does that person still needs some sort of activity or exercise?
[00:14:27] Host Amber Smith: And if so, what sorts of things do you recommend if the fall risk for someone is relatively high?
[00:14:36] Andrea Berg, MD: I recommend activity for everybody. I think that shouldn't be something that we reserve for just those at risk of falling. I'd like to take a more proactive, preventative approach. So, exercise programs, there are some that are better than others. For fall reduction, exercise programs that have more than one type of exercise have been shown to be the best.
[00:14:55] Andrea Berg, MD: And by that I mean a combination of exercises that improve gait, balance, strength and coordination. So, things with resistance bands, we often use for some of the strength training, like those big, elastic, rubber bands. But also things that focus on functional fitness, like squats, that will strengthen areas of our body, that we need to stand and to sit appropriately, even our upper arms as well, or our core.
[00:15:25] Andrea Berg, MD: Those are things that will prevent people from day to day as they're transferring and going about their days, keep them fit enough to not set them up for a fall.
[00:15:35] Host Amber Smith: Well, thank you, Dr. Berg. I really appreciate you making time to talk to us about how falls can affect the older generation.
[00:15:42] Host Amber Smith: My guest has been Dr. Andrea Berg. She's an assistant professor in geriatric medicine at Upstate. I'mAmber Smith for Upstate's "HealthLink on Air."