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| Help prevent dangerous falls. |
Guest post by Leslie Kernisan, MD MPH, Geriatrician and Caregiver educator
If you want to prevent
dangerous falls in an aging adult, here’s one of the very best things you can
do: be proactive about getting the right kind of medical assessment
after a fall.
Why? There are three
major reasons for this:
- A fall can be a sign of a new and serious medical problem that needs treatment. For instance, an older person can be weakened and fall because of illnesses such as dehydration, or a serious urinary tract infection.
- Older adults who have fallen are at higher risk for a future fall. Although it’s a good idea for any older person to be proactive about identifying and reducing fall risk factors,it’s vital to do this well after a fall.
- Busy doctors may not be thorough unless caregivers are proactive about asking questions. Most doctors have the best intentions, but studies have shown that older patients often don’t get recommended care. By being politely proactive, you can make sure that certain things aren’t overlooked (such as medications that worsen balance).
All too often, a
medical visit after a fall is mainly about addressing any injuries that the
older person may have suffered.
Obviously, this is very important! However, if you want to help prevent future falls, it’s also important to make sure the doctors have checked on all the things that could have contributed to the fall.
Even if you’re pretty
sure your loved one just tripped and stumbled, a good evaluation can uncover
issues that made those trips and stumbles more likely.
In this post, I’ll
list eight key items that you can make sure the doctors check on, after a fall.
This will help you make sure your loved one has had a thorough work-up, and can
reduce the chance of future serious falls.
This list is partly
based on the American Geriatrics Society’s
Clinical Practice Guidelines on Preventing Falls.
8 Things the Doctors
Should Check After a Fall
1. An assessment for
underlying new illness.
Doctors almost always do this if an older person has been having generalized
weakness, delirium, or other signs
of feeling unwell. Be sure to bring up any symptoms you’ve noticed, and let the
doctor know how quickly the changes came on.
Just about any new health problem that makes an older person weak can bring on a fall. Some common ones include:
Just about any new health problem that makes an older person weak can bring on a fall. Some common ones include:
§ Urinary tract infection
§ Dehydration
§ Anemia (low red blood cell count), which can
be brought on by bleeding in the bowel or by other causes
§ Pneumonia
§ Heart problems such as atrial fibrillation
§ Strokes, including mini-strokes that don’t cause
weakness on one side
2. A blood pressure
and pulse reading when sitting, and when standing. This is especially important if you’ve been
worried about falls — or near falls — that are associated with
light-headedness, or fainting.
If your older loved takes blood pressure medication, you should make sure the doctor confirms that he or she isn’t experiencing a drop in blood pressure with standing. (Note that tamsulosin — brand name Flomax — is a popular prostate medication that also causes drops in blood pressure.)
If your older loved takes blood pressure medication, you should make sure the doctor confirms that he or she isn’t experiencing a drop in blood pressure with standing. (Note that tamsulosin — brand name Flomax — is a popular prostate medication that also causes drops in blood pressure.)
A 2009 study of Medicare patients
coming to the emergency room after fainting found that checking
sitting and standing blood pressure was the most useful test. However, it was
only done by doctors 1/3 of the time.
3. Blood tests. Checking an older person’s blood tests is
often a good idea after a fall. Falls can be worsened by problems with an older
person’s blood count, or by things like blood sodium getting too high or too
low.
Generally, a complete
blood cell count (CBC) and a check of electrolytes and kidney function
(metabolic panel, or “chem-7″) are a good place to start.
Be sure to ask to the
doctor to explain any abnormalities found in the blood work, whether they might
be related to falls, and how the doctor plans to address them.
If your loved one has
diabetes and takes insulin or other medications to lower blood sugar, be sure
to bring in the glucometer or a blood sugar log. Episodes of low blood sugar
(hypoglycemia) are an important risk factor for falls, but a laboratory blood
test generally doesn’t show moments of low blood sugar.
4. Medications
review. Many older adults are
taking medications that increase fall risk. These medications can often be
reduced, or even eliminated. Be sure to ask the doctor to address the following
types of medications:
§ Any sedatives, tranquilizers, or sleeping
medications. Common examples
include zolpidem (Ambien) for sleep, or lorazepam (Ativan) for anxiety.
Antipsychotic medications for restless dementia behaviors, such as risperidone
or quetiapine, can also increase sedation and fall risk.
§ Blood pressure and diabetes medications. As noted above, it’s not unusual for older
adults to be “over-treated” for these conditions, meaning they are taking a
level of medication that causes the blood pressure (or blood sugar) be lower
than is really necessary for ideal health.
§ “Anticholinergic” medications. These medications are commonly taken by
older adults, who often have no idea that these medications worsen balance and
thinking! They include medications for allergies, overactive bladder, vertigo,
nausea, and certain types of antidepressants which may also be given for nerve
pain. For a good list of anticholinergics to try to avoid, click here.
§ Opiate pain medications, especially if they are new.
5. Gait and
balance. At a minimum, a gait
assessment means that the doctor carefully watches the way the older person is
walking. There are also some simple ways to check balance.
Simple things to do,
if gait and balance don’t seem completely fine, are:
1. Address any pain or discomfort, if that seems to be a cause of problems.
Many older people are reacting to pain in their feet, joints, or back.
2. Consider a physical therapy referral for gait
and balance assessment.
A physical therapist can often recommend suitable strengthening exercises, and
also can help fit the older person for an assistive device (e.g. a walker) if
appropriate.
6. Vitamin D
level. Studies suggest that
treating low vitamin D levels (e.g. less than 20ng/mL) might help reduce falls
in older adults. Low vitamin D levels can also contribute to fragile bones.
If your loved one
spends a lot of time indoors, doesn’t take vitamin D supplements, and hasn’t
been checked for low vitamin D, you should ask the doctor to consider this
test.
Note: I generally recommend
my patients take 800-1000IU of Vitamin D per day, unless we have documented a
severe deficiency that would warrant temporary high-dose treatment. I don’t
recommend people take high doses of Vitamin D (e.g. 2000 IU or more) without
medical supervision.
7. Evaluation for
underlying heart conditions or neurological conditions. These chronic conditions are different from
the “acute” types of illnesses that we usually look for right after a fall.
In a minority of
cases, an older person may be falling because he or she has developed a chronic
problem with the heart or blood pressure system. An example of this would beparoxysmal rapid atrial
fibrillation, which causes the heart to sometimes race.
It’s also possible for
older people to develop a new chronic neurological condition, such as
Parkinson’s disease.
If you’re worried
about these possibilities, ask the doctor “Do you think a heart condition might
have caused this fall? Or do you think an underlying neurological condition
could have caused this fall?”
It’s particularly
useful for you to ask about these kinds of problems if the falls or
near-falls keep happening, especially if you’ve already minimized risky
medications and over-treatment of high blood pressure.
8. Vision, podiatry,
and home safety referrals. Could your loved one be in need of a vision check,
podiatry care, or a home safety evaluation? If you’ve brought an older person
in after a fall, it’s a good idea to talk to the doctor about whether these
services might help.
I especially recommend home safety evaluations, if they are available
in your area. Vision checks are also an excellent idea if the older person
hasn’t had one recently. |
| Leslie Kernisan, MD MPH |
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