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Every year more than fall and sustain serious injury, costing in excess of 3 billion
dollars. Hidden costs include pain, disability, lawsuits, deterioration
in general well-being, and the impact on other family members.
Falls and the resulting injuries have become one of the elderly's
most serious health issues. As our senior population continues
to grow, falls and their consequences will increase in the future.
 The
accumulation of injuries throughout life change or damage the
central nervous system (CNS) and the body as a whole, and our
bodies deteriorate through inactivity. Vision diminishes with
advancing age, and this directly effects the sensory systems
involved with movement. The sensory cells in the ears' balance
system change, gradually decrease and cannot be replaced. The
nerves that carry sensory information to the brain from the muscles,
joints and skin can also deteriorate with age, and the complex
brain interconnections lose connecting fibers and nerve cells.
The ability of nerve endings to generate the chemicals responsible
for the transmission of information also seem to be affected
by aging. This process accelerates after the age of 50.
Many diseases affect the CNS and sense organs. Hardening of
the arteries (atherosclerosis) is probably the worst; it is accelerated
by hypertension, smoking, and diabetes. Although it gradually
increases during middle age, there is a point at which a slight
additional decrease in blood flow causes serious vascular impairment
such as a stroke.
Head injuries, sometimes caused by falls, can damage the sense
organs in the inner ears, or the brain itself. The worst disability
occurs when both sense organs and CNS structures are damaged
simultaneously. Physical activity is very important for recovery
from injury to the sensory systems. The general debility of aging
can negatively affect recovery if it results in a decreased level
of activity.
Diseases of the eyes, such as glaucoma and cataracts, decrease
visual sensory function and are a common problem in old age.
Injuries to the knees, hips, and back often do not completely
heal, leaving some limitation of motion. Arthritis can cause
permanent crippling, nonreversible effects. Osteoporosis leads
to bone weakness and increases the probability of serious injury
from a fall, or might cause a spontaneous fracture and lead to
a fall. Muscle strength gradually decreases with age. Joint tendons
and ligaments lose their flexibility and limit motion. The combined
ravages of bone and joint injury, arthritis, and inactivity can
result in a body which cannot carry out motion commands initiated
by the brain.
 As many of the problems responsible for falling
develop during early and middle age, initial efforts to prevent
injuries must be aimed at younger age groups. Many of the changes
in muscle, bone and the central nervous system are not inevitable
results of aging, but are brought on by inactive lifestyles and
self-inflicted damage from smoking, poor diet, and lack of exercise.
Although hardening of the arteries is occasionally hereditary,
in most cases it can be reduced by diets low in cholesterol and
saturated fatty acids, as well as regular physical exercise.
This stimulates the muscles as well as the cardiovascular system
and could greatly reduce this problem. If there is a family history
of hardening of the arteries, medications to lower cholesterol
are available. Early diagnosis and treatment of diabetes mellitus
and hypertension can make a difference in the progression of
arthrosclerosis. Smoking cessation might also help reduce this
disorder.
Many of the medications used to treat hypertension, heart disease,
allergy, insomnia, stomach acidity, and depression have side
effects which influence brain function and can increase the likelihood
of falling. In this time of specialization it is possible for
one patient to receive prescriptions from several physicians
that might have additive side effects on brain and sensory function.
Patients should keep a complete list of all their medications
and dosages, and make this list available to each physician they
consult. Coordination of all medications through a single primary
care physician would help avoid adverse drug reactions. Many
pharmacies use computer systems to warn the pharmacist about
potential drug interactions. This requires that the patient purchase
all medications from the same pharmacy or list all medications
with each pharmacy. Unfortunately some over-the-counter medications
such as antihistamines, sleeping medications, analgesics, and
cough suppressants can add to the side effects of prescription
medications. Alcohol also affects movement and judgement and
adversely interacts with many medications.
- Have your vision and hearing checked regularly. If your
vision and hearing are impaired, you may lose important cues
that help you maintain your balance.
- Get up slowly. A momentary
drop in blood pressure, due to drugs or aging, can cause
dizziness if you stand up too quickly.
- Maintain balance and
footing. If you sometimes feel dizzy, use a cane or walker
to help you to keep your balance on uneven ground or slippery
surfaces. Wear sturdy, low-heeled shoes with wide, nonslip
soles.
- Exercise regularly. Regular exercise improves your
strength, muscle tone, and coordination. This can not only
help prevent falls, it can reduce the severity of injury
if you do fall. Walking is a good form of exercise.
- Remove raised doorway thresholds in all rooms. Rearrange
furniture, if necessary, to keep electrical cords and furniture
out of walking paths. Fasten area carpets to the floor with
tape or tacks, and don't use throw rugs.
- Don't use difficult
to reach shelves. Never stand on a chair. Use nonskid floor
wax and wipe up spills immediately.
- Be sure stairways are
well lighted and have sturdy hand rails. If you have a vision
problem apply brightly colored tape to the first and last
steps.
- Install grab handles and nonskid mats inside and just
outside your shower and tub, and near the toilet. Shower
chairs and bath benches minimize the risk of falling.
- Put
a light switch by the bedroom door and by your bed so you
don't have to walk across the room to turn on a light. Night
lights in your bedrooms, halls, and bathrooms are a good idea.
What about patients who have already fallen? Although rehabilitation
is not perfected, much can be done.
- The first task is a thorough and complete evaluation of
the patient's sensory, CNS, and muscle/joint function.
- A careful
evaluation of the balance function should be performed. This
includes a search for causes of dizziness, such as inner ear diseases
that cause imbalance: an evaluation of the inner ear balance system
which might be adversely affected by certain drugs (such as
a class of antibiotics known as aminoglycosides); trauma; and
the aging process.
- Tests of higher mental function are important
since falling may be a sign of serious mental deterioration.
- A careful review of all medications (both prescription and
over-the-counter) used by the patient is very important.
If the patient needs medication for anxiety or depression,
switching from a long-acting drug to one which is more quickly
passed from the body seems to decrease the risk of falling.
All correctable problems should be treated. Visual correction
with proper eyeglasses, improvement of hearing by hearing aids,
adjustment or elimination of medications, and correction of hypertension
or any other disease that could impair balance must be accomplished.
Rehabilitation includes increasing the range of motion as well
as physical strength. A very important part of rehabilitation
is helping patients overcome their fear of falling and thus avoid
further injury. Walkers and canes can aid stability, and adaptations
in the home are important. Simple changes such as installing
hand holds in bathrooms or along walls could decrease the likelihood
of falling and increase patient confidence. Removing the patient
from a familiar environment, or drastically changing it, often
hampers recovery.
As soon as possible, rehabilitation should be moved to an outpatient
setting with participation of family members and home support
groups. Rapid return to physical activity and social interaction
with family and community can often stop the vicious spiral into
inactivity, reclusiveness, and progressive deterioration.
© 2004 AAO-HNS/AAO-HNSF
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