I watch my 11-month-old granddaughter attempt to walk. She grabs a bar of the crib and pulls herself to standing. She balances on one leg, and swings her other around, but she is reluctant to let go and take a step.
This reminds me that walking is a complex process made up of leg strength, balance and coordination.
I am appreciative of the ability to ambulate successfully at both ends of life — and of the important implications of being upright and mobile.
Chances are you know of loved ones or friends who have had serious injuries because of a fall, or you have fallen yourself. Earlier this year, actor Christopher Plummer died due to head trauma as a result of a fall at home.
According to the Centers for Disease Control and Prevention, 36 million older adults fall each year, and one-fifth of the falls result in broken bones or head injury.
Every year, 300,000 people older than 65 are hospitalized for hip fractures, 95 percent of which are caused by falling — usually by falling sideways. (Our hip joints are designed to withstand vertical stress, not horizontal stress.) Women experience three-quarters of all hip fractures because they fall more often than men, and because they are more likely to have osteoporosis.
Although falling increases with age, don’t assume this should be expected. There are numerous risks factors for falling, so I like to think about this topic in terms of intrinsic risks (originating within the person) and extrinsic risks (environmental).
To evaluate intrinsic risks of falling, I ask patients about previous falls and assess if there are underlying conditions such as Parkinson’s disease, diabetes, cognitive impairment or other disorders that predispose them to unsteadiness.
These other factors may include poor vision (such as from cataracts), alcohol use, leg weakness, neuropathy, balance problems, arthritis, vitamin-D deficiency or lack of exercise. Certain medications such as sleeping pills, antihistamines and blood pressure meds may increase the chance of falling.
My physical exam focuses on checking blood pressure sitting and standing, and evaluating gait, strength and balance. If a patient has not had a recent vision check, I will make a referral to optometry.
A simple functional test is called “Timed Up and Go,” or TUG. The patient sits in a chair, and when I say, “Go,” the patient stands up, walks to a line 10 feet away at their usual pace, turns around, walks back to the chair and sits down. If this takes more than 12 seconds to complete, this indicates a higher risk of falling.
To assess extrinsic factors, I ask patients about their home environment, which is where most falls occur. I inquire about loose rugs, clutter, home lighting, handrails on stairways and whether their shoes have nonslip soles.
After my assessment, I provide advice to prevent falls.
Exercise is highest on the list of recommendations. Any exercise that improves leg strength, flexibility and balance is helpful. This can include aerobics (like walking or cycling), resistance training, tai chi or yoga.
I also advise patients to safety-proof their environment, which may include placing nightlights in the bedroom and hallway, installing grab bars in the bathroom, having double-sided railings on stairs, avoiding wearing socks on hardwood floors and being sensible about attempting risky activities. (For example, I stopped cleaning gutters on my roof 10 years ago.)
As needed, I will advise some patients to use an assistive device such as a cane or walker. Other medical recommendations may include reducing or eliminating medications which cause dizziness, drowsiness or hypotension.
Mainly for women, I will check a bone density test to evaluate if there is osteoporosis. Before recommending calcium and vitamin D supplements, I often check calcium and vitamin D blood levels.
The time and energy it takes to recover from a serious fall is enormous compared to the effort to prevent one, but too often doctors and patients think about this only retrospectively.
As you can see, there are many things in our control to prevent a fall or serious injury from one. Walking without falling is a precious skill, a skill that I hope all of us can preserve throughout our life.