Monday, June 3, 2013

Falling is Death. How can we prevent it?

This post is meant for older individuals, those over the age of 65, or their family/caretaker.

By the way, any products I note below, are just because they fit
what I thought worked. 
I get absolutely no money from anybody for any of this.

I can't tell you how many times I talk about falling concerns in my patients; patients with stroke-related weakness, Parkinson's disease, MS, dementia in all its forms.... The increased fall risk is actually a combination of things usually: age-related fragility, poor eyesight, dizziness, neuropathy, bad knees & slow arms at catching oneself.

But I think most people don't realize what happens when an older person falls. Not only do they bruise themselves thoroughly, get poorly-healing abrasions, pull muscles & tendons, torque their back, and get subdural hematomas crushing their brain, and fracture their wrists, but they quite often get hip fractures

Hip fractures are surprisingly more common than people realize.
 87% to 96% of hip fracture patients are 65 years of age or older.  
Hip fractures after a fall, while more common in women due to greater prevalences of osteopenia and osteoporosis, are slightly more mortal in men. 
Half the people who fall and have ANY injury, never return home and end up spending their remaining days in a nursing home. The hip-injury group is even higher.

But let's talk about mortality:

-After a hip fracture, the 1 year mortality is 27%
-After a hip fracture, the 3.7 year mortality (length of follow up in one study that followed 428 patients) is 80% (This is a 3-fold higher chance of dying than the general population)
-The most common cause of death was circulatory diseases 

Another very large study, which compiles a bunch of other studies (called a meta-analysis) from 2010 compiled the information from hip fracture mortality studies (22 cohort studies in women and 17 in men), age 50 and older with hip fractures.  Survival curves were compared between them and a group of people of the same age and gender who did NOT have a hip fracture.

The hip fracture group had a 5- to 8-fold increased risk for all-cause mortality during the first 3 months after hip fracture. Excess annual mortality persists over time for both women and men.

OK. So if you or your loved one are somewhere between 3 and 8 times more likely to die from the complications of a hip fracture, then how can we prevent that?

Most falls occur at home, not out in public, so securing the home is paramount.

Here is my advice:

1. Keep a diary of any new symptoms on a monthly calendar, not a piece of scratch paper. A calendar gives a more visual connection to symptoms, often easier to correlate to any recent medication changes or other general health changes. It's amazing how subtle things can lead to hip fractures: I saw a woman three months ago who had nausea from a recent simple medication change lead to decreased appetite & thirst which lead to increased dizziness which lead to a fall and hip fracture. She is still in a rehabilitation center instead of comfortably in her own home.

2. Install grab bars in the shower and next to the toilet. If there is even a remote chance of falls, you can bring this up with your primary care physician, and they will gladly consult a home health company who will come out and evaluate your fall risk and install grab bars, paid for by Medicare and most private insurance companies. 

3. Use non-slip rubber mats in the bathtub and shower. They are cheap and easy to install. The grittier the better, but you may want to install them in the front half of the shower/bathtub (where most people stand to shower anyway) so that they won't be too rough on the patient's underside should they take a bath later.

4. Keep your home well lit at night (when you are NOT going to bed).

5. Once going to bed, do NOT keep a bedside lamp or overhead light on all night long. Keeping lights on like this all night long only adds to poor sleep quality and sleepiness during the day. 

I also don't even care for bright night lights like the one pictured just below:

--I like the fact that it senses when it's dark, so automatically comes on, but I don't like the fact that it is "megabrite" without a direction down onto the carpet, which means it's going to shine all over the room as a source of light pollution which can hurt night vision and interfere with sleep quality since our brain responds strongly to such light pollution (our circadian rhythm).

 I recommend the following night light; one that has these elements:
-- motion sensor which is not on any longer than it needs to be, just enough to help walking to and from the restroom
-- the ability to tilt the direction of light down to the ground instead of diffusely into the room more broadly
-- LED lights which will last and don't require frequent bulb changes

6. Remove thick or shaggy decorative rugs and replace with no rugs or at least very thin rugs heavy-weight rugs less likely to be caught be a misstep or get tangled up in a misplaced foot. Double-sided tape should also be used to secure the corners and lengths/widths. One patient of mine took regular-ole' duck tape and folded it over for cheap double-sided tape.

7. Eliminate clutter from the room: paperwork, Tupperware boxes, electrical cords.

8. Remove knee-high clutter: coffee tables, tea tables, trunks & chests, extra chairs, awkwardly-protruding lamp stands.

9. Don't store commonly used things too high or too low. Too high causes people to do silly things like stand on chairs or balance precariously on tiptoes. Too low causes people to topple over while reaching down, or toppling over when trying to lift a cumbersome box, or get dizzy when they stand back up and topple over at that point.

10. Wear sturdy shoes with non-skid soles

11. Wear non-skid slipper socks at night if you have wooden floors or wooden floors in the kitchen, often visited for a sip of water during the night. You can see below, they are not expensive at all.

12. Have a ground line phone at each level, or at the very least, a cradle with an attached cord near the master bed where the cellphone rests each night. In case there is a fall, the person can (yikes!) possibly drag themselves to the phone to pull the cord and get to the phone to call for help, so they might not languish on the floor in the same spot with a broken hip overnight, or for a day or longer depending on their situation. 

13. Use liquid soap from a secured dispenser mounted on the wall or in a secured cradle. I have had patients fall as they bend over to pick up the dropped soap or even stepping on the dropped soap.

14. Keep a large amount of space between pieces of furniture so that the person's gait can remain wide instead of getting unnaturally narrowed. 

15. Steps: They should be well-lit with down-casting night lights that automatically come on when it gets dark, and even though it looks gaudy, should have bright tape on the edges, so that the edges can be easily visualized when the person is going down AND up the stairs.

16. Lastly, make sure the cane(s) being used around the house are approved by and discussed with a physical therapist. EVERY doctor will be willing to have you see a physical therapist if there is a potential fall risk and especially if you ask. And the physical therapist will be more than willing to help you pick out and learn to wield the best cane for EVERY situation. I see people with the wrong cane (and often dangerous) for them all the time.