(This article appeared previously on BetterHealthWhileAging.net.)
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
1. Signs of 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:
- Urinary tract infection
- Anemia (low red blood cell count), which can be brought on by bleeding in the bowel or by other causes
- 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 relative 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 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 done by doctors only one-third 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 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. 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 “overtreated” 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 they worsen balance and thinking. They include medications for allergies, overactive bladder, vertigo, nausea and certain types of antidepressants that may also be given for nerve pain. For more on identifying and avoiding anticholinergics, see 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:
- 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.
- 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. For more on the proven Otago physical therapy program to reduce falls — including videos demonstrating the exercises — see “Otago and Proven Exercises for Fall Prevention.”
6. Vitamin D level. Studies suggest that treating low vitamin D levels (less than 20ng/mL) might help reduce falls in older adults. Low vitamin D levels can also contribute to fragile bones.
If your older loved one spends a lot of time indoors and doesn’t take a daily vitamin D supplement, there is a fairly high chance of having a low vitamin D level. Taking a daily supplement of 800 to 1000 IU will eventually maintain vitamin D at a normal level in most people, but if you are very concerned about falls or vitamin D, talk to your doctor about getting a level checked.
When vitamin D levels are very low, doctors sometimes treat with higher doses of vitamin D for a few months.
Note: I generally recommend my patients take 800 to 1000 IU 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 (2000 IU/day 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 be paroxysmal 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 overtreatment of high blood pressure.
8. Vision, podiatry and home safety. Could your loved one be in need of avision 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.
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