Aging & Health A to Z

Falls Prevention

Unique to Older Adults

This section provides information to help older adults and their caregivers consider their disease or condition in conjunction with other health issues.

As older adults live longer, they may have more than one chronic disease.  Or, they may have a health problem that can lead to another condition or injury if not properly managed.   The older adult may also experience healthcare in various settings, such as the hospital, assisted living facility or at home.  These situations can affect the health and function of the older adult and therefore require careful management to ensure proper care and improve or maintain quality of life.

Balance, Gait Training, and Muscle Strengthening Exercises
As part of your fall prevention program, you should follow an exercise program designed to address your need for improved skills in walking (gait), balance, coordination, and to increase your muscle strength, especially in your legs and feet. Check with your doctor before starting any exercise program, and ask him or her for recommendations. Programs can vary from once a week to three or more times per week, and sessions vary in length. Whatever you choose, it should be tailored to your own specific needs, and be combined with other strategies to reduce falls, like improving nutrition, reducing medications, and making your home safer.

Research has shown that the following programs are effective for older people, either as individualized home exercise routines, or group exercise programs:

• Balance exercises
• Strength training (resistance training)
• Flexibility training (muscle and joint stretching exercises)
• Tai chi
• Cardiovascular, endurance, and fitness training 

All exercise programs designed to reduce falls should include a regular review of your progress. As you become more secure and physically strong, the exercises can be adjusted to maximize their benefits. 

Sensory Disorders: Vision, Hearing, Numbness
Aging is often linked to vision and hearing loss.  It is also sometimes linked to decreased nerve function in the skin, leading to lack of feeling (numbness), especially in feet. Research has shown that all of these problems increase our risk of falling.

Vision

As you get older, your sight (visual acuity) and depth perception gets worse. Many older adults use glasses for reading or seeing distances by the time we reach 65 years of age, and often we need both types. Scientists have found that corrective eyeglasses may reduce fall risk, although it is important to use extra care until you are very comfortable and used to your new glasses. If you are visually impaired, there are specialized programs that train you to get around safely to reduce the impact on your daily activities.

 But aging may also bring on cataracts, macular degeneration (loss of central vision), glaucoma, and other conditions that make it harder to see clearly. If you have any of these conditions, your vision can be improved with glasses, medicines, or special equipment, training, or even  controlled medically. You should make sure that you tell your doctor any time you notice any change in your vision. He or she should assess your vision regularly at your check-ups, and order treatment as soon as possible for anything that can be improved.

• Cataracts. An outpatient surgery is usually all that is necessary to remove your cataracts. Cataract removal reduces your likelihood of falling.
• Macular degeneration. Some types can be stopped before they proceed too farwith injections of a special type of medication. Others are untreatable. But even in severe cases, peripheral (side) vision usually remains. Special lenses and devices allow many people to continue to live active lives, watch TV, and even read.
• Glaucoma. This condition is caused by high pressure in the eye which damages the optic nerve. It can be treated with prescription drops into the eye or surgery. But many people have no symptoms, and therefore you must be properly checked at least every two years to rule out this frequent cause of blindness.

Hearing

About one-third of people over 65 and half of people over the age of 85 have hearing problems. Hearing loss has been associated with a higher risk for falls, and makes it harder to:

• understand people’s speech, including instructions from healthcare providers
• hear alarms and warnings
• use the telephone
• socialize

Your healthcare professional can remove excess wax build-up in your ears, which may have been making it harder to hear. You should also have your hearing checked by a licensed professional (such as an audiologist or otolaryngologist) if you feel that it is not as good as it used to be. Many types of hearing aids are now available and are very effective. Other kinds of devices can be very helpful for different situations.

Numbness

As you get older, you may develop a painless, decreased sensitivity to touch known as neuropathy. This is often a complication of diabetes but may occur on its own. If it affects feet and legs, neuropathy can be an important risk factor for falling.

Some neuropathies can be treated once your doctor has identified the cause. Therefore it is important to let your healthcare professional know if you notice a loss of feeling in your feet or hands. Unfortunately, if your numbness is simply age-related, there may be no medical treatment at this time. 

Use of Assistive Devices
If you are having difficulty with walking, balance, coordination, reaching for things, or other activities of daily living, your healthcare professional can refer you to a trained physiotherapist or occupational therapist. These specialists can provide resources, information and training in the use of all types of devices.  These canmake life simpler and allow you to function more normally. Among the most commonly used devices are:

• canes
• walkers
• reachers (to pick up items without bending over)
• hand rails, grab bars, raised toilet seats in the bathroom.

Reduce Medication Whenever Possible
Older people are much more likely to use many prescription and over-the-counter drugs, as well as herbal and alternative preparations than their younger counterparts. Many medicines increase the risk of a fall, and drug-drug interactions may also increase risk. If you have a higher risk of falling, your doctor will try to stop as many of these medications as possible, change them to other types, or at least reduce the dosages, particularly if you are taking more than four different ones. Any changes must be monitored carefully by your healthcare professional. The following approaches will help:

• Sleep medications. Keep sleep medications to a minimum and follow your doctors instructions carefully. Many older people find that their sleeping habits change as they get older. They may sleep less and don’t feel rested in the morning. Unfortunately, sleep medicines are strongly associated with falling. The problem is compounded if you drink alcohol as well. Follow instructions about good sleep hygiene to improve your sleep without medicines.
• Manage medication side effects. Learn about the possible side effects and interactions of your medicines, and make sure that your doctor is informed of anything, especially if you feel dizzy, confused, or unsteady on your feet. If you are taking medications that reduce bone health, such as steroids or anti-seizure drugs, ask about reducing the dosage. Follow your doctor’s orders regarding reduction or elimination of your medications. 

Osteoporosis Evaluation
To assess your bone strength, your doctor will send you for a densitometry screening. This painless test will measure your bone mineral density (BMD), which tells you how much calcium is in your bones. A low BMD means you may have osteopenia or even osteoporosis, which puts you at high risk of fracture if you fall.

Control of Blood Pressure
Some frail older people experience a sudden drop in blood pressure when they stand up after lying down, or if they have been lying or sitting down for a while. This is known as postural hypotension, a condition that often results in serious falls and injuries.

Tell your healthcare professional if you have ever experienced dizziness or a feeling of fainting or blacking out when you stand up quickly. He or she will check your blood pressureand test your heart rate, rhythm and circulation. If an arrhythmia or slow heart rate is discovered, you may benefit from a pacemaker, which keeps your heart beating at a healthy regular rate. Your medications may also be causing some of these symptoms, and may need some adjustment. Some medications are also available that increase blood pressure. Your healthcare professional will know if this is right for you.

Your healthcare professional may also suggest changes to your diet, including increasing fluids, letting you eat more salt if that’s appropriate, and drinking coffee at meals if your blood pressure dips after eating.

Avoiding Tight Control of Blood Sugars in Frail Diabetics
For adult diabetic patients, the usual target blood level for a crucial marker, hemoglobin (Hb) A1c, is 7%. Doctors aim for this kind of blood sugar control (glycemic control) in order to avoid complications of diabetes such as stroke and blindness. But for older, frail adults, such strict sugar control has been questioned by several groups, such as Veterans Affairs, the American Diabetes Association, and the American Geriatrics Society.

The complications of diabetes take many years of poor sugar control to develop. Research has suggested that new residents of nursing homes are not likely to live long enough for their diabetes to advance to these stages. Also, very tight sugar control is not easy to accomplish. It involves a strict diet, frequent finger sticks, insulin injections, many medications, and the possibility of the blood sugar level becoming too low. Low blood sugar is itself linked to high risk of falling.

Frail older adults must focus on maintaining their weight and eating a robust diet in order to keep bones and muscles strong to reduce the risk and perils of a fall. Also, frequent injections and blood sampling can be very alarming to older patients who are suffering from dementia. Taking the many medications required to keep blood sugar control requires organization and discipline that is often not possible for frail older patients. For frail older people with diabetes, along with other serious diseases and a limited life expectancy, quality of life is a primary goal of care. Strict sugar control may not be the best approach. A more relaxed sugar control may also improve brain function,  and lower other side effects of treatment. If you or someone you care for is an older, frail diabetic adult, discuss the need for strict glycemic control with your doctor.

Optimizing Nutrition to Prevent Weight Loss
As we get older, it becomes more challenging to to eat a healthy diet. This may lead to malnutrition, a risk factor for increased risk of falling. For example, as you age, you may:

• have illnesses that make it hard to shop for and prepare food (e.g., arthritis, Alzheimer’s disease) or be housebound
• have difficulty chewing because of poor dental health (reducing intake of fresh vegetables, some meats, etc)
• have less appetite because of depression, lack of exercise or other activities
• be more isolated and see friends less, especially after losing a spouse
• lose your sense of taste and smell, making food less appetizing
• be on a restricted diet (for example, low-salt diet) that decreases the taste of food.

The medicines that you are more likely to take as you get older can also have an impact on your ability to digest and absorb nutrients from your food. Medications can:

• reduce your appetite
• upset your stomach (give you heartburn or ‘acid stomach’)
• decrease absorption (for example, mineral oil laxatives prevent vitamins from being absorbed).

Older adults who are not active need to consume enough food to stay strong. If you are a frail older person, you may benefit from a number of simple strategies to enable you to get those calories and counteract any new difficulties.

Optimizing Management of Congestive Heart Failure and COPD
Congestive Heart Failure (CHF)
Many older people develop progressive and incurable heart failure at the end of their lives. In CHF, your heart no longer has the strength to pump blood throughout your body, especially when you exercise. In heart failure, fluids are retained and you may develop fluid retention and swelling in your feet, ankles, and legs, making it even more difficult to walk. People with CHF also cough frequently, gain weight because of the retained fluids, have fast inefficient heartbeat, and feel very weak, light-headed, or faint. They may also be less alert and nauseated. All of these symptoms can lead to a fall.

The best management of CHF involves close monitoring by your healthcare professionals, with frequent appointments (every few months) and tests, such as echocardiograms. You must also keep close tabs on yourself, checking your weight every day to watch for water retention. 

Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is a common lung disease that makes breathing very difficult, and occurs mostly in older people. It is also progressive, with no cure. COPD is usually a combination of chronic bronchitis— a cough with mucus, and emphysema— in which the lungs are slowly destroyed. Smoking is the main cause. You may not get COPD if you smoke, but it is very rare for a non-smoker to develop the disease.

COPD reduces the amount of oxygen circulating in your blood and brain, and causes heart rhythm problems. Therefore you are at high risk of falling as a result of dizziness or blacking out if you have COPD.

Evaluating and Correcting Anemia when Possible
Your healthcare professional may discover that you are anemic from a routine blood screening or from symptoms you may have. Anemia means you don’t have enough red blood cells to carry oxygen to all parts of your body. Anemia may be caused by a number of things, including vitamin B12 deficiency, iron deficiency, or many other conditions. Many of these are much more common in older people.

Anemia can cause lightheadedness, dizziness, and fatigue which are risk factors for falls, as well as headaches, chest pain, and shortness of breath. Your doctor will do tests to find out the cause of the anemia, and then prescribe treatments. Depending on the cause, these may include:

• Supplements such as iron, folate, vitamin B12
• Surgery, to repair blood loss (stomach ulcers, etc)
• Medication adjustments, since some cause anemia as a side effect
• Blood transfusions
• Steroids or other drugs. 

Evaluating and Optimally Managing Parkinson’s Disease
Parkinson’s disease, which is more common in older people, kills the cells in the brain that produce dopamine. Dopamine is a neurotransmitter that allows messages to transfer from one brain cell to another. Without it, we can no longer control our muscles. There are many symptoms of the disease but the ones that increase the risk of falling include muscle stiffness and pain, difficulty starting or continuing a movement, slower and jerky movements, tremors (shaking), stooped position, rigid limbs.  In later stages, the mind may be affected, bringing confusion, hallucinations, depression, and even dementia.

Management: There’s no cure for Parkinson’s disease, but it can be controlled to some extent by drug treatments that increase the brain’s dopamine levels. Very rarely, surgery may be used, or an implant that produces deep brain stimulation (DBS). Your doctor will adjust drug dosages and prescriptions to get the best possible control, but there is usually a time during the day when the drugs wear off and symptoms return. Close monitoring and communications with your healthcare professionals will keep symptoms and side effects to a minimum for as long as possible. The most common medicines for Parkinson’s disease are:

• Rasagiline (Azilect), selegiline (Eldepryl, Deprenyl.  To increase small amounts of natural dopamine levels
• Carbidopa/levodopa (Sinemet). To supplement the dopamine deficiency with synthetic levadopa
• Pramipexole (Mirapex), ropinirole (Requip), bromocriptine (Parlodel). To act as a partial substitute for dopamine
• Amantadine (Symmetrel), trihexyphenidyl (Artane).  To reduce early or mild tremors only
• Entacapone (Comtan). To prevent the breakdown of levodopa.

Some of the side effects include hallucinations and delirium. These can cause a fall. Make sure to let your doctor know if you have experienced any side effects such as these so that he can adjust your medications and reduce your falling risk. 

Last Updated: March 2012
Posted:  March 2012