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.
Falls and Other Medical Conditions
Managing Congestive Heart Failure (CHF)
Many older people develop heart failure at the end of their lives. This condition cannot be cured, and it gets worse as time goes on. When you have CHF, your heart no longer has the strength to pump blood throughout your body, especially when you exercise. Fluids are kept in the body and you may develop swelling in your feet, ankles, and legs. This makes it even more difficult to walk. People with CHF also cough often, gain weight because of the retained fluids, have fast and inefficient heartbeats, and feel very weak, light-headed, or faint. They may also be less alert and feel nauseated. All of these symptoms can lead to a fall.
The best management of CHF involves close monitoring by your healthcare providers, with 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.
Managing 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 has no cure, and gets worse with time. COPD is usually a combination of chronic bronchitis and emphysema. Chronic bronchitis is when you have a reoccurring cough with mucus that lasts a long time. Emphysema is a disease where the lungs are slowly destroyed. Smoking is the main cause of COPD. 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 because of dizziness or blacking out if you have COPD.
Evaluating and Correcting Anemia when Possible
Anemia means you do not 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. Your healthcare provider may find out that you are anemic from a routine blood screening or from symptoms you may have.
Anemia can cause symptoms that are risk factors for falls, including lightheadedness, dizziness, and fatigue. It can also cause headaches, chest pain, and shortness of breath. Your healthcare provider 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, or vitamin B12
- Surgery to repair blood loss (for problems such as stomach ulcers)
- Medication adjustments, since some cause anemia as a side effect
- Blood transfusions
- Steroids or other medications
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. The symptoms that increase the risk of falling include muscle stiffness and pain, difficulty starting or continuing a movement, slower and jerky movements, shaking (tremors), stooped (curved) position, and rigid limbs. In later stages, the mind may be affected, bringing confusion, hallucinations, depression, and even dementia.
There is no cure for Parkinson’s disease, but it can be controlled to some amount by drug treatments that increase the brain’s dopamine levels. Very rarely, surgery may be used, or an implant that produces deep brain stimulation. Your healthcare provider will adjust your medication dosages and prescriptions to get the best possible control. However, there is usually a time during the day when the medications wear off and symptoms return. You can keep symptoms and side effects to a minimum for as long as possible through close monitoring and communication with your healthcare providers. Some of the side effects include hallucinations and delirium. These can cause a fall. Make sure to let your provider know if you have experienced any side effects like these so that your medications can be adjusted to reduce your falling risk.
Falls and Medication Management
Reduce Medication Whenever Possible
Older people are much more likely than younger people to use many prescription and over-the-counter medications, as well as herbal and alternative preparations. Many medicines increase the risk of a fall, and interactions between drugs may also increase risk. If you have a higher risk of falling, your healthcare provider will try to manage your medications. This may include having you stop as many of these medications as possible, change them to other types of medications, or at least reduce the dosages, particularly if you are taking more than four different ones. Any changes must be checked carefully by your healthcare provider. The following approaches will help:
Keep sleep medications to a minimum and follow your provider’s instructions carefully. Many older people find that their sleeping habits change as they get older. They may sleep less and do not feel rested in the morning. Unfortunately, sleep medicines are strongly associated with falling. The problem is also made worse if you drink alcohol. 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 healthcare provider is informed of everything, especially if you feel dizzy, confused, or unsteady on your feet. If you are taking medications that reduce bone health, ask about reducing the dosage. (These medications can include steroids or anti-seizure drugs.) Your provider may give you instructions to take less of a medication or stop it all together. Make sure to follow your provider’s orders about your medications.
Additional Health Problems Related to Falls
As you get older, your visual acuity (sight) and depth sense get 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 using corrective eyeglasses may reduce the risk of falls, 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 other conditions that make it harder to see clearly. These include cataracts, glaucoma, and macular degeneration (loss of central vision), among others. If you have any of these conditions, your vision may be able to be improved in different ways. These include wearing glasses, taking medicines, or using special equipment or training. You should make sure that you tell your healthcare provider any time you notice any change in your vision. Your provider should check your vision regularly at your appointments, and order treatment as soon as possible for anything that can be improved.
- Cataracts. Outpatient surgery is usually all that is necessary to remove your cataracts. Cataract removal reduces your likelihood of falling.
- Macular degeneration. Some types of macular degeneration can be stopped before they proceed too far, through receiving 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 with macular degeneration to continue to live active lives, watch TV, and even read.
- Glaucoma. This condition is caused by high pressure in the eye that damages the optic nerve. It can be treated by using prescription drops into the eye or even surgery. But many people have no symptoms, and therefore your eyes must be properly checked at least every two years to rule out this frequent cause of blindness.
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
Your healthcare provider can remove excess wax build-up in your ears, which may have been making it harder to hear. If you feel that your hearing is not as good as it used to be, you should also have your hearing checked by a licensed professional (such as an audiologist or otolaryngologist). Many types of hearing aids are now available and are very effective. Other kinds of devices can be very helpful for different situations.
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 your feet and legs, neuropathy can be a strong risk factor for falling.
Some neuropathies can be treated once your healthcare provider has found the cause. Therefore it is important to let them 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 for it at this time.
To measure 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 (moderate bone loss) or even osteoporosis (severe bone loss). These conditions put you at high risk of fractures 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 provider if you have ever experienced dizziness or a feeling of fainting or blacking out when you stand up quickly. They will check your blood pressure and test your heart rate, rhythm, and circulation. If an irregular or slow heart rate is discovered, you may benefit from a pacemaker. This device 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 provider will know if this is right for you.
Your provider may also suggest changes to your diet, such as including increasing fluids, eating more salt if that is appropriate, and drinking coffee at meals if your blood pressure dips after eating.
Avoiding Tight Control of Blood Sugars in Frail Diabetics
For diabetic patients, there is a crucial marker for blood sugar called hemoglobin (Hb) A1c. For adult diabetics, the target for HbA1c levels is 7%. Healthcare professionals aim for patients to have this kind of glycemic (blood sugar) control 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.
It takes many years of poor sugar control for the complications of diabetes 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 itself is linked to a high risk of falling.
Taking the many medications required to keep blood sugar under control requires organization and discipline. This is often not possible for frail older patients. Also, frequent injections and blood sampling can be very alarming to older patients who are suffering from dementia. Many frail older people with diabetes also have other serious diseases and a limited life expectancy. For these people, 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 the healthcare provider.
Optimizing Nutrition to Prevent Weight Loss
Frail older adults must focus on keeping their weight stable and eating a healthy diet. This helps keep bones and muscles strong, which can reduce the risk and dangers of a fall. As we get older, it becomes more challenging to eat a healthy diet. This may lead to malnutrition, which is 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 (such as arthritis or Alzheimer’s disease)
- be housebound
- have difficulty chewing because of poor dental health. This can reduce your intake of fresh vegetables, some meats, etc.
- have less appetite because of depression, or 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 that decreases the taste of food (for example, a low-salt diet)
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 several simple strategies that will help you to get those calories and counteract any new difficulties.
Last Updated August 2020