Nitin K Sethi, MD
Assistant Professor of Neurology
New York-Presbyterian Hospital
Weill Cornell Medical Center
New York, NY 10065
FALLS ARE COMMON IN THE ELDERLY!!!
Falls are common in neurodegenerative conditions so that is what I shall discuss in this post. Patients with diseases like Alzheimer’s dementia, fronto-temporal dementia (Pick’s disease), multi-infarct dementia (vascular dementia), Parkinson’s disease, multiple sclerosis, Progressive Supranuclear Palsy and some post stroke patients are all prone to falls either early or sometime in their disease course.
FALLS CAUSE MORBIDITY AND MORTALITY!!!
Falls are an important cause of morbidity and mortality in this vulnerable population. Imagine a-85-year old man with Alzheimer’s dementia. Even though he has cognitive deficits (decreased memory and problems with other cognitive skills like calculation, abstract thinking and language) he is still relatively mobile. Every day he takes a 30 min walk in his immediate neighbourhood. One day while walking, he trips over and falls when his foot gets caught in a crack in the side-walk. He is unable to get up by himself . Help only reaches him after an hour when his family comes looking for him. He is rushed to the nearest hospital where an X-ray reveals fracture of the hip and the pelvis. Surgical management is indicated for fracture stabilization. He is admitted to the hospital and the hospital course gets complicated by development of pressure sores (bed sores), deep venous thrombosis (blood clots in the veins of the legs) and pulmonary embolism (blood clot in the lung vasculature). All these are directly related to his forced immobilization due to hip and pelvic fractures. He gets progressively more disoriented during his prolonged hospital stay though survives and makes a slow recovery and is discharged to a sub-acute facility.
FALLS HURT AND CAUSE INJURIES!!!
Falls may lead to various injuries:
1) Fractures of the hips, long bones: tibia, fibula, femur, neck of femur, radius, ulna
2) Neurotrauma: head injuries: subdural and epidural hematomas, sub arachnoid hemorrhage, intracranial hemorrhage (bleeding into the brain)
3) Craniofacial injuries: injuries to the face, eyes, the orbit
4) Fractures of the ribs
5) Back injuries
THE STATISTICS ARE SCARY!!!!
The incidence of hip fracture increases as the population ages. One in five persons dies in the first year after sustaining a hip fracture, and of those who survive past one year many have significant functional limitation. Of those who survive one year after hip fracture, only 40 percent can perform all routine activities of daily living and only 54 percent can walk without an aid.
WHY DO THE ELDERLY FALL???
Why are falls common in the elderly and more so in the elderly population with a neurodegenerative condition? The causes are many:
1) Poor eye-sight (as we age cataracts and other retinal degenerative conditions become common contributing to poor eye-sight). They have poor depth perception and visual contrast sensitivity.
2) decreased acuity of hearing
3) concomitant neuropathy (many of the elderly population may have a condition like diabetes giving rise to a concomitant peripheral neuropathy. Persons with a sensory motor polyneuropathy are not able to sense the ground and thus their righting reflex is off). RIGHTING REFLEX: various reflexes that tend to bring the body into normal position in space and resist forces acting to displace it out of normal position.
4) Neurological conditions like Parkinson’s disease and Alzheimer’s dementia impair these postural reflexes/ righting reflexes making patients even more prone to falls and resultant injuries.
5) The elderly are on multiple medications like benzodiazepines, anticonvulsants, sedatives and antihypertensives which may contribute to the falls.
6) Risk of osteoporosis and osteopenia increases as we age: when the elderly fall they are more likely to hurt themselves or fracture their bones.
7) Other concomitant medical conditions like diabetes, kidney problems, thyroid problems, blood pressure problems and cardiac problems may contribute to the falls.
WHAT CAN BE DONE?
The big question is how to prevent falls in the elderly. A number of interventions may help.
1) Treat the neurodegenerative/ underlying condition contributing to the falls. Gait and postural reflexes of patients with Parkinson’s disease improve when they are treated with medications like Levodopa-carbidopa and dopamine agonist. The response though varies, their tremor may improve though their gait may still remain off.
Good control of blood sugar in a diabetic patient helps and may halt the progression of the neuropathy.
Alzheimer’s disease patients also gain some benefit in their gait and mobility when they are treated with medications like Aricept.
2) Correct visual/ eye problems: timely cataract surgery, corrective lenses and glasses all help in improving stability and confidence of the elderly patient.
3) Hearing aids may be of help in those who have hearing loss.
4) Restriction of outdoor activities may be advisable in a patient who is at high risk of falls. If that is not acceptable, these activities should be carried out under direct supervision. Keep a walking partner etc.
5) Correct mechanical/ musculoskeletal gait problems such as ingrown toe nail, back and hip pain, foot drop etc.
6) Regular exercise is helpful. By keeping muscles supple and maintaining their tone it ensures that righting reflexes are not lost.
7) Physical therapy may be immensely helpful in some patients (laying emphasis on gait retraining).
8) Use of assist devices like canes (single point, four point), walker is helpful.
9) Fall proof the home and immediate patient surroundings: remove anything which may cause injury if the patient falls-this includes sharp objects, tables with sharp edges, loose carpets.
have fall prevention devices at the top of stairs.
have a bed whose sides can be put at night (just like in the hospital).
have an alarm or some other call device set-up at home so that help can be summoned.
Last but not least” MOST FALLS OCCUR TO AND FROM THE BED TO THE BATHROOM AT NIGHT, SO LEAVE THE BATHROOM LIGHT ON AT NIGHT!!!”
Braindisease's Weblog 
Thank you for your article “Fall in Neurodegenerative Conditions”. After conducting training seminars in 11 states for health care workers in long term care facilities, I am encouraged to get the word out. Benevolent Ballet-Fall Prevention for the Elderly is a unique approach to exercise. The integratiion of music with exercises is especially effective for those with neuro muscular difficulty. The program was developed to address several quality of life concerns.
1. First of all, we all know that exercise is important to maintain mobility and to reduce the risk of falls.
2. We also know that it is often difficult to engage the elderly in activities. Motivating the frail elderly or those with Alzheimer’s or other dementias is especially difficult.
3. Although staff tries to provide their residents with joyful moments, it can be very challenging with the frail elderly who may be apathetic, withdrawn, depressed, angry or anxious.
The exercises (chair and standing if capable) are adapted to the physical and cognitive ability of the participants. The use of classical and semi classical music adds an enriching arts component to the program and improves the quality of movement. The program can be implemented in community settings, or nursing and assisted living facilities.The Benevolent Ballet-Fall Prevention for the Elderly program builds on the residents retained strengths including their appreciation of music,beauty and humor. The staff training includes approaches to communicating with and inspiring the residents to participate and to do so to the best of their physical and cognitive ability.
As for my background, I was trained to teach in London at the Royal Ballet School. After a forty year career of working with populations ranging from the very gifted to those with physical and mental challenges it was suggested that I develop a program for the elderly. The idea being that through the magic of classical music and movement the elderly (even those with Alzheimer’s and other dementias) would be motivated to participate. It works!