Walking confidently in the autumn of life | Daily News


Today is World Elders Day

Walking confidently in the autumn of life

The physical changes in the body inherent to ageing can reduce autonomy and functional independence which may directly or indirectly lead to a fall. Among the elderly, falls are one of the main causes of functional decline, injuries, hospital admission, psychological trauma and even death.

Q. What is the significance of a fall for the elderly?

A. The incidence of a fall increases as age advances. About one-third of people aged more than 65 years fall at least once each year. You could understand how common this problem is among the elderly population. Therefore, in geriatric medicine, falls are considered as one of the five geriatric giants out of intellectual impairment, immobility, urinary and faecal incontinence and medicine-related problems. Most of the time, a fall occurs as a result of more than one contributing factor. We could understand that the consequence of a fall in the elderly is a spectrum ranging from mild injury to grievous injury, even leading to death.

Q. What are the risk factors for falls?

A. A fall is often due to multiple interacting conditions that result in reducing tolerance to any type of external stress. I will explain common risk factors causing falls in the elderly. There is gender preponderance. Due to the differences in biophysiological changes happening in ageing, females are more prone to falls than males. Vision and hearing problems are common among the elderly. Those are leading contributing factors for falls as well as recurrent falls. Also due to loss of muscle mass, strength and function with the advancement of age, the condition which is called sarcopenia, they lose their functional capacity, especially mobility and balance. As a consequence, gait disturbances and reduced walking speed is common among elders ultimately leading to a fall even with a minor change in their surroundings.

Dr. Lasantha Ganewatta
MBBS (SL), MD (Colombo), FRCP (London),
MRCP (UK), DGM (Geriatrics) (UK), 
MRCP-SCE (Geriatrics) (UK)

Cognitive decline often occurs among older adults causing different levels and types of dementia. This is also an important predisposing factor for a fall as the elderly lose the understanding of their surrounding environment and acquire different visual and auditory hallucinations. In addition, sleep disturbances are common in people with dementia which results in wandering during the darkness leading to a fall.

Most of the elders suffer from multiple chronic illnesses such as diabetes mellitus, high blood pressure and heart diseases needing them to have a variety of medications. Multiple comorbidities per se lead to the decline in their in-built physiological reserve - the phenomenon called frailty, an independent risk factor for falls. On the other hand, because of these chronic illnesses, they are prescribed multiple medications causing numerous interactions and side effects leading to poor mobility, loss of balance, drowsiness and loss of energy, making them vulnerable to a fall.

As we know, bones and joints are very fragile in the elderly. Osteoarthritis in hip, knee and spine causes difficulty in walking and climbing stairs predisposing them to fall. There are many neurological problems happening with ageing leading to mobility problems. Among them, common conditions such as stroke, Parkinson’s disease and sensory impairment of feet influencing walking ability and balance of elderly individuals precipitate the risk of falls. Blackouts, fainting attacks, vertigo and lightheadedness are frequent medical problems in the elderly due to many factors. Those often precede falls in many community dwellings.

In addition, there are problems in urinary and faecal continence among older adults. Most of them cannot hold the requirement for a while until they walk to the toilet, especially males who suffer from prostate gland enlargement. They tend to fall when rushing to the toilet.

Environmental hazards are the other major contributory factors for falls both in their residence and in the public places. Home hazards include poor lighting, loose or absent railings, throw rugs, trailing cords and wires, uneven transitions such as level changes between rooms, lack of bars in bathrooms, slippery floors and cluttered walkways. In public places uneven and broken sidewalks, wet surface, irregular steps and unpredictable level changes lead to injurious falls. Due to poor muscle strength, impaired mobility and poor sensory input, they cannot adjust their reflexes according to the unexpected environmental changes.

All these risk factors are well known to all of us. There is another predisposing factor in the elderly which is a hidden problem, though it is common among them. That is the fear of falling (FoF).

Q. What is ‘Fear of Falling’?

A. Fear of falling is a major health problem among the elderly who live in communities which do not come out for the attention of family members or healthcare workers. Fear of falling presents in older people who have fallen and also in elderly people who have never experienced a fall. When an elderly person experiences a fall, they rapidly lose the confidence of walking and support of the surroundings. Probably you also would have noticed that when some elders walk, they strongly hold various objects in the vicinity showing great fear due to psychological distrust of falling.

Then there is a gradual decline in walking ability, mobility and balance. Psychological confidence is a major supportive factor for them to have a stable gait. With all diseases and disabilities happening in old age, as explained earlier, if they develop a fear of falling it is going to be a vicious cycle for recurrent incidence of falls. Due to various physical and psychological disabilities, as I explained earlier, some individuals develop a fear of falling even without a prior fall. As a result of this serious anxiety-related issue, elderly people try not to mobilise on many occasions which lead sometimes to permanently immobility.

Q. What are the consequences of falls?

A. There are many consequences of falls for the elderly, which are recognised as common indications needing hospitalisation. Some people end up with mild injuries. However, as osteoporosis is widely prevalent among them, bone fractures are frequently happening following falls. Of them, hip fractures lead to serious outcomes. Head injuries and brain bleeds are the other dangerous consequences of falls. In addition, pain, bruises and blood clots can occur following falls. Psychological fear of falling is also an unfavourable outcome of falls in the elderly.

Therefore, falls in the elderly is a costly health problem. As physicians, we know that when an older adult with a fracture is admitted to hospital following a fall, they acquire many other hospital-related problems, including pneumonia, bedsores and depression, leading to an increase in the length of hospital stay. Therefore, the family and caregiver burden too rises eventually. Sometimes they do not recover from those multiple medical problems and ultimately die due to hospital-acquired illnesses.

The doctor should evaluate the patient carefully to minimise the adverse consequence of falls.

Q. What are the basic evaluation steps in a fall?

A. Obtaining a complete history, circumstances and symptoms surrounding the fall and comprehensive physical examination by a physician is crucial. If the patient cannot give a history, obtaining a collateral history from a witness is important. Some of the circumstances that can point towards the cause of the fall include, sudden rise from a lying or sitting position leading to a sudden drop of blood pressure causing dizziness, trip or slip, looking upward or sideways causing compromise of brain blood flow, fainting attacks and blackouts.

Also, recent onset fever, urinary incontinence, cough and diarrhea-like symptoms pointing towards an infection causing a reduction in baseline mobility in the elderly and their cognitive functions lead to falls.

Evaluation of existing medications and recent changes in prescription is also important. Concomitant medical problems should be addressed carefully. Basic neurological assessment, joint and bone examination, and assessment of muscle strength are important steps in the evaluation process. Vision and hearing assessment should be performed at the beginning.

Testing of walking, balance and climbing steps is performed by a physiotherapist to have a sound idea about their mobility and disabilities.

Importantly, we need to have perfect knowledge about their home environment and surrounding. As explained earlier, there are many home and public hazards predisposing them to fall. Ideally, a home visit should be undertaken by an experienced occupational therapist to assess the problem properly.

Psychological assessment is also important to evaluate the fear of falling - the hidden problem among the elderly.

Q. How to prevent or minimise the possibility of a fall in the elderly?

A. Prevention is the best way to avoid injuries and other problems related to falls. Programmes for the prevention of falls should be introduced by the health authority to healthy adults who are mobilising well. Introducing regular exercise programmes to target strength, balance and flexibility are of paramount importance to recover muscle power and function in order to have confidence in walking and climbing stairs. We should encourage them to have nutritious meals rich in protein, calcium and vitamin D which need to strengthen the muscles and bones.

As physicians, we should always assess their medications and possible side effects in each medical consultation. They should only be given a minimum number of essential medications. Improving their sleep, reducing anxiety and treating depression have been shown to reduce the incidence of falls. Adequate hydration should be prompted always to improve mobility.

Walking, balancing and step assessment of the elderly who have some mobility problems should be carried out and the introduction of appropriate walking aids is important.

Their continence should be assessed and incontinent problems should be addressed properly.

The home environment needs proper assessment by a trained occupational therapist and necessary modifications should be carried out immediately to make it safe.

When an aged person is admitted in hospital following a fall and its complications, he or she needs to undergo the rehabilitation process.

Q. What do you mean by fall rehabilitation?

A. When we encounter elderly patients following a fall, it is important to rehabilitate them with the support of a multidisciplinary team mainly consisting of a physiotherapist, an occupational therapist, a nurse and a social service officer who provides some aids and equipment to modify the home environment. During the process of rehabilitation, they may be introduced with walking aids to improve their self-confidence. The ultimate objective of this assessment and rehabilitation is to make them independent in their basic activities of daily living and to have happy healthy ageing.

(Dr. Ganewatta is a Consultant Physician attached to the Health Ministry. Additionally, she obtained required qualifications in Geriatric (Elderly Care) Medicine from Royal College of Physicians, London and obtained on-the-job training attached to the Geriatric Medical Ward in Queens University Hospital, London, UK)

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