Learning objectives
- •
Recognize endogenous causes of repeated falls.
- •
Alcohol and over-the-counter medications that increase the fall risk.
The case study
Reason for seeking medical help
- •
AB was referred to the office after having sustained six falls in the last 6 months. His wife is concerned that he is at risk of sustaining fractures. He has osteopenia, as evidenced by a T-score of −1.6 in his left femoral neck. His FRAX scores are 15% and 3.5% for the risks of sustaining a major or hip/femoral neck fracture. He is being treated with alendronate 70 mg weekly.
Past medical/surgical history
- •
Benign prostatic hyperplasia.
- •
History of basal cell skin cancer.
- •
Right knee replacement 2008.
- •
Arthritis left hip.
- •
Seasonal allergies.
Personal habits
- •
No cigarette smoking.
- •
No excessive sodium.
- •
Drinks two cups of coffee a day and an occasional glass of sweet tea.
- •
Drinks one beer a couple days of week.
- •
Enjoys milk daily.
- •
Walks most days for about half an hour with his wife and dog.
Medication(s)
- •
Flomax 0.4 mg daily.
- •
Atorvastatin 10 mg daily.
- •
Vitamin D3 1000 units daily.
- •
Multivitamin daily.
- •
Melatonin 3 mg at bedtime as needed.
- •
Tylenol arthritis as needed.
Family history
- •
Positive for osteoporosis, older sister has no fractures.
- •
Positive for cardiovascular disease, father and brother have coronary artery disease.
Clinical examination
- •
Weight: 148 lbs., height: 71″.
- •
Mild kyphosis, mostly postural.
- •
Clinical examination does not reveal any significant clinical finding.
Laboratory results
- •
CMP: WNL, except GFR 59 mL/min.
- •
Serum 25-hydroxy-vitamin D: 46 ng/mL.
Multiple choice questions
Multiple disease processes can increase the risk of falls in the elderly. Arthropathies can cause gait imbalance due to pain. AB has a history of a knee replacement and has arthritis in his left hip that can cause a shift in his center of gravity as he ambulates and subsequently changes his overall gait.
His cognitive status is important to ascertain as confusion can lead to risky behavior, such as climbing ladders, walking up and down the stairs, without paying due attention to the stairs or activities he would normally avoid as they may increase the risk of sustaining a fall.
Cardiovascular disorders, such as orthostatic hypotension or arrhythmias, can also cause the patient to have dizziness upon standing. About 40% of older adults with cardiovascular disease experience orthostatic hypotension.
Frequent urination as with BPH or a UTI can make the patient hurry to reach the bathroom in time and may trip over various objects.
- 1.
Other endogenous factors to consider include:
- A.
Medications.
- B.
Visual impairment.
- C.
Sedentary lifestyle.
- D.
Vestibular diseases.
- E.
All of the above.
Correct answer: E
Comment:
In older people repeated falls often have a multifactorial etiology. Preventing them is aimed at decreasing as many of the modifiable risk factors as possible. Medications, such as hypnotics, sedatives, hypotensives, and diuretics, can all contribute and increase the risk for falls. Visual impairment, especially cataracts and bifocal eyeglasses, can add to the decreased or distorted perception of the environment and may lead to multiple falls. Sedentary lifestyles decrease muscular strength and can lead to muscle wasting. Vestibular diseases make patients dizzy and unstable, increasing their risk of falls.
- A.
- 2.
His last fall occurred in the middle of the night as he was going to the bathroom. He remembers heading to the bathroom to micturate and the next thing he knew he was lying on the floor. Luckily his wife was able to help him up and he did not sustain any serious injuries. Aside from environmental factors, AB can decrease the risk of sustaining another fall by:
- A.
Discontinuing melatonin use.
- B.
Gait and strength evaluation to determine if physical therapy is needed.
- C.
Limiting his fluid intake late in the evening and at night to decrease the number of times he needs to use the bathroom at night.
- D.
Consider the use of a urinal at night.
- E.
All of the above.
Correct answer: E
Comment:
If AB has decreased strength or pain in the legs and/or an abnormal gait, these can contribute to his likelihood of having another fall. Limiting his fluid intake could potentially decrease the need for urination during the night. It is nevertheless important to balance this by making sure he is properly hydrated during the day to prevent dehydration. If AB is having a marked decrease in blood pressure, i.e. a drop of 20 mm or more in the systolic and/or diastolic blood pressure upon rising from the bed associated with dizziness, this increases the fall risk.
Research regarding melatonin is limited. Discontinuing it may be appropriate if AB feels groggier or sedated when he takes it.
- A.
- 3.
AB states that he experiences nocturia and typically needs to urinate 3–4 times per night. He usually goes to bed around 10 pm and wakes up at about 3 am but has difficulties falling back asleep after he urinates. An additional concern regarding his frequent urination is:
- A.
Disrupted circadian rhythm that may potentially increase the risk of falls.
- B.
He probably will need to nap during the day, as his sleep is less restful.
- C.
He may have a urinary tract infection.
- D.
A and B.
- E.
All of the above.
Correct answer: E
Comment:
A dysregulated sleep cycle can lead to orthostatic intolerance and further lead to falls. It can also lead to cognitive decline. Melatonin plays an important role in the sleep/wake cycle which tends to decrease with age. Decreases in melatonin also may be linked with bone loss and subsequent osteoporosis.
- A.
- 4.
The following is/are true:
- A.
A number of home-based exercise programs are available.
- B.
Home-based strength and retraining programs significantly reduce the rate of subsequent falls.
- C.
Adverse events included falls, injuries, and muscle soreness related to the exercise intervention.
- D.
All of the above.
- E.
None of the above
Correct answer: D
Comment:
All the above are true. Their success is probably dependent on a number of factors including expertise and availability of staff to man such home-based strength and retraining programs.
- A.
- 5.
During his visit AB reveals that he often drinks a beer on the nights he has more trouble sleeping. His normal routine is to get up and drink at least another beer before going back to bed. Important points to remember:
- A.
Older adults are affected more rapidly and to a larger extent by alcohol than women.
- B.
Melatonin may interfere with the sleep/wake periods.
- C.
Beer increases the risk of nocturia.
- D.
A and C.
- E.
All of the above.
Correct answer: E
Comment:
AB is having at least one beer on nights he is unable to sleep but may be having up to three beers on some nights. This will affect his coordination and gait, making him at increased risk for falls. The alcohol will also increase his nocturia. Adding a dose of melatonin with the alcohol may compound the problem by further impairing his cognition, gait, and reaction time, making his walk to the bathroom more dangerous. Melatonin research with regard to falls is somewhat limited at this time.
- A.
- 6.
Interventions to decrease the fall risk for AB include:
- A.
Develop a sleep routine.
- B.
Limit alcohol intake before going to bed.
- C.
Limit/discontinue melatonin use.
- D.
Physical exercise.
- E.
All of the above.
Correct answer: E
Comment:
As previously discussed, alcohol is harder to process in older adults. Limiting AB’s intake to 1 beer and disassociating it from being considered a sleep aid will help with his cognition and balance, especially if he has polyuria at night. Creating an environment conducive to sleep, blackout curtains, cooler temperatures in his bedroom, consistent bedtimes, and limiting blue light exposure at nighttime should help with his ability to drift off to sleep. Melatonin use, while it can help reset his sleep/wake cycle, may impair his coordination and leave him more susceptible to sustaining repeated falls.
Then, lastly, AB should be encouraged to remain awake during the day and to exercise as much as possible. Several exercises can be done while seated. Walking along the corridors during the day may help. The more he is able to move, within his abilities, the better he will sleep. Slowly increasing the distance walked will help strengthen the skeleton and increasing muscle mass. Also, exposure to sunlight will naturally help his circadian rhythm, which diminishes as age increases. AB, however, needs to be cautious about the amount of sun exposure as he has a history of skin cancer.
- A.
- 7.
AB also reveals he occasionally takes Benadryl for sleep. He states at least once a week he will have a dose of Benadryl, usually after a particularly bad night. Adverse effects of antihistamines include:
- A.
Increased fall risk.
- B.
Aggravated prostatic hypertrophy.
- C.
Dizziness and impaired coordination.
- D.
Blurred vision.
- E.
All of the above.
Correct answer: E
Comment:
Anticholinergic medications can increase the risk of falls by all of the above. In addition, anticholinergic use, greater than 3 months, increases the risk of dementia in older individuals. Given AB’s recurrent falls, benign prostatic hypertrophy, nocturia, and age, he should discontinue any further Benadryl use. It is also important to avoid analgesics with sedative effects as these can also contribute to an increased risk of falls.
- A.
- 8.
AB’s evaluation reveals he has orthostatic hypotension: His supine blood pressure is 130/72, dropping to on standing of 95/65 standing up. Standing up induces dizziness and unsteadiness. The following is appropriate:
- A.
Stop tamsulosin (Flomax).
- B.
Continue Flomax and monitor his orthostatic hypotension.
- C.
Caution him of the use of Flomax because of his orthostatic hypotension.
- D.
Evaluate his need for Flomax, his symptom relief, and his degree of orthostatic hypotension and subsequent fall/fracture risk.
- E.
B and C.
Correct answer: D
Comment:
The best option for AB is to evaluate the effectiveness of Flomax. If there is an appropriate alternative for him that does not have the same risk factors, then discontinuing it and starting a new medication is preferable. If Flomax is not relieving his symptoms, he can discontinue it and then be reevaluated for orthostatic hypotension. Given his recurrent falls, it is important to decrease any dizziness or unsteadiness related to medication use if possible.
- A.
- 9.
AB is found to have peripheral neuropathy after a thorough history, laboratory studies, and clinical exam. Peripheral neuropathy:
- A.
Increases AB’s fall risk.
- B.
Can impair AB’s dynamic balance.
- C.
Can be addressed with physical therapy.
- D.
A and B.
- E.
All of the above.
Correct answer: E
Comment:
Peripheral neuropathy results in muscle weakness and balance and gait disturbance. Physical therapy can be used to address the effects of peripheral neuropathy in the lower limbs.
- A.
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