Learning objectives
- •
Recognize common environmental hazards increasing the risk of falls.
- •
Identify modifiable risk factors that increase the risk of repeated falls and fractures.
The case study
Reason for seeking medical help
TC is a 76-year-old Caucasian woman referred because she had 3 accidental falls about 4 weeks ago while visiting her daughter, son-in-law, and grandchildren. She sustained extensive superficial injuries but did not fracture any bone. She is now back home and is concerned about these falls, especially as she is known to have osteoporosis. Her lowest T-score was −2.8 in the left femoral neck and she is being treated for osteoporosis. Otherwise, she is known to be in good health. She is receiving zoledronic acid (Reclast) yearly infusions since her diagnosis of osteoporosis just over 2 years ago. She is tolerating it well, but is concerned about the repeated falls she sustained.
Past medical/surgical history
- •
Surgical menopause age 48, 2 years of hormonal replacement therapy.
- •
Fractured right wrist in her 30s doing step aerobics class.
Lifestyle
- •
Sedentary lifestyle. She does not exercise regularly.
- •
Works in her house, including cleaning and cooking.
- •
Babysits her 3-year-old grandson five days a week.
- •
She does not drink milk: she thinks she has lactose intolerance.
- •
She has one cup of coffee every day.
Medication(s)
- •
Vitamin D3 1000 IU daily.
- •
Calcium carbonate 1200 mg daily.
- •
Multivitamin daily.
- •
Reclast IV yearly; she has received two infusions. The next one is scheduled in about 9 months.
- •
Atorvastatin 10 mg daily.
Family history
- •
Positive for osteoporosis, mother sustained a distal radius fracture after minimal trauma: sliding on the wet floor in her bathroom.
Clinical examination
- •
Weight: 132 lbs; height: 64″, mild kyphosis.
- •
Mild osteoarthritic changes in both hands and knees. No pain. No limitation in the range of motion.
Laboratory results
- •
CMP and CBC: within normal limits.
- •
Serum 25-hydroxy-vitamin D: 45 ng/mL.
Multiple choice questions
- 1.
TC’s most recent fall was about two weeks ago. She was wearing her slippers, carrying a laundry basket, and fell down three steps in her basement. She did not sustain a fracture but was badly bruised and is afraid of sustaining more falls.
Recommendations for TC should include:
- A.
Avoid carrying large objects while going downstairs, if possible.
- B.
Wear appropriate footwear when going down the stairs to the basement.
- C.
Referral for a physical therapy evaluation to improve strength and balance.
- D.
Make sure lighting is adequate before going downstairs.
- E.
All of the above.
Correct answer: E
Comment:
It is important to assess extrinsic factors that can cause a hazardous environment for patients such as TC. The stairs to her basement, especially if she cannot see them clearly, are an obvious risk factor, along with her loose ill-fitting slippers. In addition, she was carrying something so large that she could not see clearly the areas immediately surrounding her feet when she fell. Recommending her to use rubber-soled footwear for going up and down to the basement or any slippery surface will improve her traction on the steps. Having someone to help her carry laundry up and down or if she uses smaller baskets to transfer clothes can also decrease her risk factors.
Given TC’s bruising, it is important to keep in mind that abuse could be a contributing factor to falls.
- A.
- 2.
TC states that this is her fourth fall in a year. She is now fearful she will fall again. Risk factors for falls include:
- A.
Balance and gait issues, joint disorders, muscle weakness.
- B.
Poor vision.
- C.
Impaired cognition.
- D.
Environmental causes.
- E.
All of the above.
Correct answer: E
Comment:
Balance and gait issues, poor vision, impaired cognition, and environmental causes are all risk factors for falls in older people. In TC’s case, environmental causes seem to be the main cause of her most recent falls. However, impaired balance, localized muscle weakness, impaired vision and cognition should all be assessed to ascertain if they also contributed to her fall.
Patients can get easily in a vicious cycle with repeated falls: by decreasing their physical activity, their muscle strength and coordination are decreased, they feel unsteady, limit the amount of physical exercise performed, which in turn causes their muscles waste and they end up further increasing the risk of falling. TC needs to break the fall cycle as soon as possible before muscular atrophy starts to develop.
Several additional risk factors include loose rugs, pets, and especially clutter. Rugs, especially small ones, that are not properly secured to the floor can also cause tripping or sliding, leading to a fall.
Small pets, such as cats and dogs, can get underfoot or larger dogs can jump and knock an individual over. Lighting is often a big issue as older individuals often have trouble with cataracts. Bright lights, however, can also cause glare. Low lighting creates a dark environment, making it difficult to see items in their pathway. In addition, clutter can also create an environmental hazard, increasing the fall risk.
- A.
- 3.
Fracture Risk Assessment can be performed to determine a patient’s risk of sustaining a fracture in the next 10 years. Risk factors included in the FRAX score are as follows:
- A.
BMD of femoral neck.
- B.
Age.
- C.
Previous fracture.
- D.
Current smoker.
- E.
All of the above.
Correct answer: E
Comment:
Given that most fractures are preceded by falls, and that most falls are not followed by fractures, clinicians have an ideal opportunity of identifying and quantifying the risk of falls. Once a fall has occurred, the patient’s fracture risk is elevated. Several algorithms are available to identify and quantify the risk of falls. The FRAX instrument incorporates multiple factors to determine a patient’s 10-year probability of sustaining a major osteoporotic fracture and a hip fracture. It can be calculated with or without the bone mineral density and is typically used to determine if a patient with osteopenia should receive pharmacologic treatment for osteopenia or if a nonpharmacologic treatment approach is best. The FRAX algorithm is best used in addition to a thorough clinical assessment and history and not a stand-alone tool, unless it is for screening purposes.
- A.
- 4.
TC has sustained several falls in the past few months and is now fearful she will fall again. She is experiencing the postanxiety fall syndrome. The following is/are correct:
- A.
Repeated falls may lead to a fear of falling: the patients decrease their physical activity, which causes a loss of muscle bulk, decreased strength, impaired balance, and poor coordination. This leads to decreased overall function and increases the risk of the patient sustaining another fall.
- B.
An anxiolytic is needed.
- C.
The use of a walking aid such as a cane or walker should be discussed with the patient.
- D.
Patients should be referred for physical therapy to improve their balance.
- E.
A, C, and D.
Correct answer: E
Comment:
The postfall anxiety syndrome: Multiple falls can create an anxiety/fear cycle: a fall also can lead to avoidance of activities perceived as activities that may increase the risk of falling, which in turn leads to loss of muscular strength, balance, and coordination and further decreases in physical functions.
It is important to break this cycle. If TC continues to reduce her degree of physical activity due to fear, she may increase the rate of her bone and muscle mass loss. Patients need physical therapy to help improve their balance. Thoroughly assessing the causes and pattern of falls and modifying risks factors should help decrease the anxiety experienced about falls.
A walker or a three- or four-pronged cane may be appealing to the patient. Single-pronged canes are not recommended as they may increase rather than decrease the patient’s stability. The risk with anxiolytics is clouding of consciousness and impaired coordination, which may in turn increase the risk of sustaining falls.
- A.
- 5.
With any fall, it is important to obtain a complete account if possible. Important factors to determine include:
- A.
Symptoms developing immediately prior to the fall such as lightheaded, dizziness, and palpitations.
- B.
Activity involved in when the fall occurred: walking, climbing a ladder, going down steps.
- C.
Location of the fall: where do the fall tend to occur and how the patients land.
- D.
Injuries associated with the fall.
- E.
All of the above.
Correct answer: E
Comment:
A thorough assessment of events occurring immediately prior to the fall, during the fall, and postfall will help identify many risk factors for repeated falls. If any factor is modifiable, it can be addressed immediately in order to help prevent a recurrence. Also, if someone witnesses the fall, the witness can help add details as the patient does not always have a clear memory of the events leading up to, during, and after the fall. TC did not experience any endogenous factor related to her fall. These are discussed in another case in this series.
- A.
- 6.
Recommendations to increase muscular strength and balance following a fall include:
- A.
Home-based exercise program with a physical therapist.
- B.
Gym-based exercise program with a personal trainer.
- C.
In-office exercise classes.
- D.
No exercises are recommended.
- E.
A, B, and C.
Correct answer: E
Comment:
Following a fall, a home-based exercise program led by a physical therapist is the best intervention to improve strength. Patients can graduate to a gym-based program with a personal trainer if they so desire and have the financial means to accommodate this. A more accessible option is an in-home program with the goal of continuing the exercises even after the sessions have ended. Strength and balance training should continue for fall prevention.
- A.
- 7.
Modifiable risk factors in relation to osteoporosis that increase the fracture risk:
- A.
Malnutrition.
- B.
Alcohol abuse.
- C.
Regular intake of over-the-counter hypnotics.
- D.
Bifocal eyeglasses.
- E.
All of the above.
Correct answer: E
Comment:
Malnutrition can contribute to an increased fall risk and osteoporosis. A well-balanced diet is essential. Similarly, excessive salt, caffeine, and phosphoric acid induce a negative calcium balance and cause bone demineralization. It is important to address these modifiable risk factors with TC to help improve her osteoporosis and hopefully prevent a fracture should she sustain another fall in the future. Alcohol is better avoided, although one drink daily for women and two drinks for men appear to have a protective effect on the skeleton. It is, however, not clear whether it is the alcohol itself or the lifestyle associated with moderate alcohol intake that is beneficial. An excessive alcohol intake, however, has a negative effect.
Over-the-counter hypnotics increase the risk of falls and fractures as many hypnotics cloud the sensorium and interfere with neuromuscular coordination.
Bifocal eyeglasses increase the risk of fall and fractures. Patients, for instance, may experience difficulties finding the switch of the bedside lights, and selecting the correct eyeglasses at a time when a number of neural signals originating in the distended urinary bladder and retinas are streaming to the cerebral cortex.
- A.
- 8.
Tools to assess the fall/fracture risk include:
- A.
Falls efficacy scale.
- B.
Vulnerable elder survey.
- C.
Get-up-and-Go test.
- D.
STEADI initiative (stopping elderly accidents, death, and injuries).
- E.
All of the above.
Correct answer: E
Comment:
According to the CDC, more than 95% of hip fractures in older adults are caused by falls. Given this substantial risk, it is important to know what tools are available to help guide a fall risk assessment on a patient to hopefully avoid further falls and potential for hip fracture.
The Falls Efficacy Scale (FES) is one way to assess the fall risk, based on a self-assessment focused on ADLs, such as dressing, bathing, and walking around the house, and asks patients to rate their confidence level in performing these activities.
The Vulnerable Elder Survey (VES) also addresses ADLs but asks if the patients are unable to perform the task, if it is due to health or another reason entirely. VES also includes questions regarding needing help managing money, walking, bathing, lifting items, and crouching.
The Timed Get-up-and-Go (TUG) test is an in-office test to see how long it takes the patient to go from the seated position to standing without using arm rests, walking 3 m or 10 ft before returning to sitting down. An older adult who takes 12 or more seconds to complete this task is at an increased risk of falling. Patients may use a waking aid during the task. TUG test should be used in conjunction with other testing or clinical exam as a predictor of falls. This test is objective versus the previous surveys that rely more on patients’ self-assessments.
The STEADI initiative developed by CDC focuses on screening, assessing, and intervening for fall risk in adults 65 and older. The TUG test is included in the assessment as well as polypharmacy, home hazards, and orthostatic blood pressure. The STEADI initiative considers multiple factors including intrinsic and extrinsic factors, clinical data, and clinical assessment to help the provider develop an individualized plan for fall intervention.
- A.
- 9.
Elderly patients who fall typically fall:
- A.
Backwards.
- B.
Sideways.
- C.
Forward.
- D.
A and B.
- E.
A, B, and C.
Correct answer: D
Comment:
Elderly patients typically fall backwards or sideways versus younger people who tend to fall forward and therefore may catch themselves with their hands to reduce the impact of the fall. This is a reason why hip fractures are more common in the elderly population.
Also, as individuals age their proprioception decreases and they tend to have more problems with stability. According to a study on adapted Utilitarian Judo, teaching patients how to fall backwards and sideways and get back decreased their fear of falling. This study, however, included a very limited number of participants and needs further exploration, but is a good starting point in improving outcomes with falls and overcoming the fear of falling.
- A.
- 10.
Assistive technology that helps prevent falls includes:
- A.
Motion-activated lighting.
- B.
Walking aids: 4- or 3-pronged canes, walkers, rollators.
- C.
Reaching aids.
- D.
Virtual reality games.
- E.
All of the above.
Correct answer: E
Comment:
Motion-activated lighting will illuminate the space to decrease the chances of falls. Walking aids provide stability if patients are unsteady when walking. “Reachers” or “grabbers” help patients reach objects without having to overstretch and increase the risk of falls. Virtual reality games can also help increase awareness about environmental hazards. Falls Sensei is a 3D virtual reality game that educates older adults about environmental hazards which can increase the risk of fall.
- A.
Case summary
Analysis of data
Factors predisposing to bone demineralization/osteoporosis in Mrs. TC’s case
- •
Surgical menopause age 48.
- •
Positive family history.
- •
No regular exercise.
Factors reducing to bone demineralization/osteoporosis
- •
Zoledronic acid (Reclast) yearly IV infusion.
- •
Daily calcium tablet.
- •
Involved in house activities.
Facts increasing risk of falls/fractures
- •
Several recent falls.
Diagnosis
- •
Osteoporosis.
Management recommendations
Treatment recommendations
- •
Continue annual zoledronic acid (Reclast) IV infusions, for at least 2 years. Then reevaluate the patient to determine whether or not to continue with zoledronic acid (Reclast).
Diagnostic test(s)
- •
None needed at this stage.
Lifestyle
- •
Incorporate and develop a regular exercise program.
Rehabilitation
- •
Physical therapy to help with balance.
DXA and radiologic
- •
Repeat DXA scan in 2 years.
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