December 19, 2011

Falling is a frightening but all too common experience for elderly patients. The unpredictable nature of falling makes it a difficult problem clinically. Falling even has its own ICD-9 code (E888.9). Hip and wrist fractures are common resulting injuries, as are black eyes, broken glasses, broken noses, and injured pride. Even if patients are lucky enough to avoid injury, falling is an embarrassment that causes many patients to avoid going out.

I fell once in my office parking lot, and it didn’t help my self-esteem a bit. I’m not sure if I was admiring the blue sky or my head was in a cloud, but either way I didn’t have my eyes on the ground when my foot caught a concrete parking stop. I lurched forward a few feet, lost my balance, and fell face forward, bloodying one palm and one elbow. It wasn’t much fun, and I wondered how I would explain myself as I slunk through the back door of my office. The nurse discreetly bandaged my wounds, and an early-morning drug representative cooed sympathetically.

Among the many factors that contribute to falls are old age, weakness, muscle atrophy, arthritis, and medications. Many arthritis patients can’t take nonsteroidal anti-inflammatory drugs because of such contraindications as GI issues, chronic kidney disease, or concomitant treatment with anticoagulants to name a few. Given that arthritis patients frequently don’t get sufficient pain relief from acetaminophen, they end up using opioids for management of chronic pain. These medications can contribute to dizziness, decreased alertness, and falls. Many other categories of medication contribute to dizziness and falls, including medications used for hypertension, neuropathy, anxiety, and depression. Domestic hazards include items such as loose rugs or slippery floors. Even pets or small children can be risk factors since they sometimes get tangled up in the frail legs of patients who no longer have the agility to rapidly compensate if they stumble.

A patient of mine in his 90s recently fell down the three stairs outside his back door. He landed on a concrete landing and stayed there until his son found him. Although he didn’t break his neck as the emergency department personnel had initially suspected, he had an orbital fracture and diplopia. When he was in his 70s he had been a champion skeet shooter. Men were men, and skeet were nervous. He had to give up skeet shooting because osteoarthritis in his knees prevented the rapid pivoting necessary to shoot skeet out of the sky. Those glory days are gone, and now he would be happy to be able to walk without falling. He sat in his wheelchair with his son at his side telling me the sad story of his mishap. His son had a younger version of his father’s face, and both faces expressed a worried concern about the future.

Another patient, age 70, told me a scary story about multiple falls in the 6-month interval since his last visit. My patient didn’t seem worried, or if he was concerned, he was doing a good job of keeping a poker face. He blamed the falls on his left knee "giving out." His radiographs showed advanced osteoarthritis in both knees. On his way out, I asked him if he would consider using a cane. He said he would consider it, but it was obvious that his answer really meant he would think about my advice the next time he dusted himself off after a fall.

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