Falls

A healthy 72-years old, a friend’s mother, stepped outside the home into a gap between two paver stones on the footpath, stumbled, fell, broke her hip, was operated within 48-hours but just couldn’t get back to her normal routine, deteriorated physically and mentally and died 14 months later.

This is not an uncommon story. Many of you have likely already faced such situations, either with yourselves or with elders in the family and realized how devastating falls and fall related injuries and their aftermaths can be.

The 2011 Census reported 104 million people in India above the age of 60, grown to around 139.5 million in 2020 (10.1% of the population), including 91 million above the age of 65 (6.57%) and  52.5 million above the age of 70, (3.8%) of the population.

Worldwide, the incidence of falls in 2017 was 172 million. In India, the estimated incidence was 22 million falls(accounting for 12.7% of all global falls) across all ages. Falls are now the 10th commonest cause of death in India and around 220,000 people across all ages died of falls or fall-related complications in 2019.

While good data from India is limited, one recent review suggested a fall rate of around 31% [1] in those over the age of 60, paralleling data from the US where 28.7% of people above the age of 65 fell in 2015 [2].

In short, we need to not fall and if we fall, not fracture. This is one of the 5 major factors that we need to control to be atmasvasth.

Today’s focus is on falls prevention. I will tackle the issue of bone health and other measures to reduce our risk of fractures, if we fall, in another piece.

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There are many guidelines and suggestions, some based on data and some on common sense telling us what to do to prevent falls. These can be broadly classified into

1. Exercise

2. Personal measures

3. Home measures

Unfortunately, given the very nature of the problem, the data for most interventions and measures to prevent falls is not very robust, except for exercise and individualized multifactorial assessment and management, as was highlighted in a recent US Preventive Services Task Force (USPSTF) review [2] and an accompanying commentary [3].

Exercise

Exercise, as I keep repeating ad nauseam, in any form, is the one magic pill (as we say in Hindi lakh dukho ki ek dawa, which loosely translates to - one pill for a million problems) that makes a difference. For falls prevention though, strength and balance training as part of our exercise regimen, is important. Tai-chi reduces the incidence of serious injurious falls [4] and hence, logically, even yoga should help. Though yoga has been found to improve balance [5], studies showing its efficacy in reducing the incidence of falls are lacking, a deficit that will hopefully be addressed in the near future. So, if you regularly practice yoga, as I do, please continue to do so.

Personal Measures

The following need to be addressed

1. Vision and hearing. We should be aware of what is happening around us.

2. Medications. All medicines that can lead to falls should be reviewed. Many people, by the time they reach 65-70 become victims of polypharmacy, taking multiple drugs for multiple problems, whether needed or not. Not just for falls prevention, but even otherwise, every couple of years, it is a good idea to review the list of medicines and reduce them to the lowest number needed to maintain optimal health.

3. Hypotension and giddiness, especially postural. If we lose balance or become giddy when getting up suddenly from bed or from the toilet seat, we should learn to take it slow and easy during these activities.

4. Supplements. Vitamin D and calcium supplements help when there is deficiency, but not otherwise.

5. Canes and walkers. They make a difference [6]. The problem is that those who are currently over 70 have a marked antipathy to using them for a variety of socio-cultural reasons, a problem that needs to be addressed gently and tactfully.

6. Dangerous activity avoidance. The last two parents of friends who fractured had similar stories. They were climbing on footstools to reach out for something in the kitchen and fell and fractured. I am not even talking of dangerous activities like skiing or skating…even climbing onto ladders or unstable stools, trying out new dance steps (one parent during a wedding sangeet started dancing vigorously, slipped, fell and fractured), aggressive yoga postures…as we age, we need to understand the limitations of our bodies and behave accordingly.

Home Measures

These involve assessing the home for fall risks (e.g. slippery floors, placing railings in the toilets and bathrooms, replacing worn out carpets, etc) as well as addressing issues in the buildings (e.g. lack of guide rails, good lighting, etc) and instituting measures to improve our surroundings to reduce the risk of falls. It is a good idea, every now and then to do a quick recce of our homes and surroundings to make sure they are fall-proof.

So, what is your matka here? To live long, healthy and be atmasvasth, you need to make sure you do not fall and if you do fall, that you do not land up with serious injury. Exercise helps build muscle strength and improves balance. You should check your vision and hearing, reduce unnecessary medications, use canes if needed, avoid stupid dangerous activities and ensure that your home and surroundings are “fall-proof”.

Footnotes

1. Kaur R, Kalaivani M, Goel AD, Goswami AK, Nongkynrih B, Gupta SK. Burden of falls among elderly persons in India: A systematic review and meta-analysis. Natl Med J India. 2020 Jul-Aug;33(4):195-200. doi: 10.4103/0970-258X.316253. PMID: 34045371.

2. US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW Jr, Kemper AR, Krist AH, Kubik M, Landefeld S, Mangione CM, Pignone M, Silverstein M, Simon MA, Tseng CW. Interventions to Prevent Falls in Community-Dwelling Older Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Apr 24;319(16):1696-1704. doi: 10.1001/jama.2018.3097. PMID: 29710141.

3. Reuben DB. New Prevention Guidelines for Falls and Fractures-Looking Beyond the Letters. JAMA Intern Med. 2018 Jul 1;178(7):892-893. doi: 10.1001/jamainternmed.2018.1809. PMID: 29710323.

4. Li F, Harmer P, Eckstrom E, Fitzgerald K, Chou LS, Liu Y. Effectiveness of Tai Ji Quan vs Multimodal and Stretching Exercise Interventions for Reducing Injurious Falls in Older Adults at High Risk of Falling: Follow-up Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2019 Feb 1;2(2):e188280. doi: 10.1001/jamanetworkopen.2018.8280. Erratum in: JAMA Netw Open. 2019 Mar 1;2(3):e192314. PMID: 30768195; PMCID: PMC6484587.

5. Youkhana S, Dean CM, Wolff M, Sherrington C, Tiedemann A. Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis. Age Ageing. 2016 Jan;45(1):21-9. doi: 10.1093/ageing/afv175. Epub 2015 Dec 25. PMID: 26707903.

6. Luz C, Bush T, Shen X. Do Canes or Walkers Make Any Difference? NonUse and Fall Injuries. Gerontologist. 2017 Apr 1;57(2):211-218. doi: 10.1093/geront/gnv096. PMID: 26209797.

A slightly different version was posted in the TOI

Do not fall and if you fall, do not fracture

A healthy 72-year-old, a friend’s mother, stepped outside the home into a gap between two paver stones on the footpath, stumbled, fell, broke her hip, was operated within 48-hours but just couldn’t get back to...

Times of IndiaBhavin Jankharia