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Falls in older people: how can we prevent them?

A senior citizen reviewing her medication with a pharmacist. (Getty Images)
A senior citizen reviewing her medication with a pharmacist. (Getty Images)

As we advance in age, our body’s capacity to maintain balance diminishes. Our vision and hearing gets compromised. Our health deteriorates. Our joints and muscles do not function as well as they should. Eventually, we become vulnerable. Our safety is threatened.

This week is seniors week to highlight the problem of falls and how to prevent them.

Falls are common among people aged 70 and over. According to statistics in the British Medical Journal Study Module on this subject, 30 per cent of seniors fall each year and 20 per cent experience recurrent falls, with the risk of falling increasing with age. Half of those who fall sustain minor injury and 20-30 per cent result in serious injury. One third of patients who fall need medical attention. The cost of morbidity and mortality is high.

For example, winter is a bad time for people of any age to slip on ice and fall. The risk for seniors is higher than other age groups. Whatever the weather, seniors can fall indoors or outdoors. There are various predisposing factors that make certain seniors more prone to falls than others. So the first thing is to identify people at risk of falling. The caregivers should use the national guidelines to guide the assessment and management of people at risk of falling.

Second important thing is to encourage older people, no matter how frail, to engage in balance and strength exercises. They should be encouraged to join group exercise programs in their nursing homes or in their community if they live independently. Studies have shown this is beneficial.

Thirdly, physicians and other caregivers should identify medications that increase the risk of falls. According to American Family Physicians (Am Fam Physician. 2000 Apr 1;61(7):2173-2174), the side effects of some medicines can upset your balance and make you fall. Medicines for depression, sleep problems and high blood pressure often cause falls. Some medicines for diabetes and heart conditions can also make you unsteady on your feet. You may be more likely to fall if you are taking four or more medicines. You are also likely to fall if you have changed your medicine within the past two weeks.

There are many other things you and your family can do to prevent fall among seniors in your home.

Here are 10 tips from the American Family Physicians:
1. Wear shoes with nonskid soles (not house slippers).
2. Be sure your home is well lit so that you can see things you might trip over.
3. Use night lights in your bedroom, bathroom, hallways and stairways.
4. Remove throw rugs or fasten them to the floor with carpet tape. Tack down carpet edges.
5. Don’t put electrical cords across pathways.
6. Have grab bars put in your bathtub, shower and toilet area.
7. Have handrails put on both sides of stairways.
8. Don’t climb on stools and stepladders. Get someone else to help with jobs that call for climbing.
9. Don’t wax your floors at all, or use a non-skid wax.
10. Have sidewalks and walkways repaired so that surfaces are smooth and even.

This brief article covers a lot. Review your medications and the environment you live in. That will be a good start to be safe. Now, go and listen to some music, dance safely and have some fun. You only live once … or maybe twice if you are James Bond.

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Broken-Heart Syndrome is also known as Takotsubo (Stress) Cardiomyopathy

Nurse helping a senior patient. (Wavebreak Media)
Nurse helping a senior patient. (Wavebreak Media)

Takotsubo cardiomyopathy is a transient acute illness typically precipitated by acute emotional stress. It is also known as “stress cardiomyopathy” or “broken-heart syndrome.” In 2011, there was an article on this subject in a medical journal, Circulation, by Dr. Scott W. Sharkey and his colleagues from the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN explaining the signs, symptoms and treatment of this illness.

In Japanese, “tako-tsubo” means “fishing pot for trapping octopus,” and the left ventricle (pumping chamber of the heart) of a patient diagnosed with this condition resembles that shape.

This is a fairly new condition recognized initially in Japan in 1990, with the first report emerging from the United States in 1998. Takotsubo cardiomyopathy starts suddenly, with symptoms of chest pain and, often, shortness of breath. The condition affects women older than 50 years of age (only 10 per cent in men). Most patients go to the emergency department thinking they have a heart attack.

Sharkey gives examples of emotional stressors which include grief (death of a loved one), fear (armed robbery, public speaking), anger (argument with spouse), relationship conflicts (dissolution of marriage), and financial problems (gambling loss, job loss). Physical stressors include acute asthma, surgery, chemotherapy, and stroke.

“Although patients with takotsubo do not have significantly narrowed coronary arteries, in the early hours takotsubo and heart attacks share many similarities in presentation, including chest pain and breathlessness, as well as abnormalities in both the electrocardiogram and blood biochemical tests,” says the article. But coronary angiogram will show normal coronary arteries but unusual shape of the left ventricle that has given takotsubo its unique name.

Once the diagnosis is made (via several invasive investigations) patients are in the intensive care unit for at least 24 hours, during which time vital signs are monitored and blood is tested for troponin (a protein released by injured heart muscle). Medications are used to promote recovery of heart muscle and blood thinners are used to avoid a stroke caused by a blood clot traveling from the heart to the brain.

Major life-threatening complications are infrequent. Low blood pressure (hypotension), fluid buildup in the lungs (congestive heart failure) and a chaotic heart rhythm will require appropriate medications.

“Fortunately, with timely recognition and supportive therapy, takotsubo events are reversible, and recovery is usually rapid and complete. Heart function (contraction) gradually improves over several days and is usually normal by hospital discharge (3–7 days). The term stunned heart muscle is commonly used to indicate that injury in takotsubo, although initially profound, is only temporary. Drugs are discontinued once heart contraction has returned to normal,” says Sharkey.

Why would acute stress cause heart failure? This is an unresolved question. It may have something to do with the autonomic nervous system. It has been suggested that when powerful hormones such as adrenaline are released in excess, the heart muscle can be damaged in patients with takotsubo. Fortunately, the long term prognosis is good. Nearly all patients survive an acute takotsubo episode. In approximately five per cent of patients, a second (or third) stress-induced event may occur. Best thing is to avoid stressful situations. Relax, do deep breathing exercises and keep smiling.

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Low Dose Aspirin Increases the Risk of Upper Gastrointestinal Bleeding

Aspirin bottle. (iStockphoto)
Aspirin bottle. (iStockphoto)

Low-dose acetylsalicylic acid – also known as aspirin – (75 mg⁄day to 325 mg⁄day) is recommended for primary and secondary prevention of cardiovascular events, but has been linked to an increased risk of upper gastrointestinal bleeding (UGIB), according to a study published by Valkhoff and his colleagues (Can J Gastroenterol. 2013 Mar;27(3):159-67).

They analyzed several studies. All studies found low dose aspirin use to be associated with an increased risk of UGIB. The mean number of extra UGIB cases associated with low dose aspirin use was 1.2 per 1000 patients per year. Sounds like a small number when you think of the number of people who take aspirin all over the world. But the authors indicate use of low dose aspirin was associated with a 50 per cent increase in UGIB risk.

What about other anti-inflammatory drugs? Are they safe?

Commonly used traditional anti-inflammatory drugs like ibuprofen are also known as non-steroidal anti-inflammatory drugs (NSAID) are widely used for all kinds of pain. An editorial by Jacob Josh, Professor of Medicine, University of Ottawa, Ottawa, Ont. titled, “Anti-inflammatory drugs: What is safe?” (CMAJ August 29, 2006), says “Sixteen thousand deaths a year in the United States and 1900 a year in Canada were blamed on NSAID-induced gastric perforations, obstructions and bleeds. NSAID use was complicated also by numerous other side effects, including hypertension, heart failure and renal insufficiency.”

The risks are not limited to long-term use. Clinically significant adverse cardiovascular events are noted within the first 30 days of treatment.

Do you always have to take an NSAID if you are in pain and thus increase the risk of complications? Not really. You can try other modalities of pain relief by rest, application of ice and use of acetaminophen. Acetaminophen, up to 4 g/day, is as effective as an orally administered NSAID in about 40 per cent of patients with mild to moderate osteoarthritis.

Then there are occassions when pain cannot be relieved by what we call conservative measures. So we have to weigh our options. First, we should assess patient risk. There is an increased risk of gastric toxicity if:
-the patient is over 65,
-has had previous upper GI bleed,
-there is concurrent therapy with low-dose aspirin, corticosteroids or anticoagulants.

Under these conditions we should try prescribing a coxib (like Celebrex) or traditional NSAID with concurrent cytoprotection (to protect the stomach lining) with misoprostol or a proton pump inhibitor. If the patient has had a recent heart attack or episode of congestive heart failure, then he should not take NSAID or coxib.

Josh says, “In case of uncontrolled hypertension, we should not choose an NSAID or coxib until the blood pressure is well controlled. If the patient has controlled blood pressure that becomes elevated while taking an NSAID or coxib, even by 5 mm Hg systolic, adjust the antihypertensive medications or stop the anti-inflammatory, or both.” Monitor renal function as well.

Josh says there is nothing like a safe NSAID or coxib. In high-risk patients, we should avoid them. Concomitant use of low dose aspirin does not protect you from cardiac side-effects of NSAID or coxib. There is adequate data to suggest aspirin enhances the gastric toxicity of anti-inflammatory drugs as mentioned earlier.

If you are in pain, careful use of painkillers is very important. If you are taking aspirin as a prophylaxis against cardiac problems then weigh your risk factors and your options. If you are taking NSAID for chronic pain then you need to know your risks. Discuss risk vs. benefits of the medications you are taking with your doctor.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Georgia (and the Masters) on my mind!

General view of the Augusta National Golf Course.
General view of the Augusta National Golf Course.
Noorali with the Masters trophy at the Augusta National Golf Club.
Noorali with the Masters trophy at the Augusta National Golf Club.
Noorali with Tianlang Guan from China, 14-yr-old eighth grader in school, the youngest player to play the Masters and make a cut.
Noorali with Tianlang Guan from China, 14-yr-old eighth grader in school, the youngest player to play the Masters and make a cut.
Kitchen encounter with "Mr. 59". Al Geiberger. From L to R: Al Geiberger, Harry, Tony, Noorali, Dan.
Kitchen encounter with “Mr. 59”. Al Geiberger. From L to R: Al Geiberger, Harry, Tony, Noorali, Dan.
With Dave Stockton, short game guru and a well known American Golfer. From L to R: Noorali, Tony, Dave Stockton, Dan, Harry.
With Dave Stockton, short game guru and a well known American Golfer. From L to R: Noorali, Tony, Dave Stockton, Dan, Harry.
Having breakfast in the clubhouse - restricted to members and their guests. L to R: Harry, Noorali, Dan, Tony.
Having breakfast in the clubhouse – restricted to members and their guests. L to R: Harry, Noorali, Dan, Tony.
Bubba Watson - 2012 Masters champion quenching thirst during the Masters practice round before hitting his tee shot.
Bubba Watson – 2012 Masters champion quenching thirst during the Masters practice round before hitting his tee shot.
Augusta National Golf Club coffee cup and saucer.
Augusta National Golf Club coffee cup and saucer.
General view of the Augusta National Golf Course.
General view of the Augusta National Golf Course.
General view of the Augusta National Golf Course.
General view of the Augusta National Golf Course.

We (Tony, Dan and yours truly) arrived in Atlanta, Georgia on Friday April 5. We were picked up by our friend from Kentucky, Harry and drove to Reynolds Plantation in Greensboro, GA. We checked into our hotel, The Ritz-Carlton.

Reynolds Plantation is a golf and lake community providing a lifestyle with six golf courses and access to Lake Oconee, Georgia’s second largest lake. It has 10,000 acres of land, four full service marinas and 90 miles of shoreline.

We had tickets to the Masters for Tuesday April 9 practice round and Thursday April 11, first day of the Masters. We had decided to golf for three days at Reynolds Plantation before going to Augusta. On Saturday we golfed at The National and Great Waters – 36 holes for the day. On Sunday we golfed The Plantation Course and Harbour Club. Monday we golfed in the morning at The Oconee and drove to Augusta in the afternoon.

In Augusta, we were accommodated in a beautiful house by our host. On Tuesday, we were driven to the Augusta National Golf Club by our host who had special privileges at the Club House. We drove through the famous Magnolia Lane and then given a tour of the clubhouse. We had breakfast at the clubhouse where only members and their guests are allowed. We also had lunch on the lawn which is also a restricted area. We had our pictures taken with the Masters trophy which sits in the clubhouse.

Practice round is the only day cameras and cellphones are allowed on the course. We had an opportunity to walk around the course, follow some famous golfers on the course, take hundreds of pictures of who’s who on the PGA tour, we had a group photo with Dave Stockton, the short game guru of many players including Phil Mickelson. In the evening we had a kitchen encounter in a private home with “Mr. 59” Al Geiberger and his two sons who are also well known in their own sporting fields.

Al Geiberger, won eleven times on the PGA Tour, with victories that included one major championship, the 1966 PGA Championship. On June 10, 1977, in the second round of the Danny Thomas Memphis Classic played at the Colonial Country Club in Cordova, Tennessee, he became the first person in history to post a score of 59 (par was 72) in a PGA event. Incidentally, Dave Stockton was one of Geiberger’s playing partners that day.

That Tuesday afternoon we were free so we booked a course (The River Golf Club) in North Augusta, South Carolina – a 45-minute drive from Augusta, GA. On Wednesday, April 10, we played 36 holes of golf at Palmetto Golf Club in Aiken, South Carolina. So, by that time we had played nine rounds of golf in five days – this is the most golfing I have done in five days. At the end of it I felt tired but rejuvenated that I still had stamina to do this amount of activity! A self vote of confidence – so to speak.

Thursday was the big day – first day of the Masters. We arrived at the course at seven in the morning, first tee time was at eight. Parking is free near the course – about five minutes walk from one of the gates. We went through the security and carefully walked to 14 and 15 hole and put our chairs at the rope around the green. If you are found running then you will be thrown out. There are too many rules to take care of. No cell phones or cameras are allowed inside after Thursday. There are thousands of people, so if you part with the members of your group then you will have hard time contacting them.

Once you put your chair down then nobody will move it. You can walk around and follow a group of golfers for a while. It is a long course. Every fairway has a hilly area to climb. When you are tired you can sit down and watch all the golfers go by. You can decide how you want to spend the day. I was thrilled to see all the players in person so closely from the ring side sit. It was a memorable moment. We returned home on Friday to watch the rest of the Masters on TV.

Masters ticket are one of the most difficult to buy. You can go to their website and apply. You can buy them from a certified ticket broker. According to Augusta Chronicle (April 7 2013), “… practice round tickets were ranging from as low as $350 for Monday, to more than $1,000 for Wednesday, ticket brokers said. A four-day tournament badge was going for about $6,500 but … prices can fluctuate wildly on any given day.” The law also sets a 2,700-foot boundary around the venue where no tickets can be resold. Augusta National policy prohibits the resale of Masters tickets.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!