Scientists Weigh In on Fall Prevention
By Susan Seliger, New
York Times
July 12, 2012
World
Who would
have thought that popping a pill could help
prevent falls in the elderly? According to a new
report on fall prevention, published in Annals
of Internal Medicine, vitamin D, of all things,
may help adults age 65 and older stay steady and
upright.
Falls are the leading cause of injury in adults
65 and older, and preventing them is much more
effective than treating them. Thirty percent to
40 percent of the elderly fall at least once a
year; many who had been living independently
never regain their previous functioning, ending
up in assisted living and nursing homes.
Taking vitamin D supplements daily is one of
three major recommendations on fall prevention
recently issued by the United States Preventive
Services Task Force. “The exact mechanism is not
known, but it seems to help muscle strength and
balance,” said Dr. Al Siu, vice chairman of the
task force and chairman of the geriatrics and
palliative medicine department at Mount Sinai
School of Medicine.
And the help is significant. In a review of nine
trials, the task force found that a daily dose
of 800 international units (I.U.) reduced the
risk of falling by about 17 percent, compared
with those who did not take the vitamin.
The task force is the first major medical group
to recommend vitamin D supplements for those who
live at home (not in assisted living or nursing
homes) and are at higher-than-normal risk of
falling — that is, those over age 65 who have
already fallen or who have had limitations in
mobility within the last year.
That may come as a surprise, since in another
recent draft report the task force also
recommended against postmenopausal women taking
vitamin D to prevent fractures.
According to Dr. Siu, the fractures report
looked at a larger population: all men and
women, not just those at high risk for falling.
Second, it made negative recommendations only
for lower doses of vitamin D — less than 400
I.U. daily.
“We do have evidence that low doses of vitamin D
and calcium supplementation for postmenopausal
women do not work,” Dr. Siu said. “We don’t know
if higher doses work — the evidence is
insufficient. So for the larger population of
older men and women, we don’t say ‘Take it’ or
‘Don’t take it.’ ”
But for those at increased risk of falling, Dr.
Siu added, the task force decided that there was
sufficient evidence that 800 I.U. of vitamin D
taken daily can help prevent further tumbles.
Not all experts are so enthusiastic. The
American Geriatrics Society and the British
Geriatrics Society, in updated fall prevention
guidelines issued last year, merely recommended
that vitamin D supplements be “considered.”
Those guidelines focused more on advising
doctors to review medications used by patients
that might increase falls. In another new
recommendation on fall prevention, the
preventive services panel took a different tack,
saying that doctors should do a “multifactorial
risk assessment with comprehensive management of
identified risks.”
Translation: Doctors should be asking their
patients more questions than they typically do
about a history of falls — and should observe
their patients in action — to identify those at
higher-than-average risk.
“It isn’t standard practice for doctors to ask
if you’ve fallen in the last 6 to 12 months or
to observe patients walking and see if they can
get up and walk at a normal pace or not,” said
Dr. Siu — but it should be.
The task force’s last recommendation for fall
prevention involves exercise. Though the new
report is short on specifics (unlike those by
the American and British geriatrics societies,
which commend tai chi), Dr. Siu said the
appropriate exercise should be any balance,
strengthening and aerobic moves the patient
likes enough to actually do regularly.
The physical therapy should be customized to
correct uneven gaits and to keep patients
mobile, helping them maintain or regain
strength. “No one size fits all,” said Dr. Siu.
So is that all the elderly and their caregivers
need to know about preventing falls? Probably
not. The task force reviews medical research to
make unbiased recommendations about what works
best to prevent illness and injury. The
guidelines are based on whether the benefits of
an intervention outweigh the harms, without
considering the cost involved.
The task force did not address hazards around
the house, which are implicated in more than
one-third of falls among the elderly, according
to Jon Pynoos, a gerontologist at the University
of Southern California and a director of the
Fall Prevention Center of Excellence in Los
Angeles.
“Most people live in ‘Peter Pan’ housing, not
designed for anyone who will grow up or grow
old, so the home is an accident waiting to
happen for older people,” said Dr. Pynoos.
If you cannot wait for an occupational therapist
to do an evaluation of your home, here are the
prime places to start on your own.
Unsurprisingly, stairs are the most likely
places to experience serious falls. Put up
railings on both sides. Replace worn carpet, as
it can be slippery. Install lighting at the top
and bottom of the stairs. Mark the top and
bottom steps clearly with a different color of
carpeting (tape tends to need replacing too
often). Stair glides are excellent, but
expensive.
Bathrooms are the next big fall zone. Hard tiled
surfaces are slippery when wet and unforgiving
on fragile aging bones. Secure grab bars (not
the suction-cup variety) into the walls at
varying easy-to-grab angles in addition to
vertically and horizontally. Place them not only
where you enter the tub or shower but also in a
second midway spot — for example, where the
built-in soap holder usually is, and by the
toilet.
A more costly solution: “I recommend walk-in
showers — they have no lip,” said Dr. Pynoos.
Costs start at $1,000.
“Comfort-height” toilets, slightly higher than
regular ones, can make getting down and up
easier, with less chance of losing balance.
Nonskid tiles are wise.
Good lighting throughout the home can be an easy
and inexpensive safety improvement. Dr. Pynoos
recommends extensive deployment of night lights
with light and motion sensors.
Getting rid of clutter is critical but, as
readers here know, easier said than done. “Some
older people are hoarders — for me, it’s books,”
Dr. Pynoos said. The key is to get the stuff —
newspapers, magazines, books, whatever – off the
floor.
Pets and their paraphernalia can also pose a
hazard. Pet collars that glow at night or have
bells can help reduce the chances that an
elderly owner will trip over Fido. Still, it’ll
take a genius to figure out how to stash the
water bowl both near the sink and completely out
from underfoot. (If you’ve figured out a fix,
let us know.)
“I did some of these things for my
father-in-law’s house,” recalled Dr. Pynoos,
“and he said to me: ‘This is the best gift you
could have given me — redesigning things so I
can live independently.’ “
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This post has been revised to reflect the
following correction:
Correction: July 13, 2012
An earlier version of this article misstated, in
a quotation, the family member whom Jon Pynoos
said he helped by taking measures to prevent
falls in the home. Dr. Pynoos did this for his
father-in-law, not his father.
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