Falls Prevention a New Focus for Endocrinologists

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By Dace Trence, MD, FACE

This past year, the American Association of Clinical Endocrinologists (AACE) formed a task force of physicians to look at issues surrounding the risk of falling in the elderly. Why, you might ask, is this important? And more specifically, why is it important to medical professionals such as AACE members who specialize in endocrinology and metabolism?

Here are key points put forth in a major paper focusing on the problem of falls published in the association’s peer-reviewed medical journal Endocrine Practice and spearheaded by endocrinology and aging expert Dr. Aaron Vinik (interviewed in this magazine):

  1. Falls are a major health issue for older adults, leading to adverse events and even death. This is a not well-recognized public health concern. Yet falls could be prevented.

  2. Older persons with type 2 diabetes are at increased risk of falling compared to healthy adults of a similar age. And diabetes itself, or diabetes-associated conditions, are a large portion of what many endocrinologists spend their day caring for.

  3. Over 400 factors are associated with falls risk, making identification and targeting of key factors to prevent falls challenging. However, major risk factors include hypertension, diabetes, pain, and the simultaneous use of multiple drugs by a single patient (called polypharmacy).

  4. In addition to age and polypharmacy, diabetes-related loss of strength, sensory perception, and balance secondary to neuropathy (nerve disease), along with the decline in ability to think clearly and quickly (cognitive function) lead to increased risk of falling.

  5. Designing specific interventions such as strength improvement and balance training, reducing polypharmacy to improve cognitive function, reviewing goals of diabetes control and management to prevent low blood sugar and low blood pressure, and helping to relieve pain safely could provide benefits in reducing falls

Let’s look at the big picture. According to a 2016 National Council on Aging report, one in four Americans 65 years or older fall each year. Every 11 seconds, an older adult is treated in an emergency room for a fall. Even more concerning is that every 19 minutes an older adult dies from a fall. Falls are not only the leading cause of fatal injury, but also the most common cause of trauma-related hospital admissions among older adults. More than 2.8 million injuries from falling are treated in emergency departments each year, there are over 800,000 hospitalizations and more than 27,000 deaths are related to falls. The numbers demonstrate that falls are clearly a problem in need of attention.

Even the fear of falling can impact life. Many older adults are concerned with falling -- either because they have fallen themselves or because of falls experienced by friends or family that resulted in a major impact on their lives. Pain, prolonged hospitalization or prolonged nursing home rehab stays, incapacitation, loss of home and loss of independence are powerful drivers for those that have fallen to do as much as possible to prevent falling again.

Following a fall, physical activities can become limited, even in one’s own home, and the possibility of getting out of the home becomes less frequent - or even non-existent. After all, snow and ice remain in many parts of the country for many months of the year, and even in warm climates, it can be dark outside during fall, winter and spring. We all need brighter light to see as our eyes age – Mother Nature does not accommodate!

This restriction in activities, and the resulting lack of social interaction, can result in further physical decline, often leading to depression and feeling socially isolated, lonely, or helpless. Increasingly, it is recognized that as we all get older, we need social contacts even more than when we were younger, as socialization is directly related to a longer and better quality of life.

Further, sometimes the fear of falling and, even more so, the subsequent results that come from a fall, can make a person hesitant to report a fall to their family or even their healthcare teams. It’s easy to understand the line of thinking: If I report I’m falling, my family will make me move and leave where I am comfortable, make me go to assisted living, and my life will be changed forever. No one wants that! So, it’s not surprising that falls often aren’t reported, even to primary care providers. A 2012 study of Medicare data revealed an estimated 7 million Medicare beneficiaries fell in the prior year, yet less than onethird had advised their healthcare provider and discussed fall prevention.

So, what causes falls?

A combination of age (over 65 years) and diabetes increases the risk of falling 17-fold. Alas, we can’t do much about aging, but what about the connection between falling and diabetes? It is believed that the link is related to loss of nerve function (common in diabetes) that automatically tells us when we are balanced, or not, based on where we feel the position of our feet. Additional contributing factors are loss of vision, slower automatic responses to “catch” ourselves when balance is off and sarcopenia, a loss of muscle strength as a natural part of the aging process.

Additionally, diabetes management itself poses an oftenunrecognized fall risk in the form of low blood sugar (hypoglycemia) episodes. And diabetes management can also include the need to control high blood pressure often associated with the disease, as well as deal with the side effects of blood pressure medications that can increase the risk for dizziness. Dizziness and feeling off-balance are reported as second only to lower back pain as the most common reasons Americans visit the doctor. Even moderate dizziness can affect mobility, activity levels and overall quality of life.

Cognitive decline also is a contributing factor to instability that leads to falls. Not the normal decline of forgetting where you last put your car keys, for example, this decline is specific to what has been called “executive function” – examples of which include being able to pay attention, being able to focus on what you are doing, being able to organize the process of planning and thinking what may be required to walk (such as knowing that you may need to get up slowly from a chair and remain standing for a few seconds standing before taking the first step forward). The substantial impact of cognitive impairment was revealed recently by the American Geriatrics Society, which noted that approximately 60 percent of older persons with cognitive impairment report a fall each year.

The side effects experienced from many medications are also a key culprit in falls, with effects ranging from light headedness and dizziness to drowsiness and outright sleepiness.

What can I do to minimize the risk of falls?

Nicely outlined in the Endocrine Practice review are some practical suggestions to help avoid falls.

Remove obstacles

This includes getting rid of loose rugs, keeping as many items off the floor as possible (books, papers, dishes, clothes) and removing items that have square corners (such as coffee tables). For an extra layer of safety, look for tables with rounded corners. That footstool might seem very comfortable for propping your feet up while sitting but could pose a danger to falling as you try to get up. Is it worth it?

Identify and manage hazards at home

This can include the installation of grab bars near showers, tubs and toilets. Canes and walkers also are helpful for those that have difficulty with balance. Install night lights in hallways near bedrooms and bathrooms. Make sure your lighting inside your home is adequate, even if you need to get another lamp. For some tasks, someone aged 60 may need 10 times the light that a person of 20 would need. Keep in mind that direct lighting can reduce glare, which is a more common problem as we age.

Engage in daily physical activity

The key to improving strength and balance is simple: Exercise, exercise, exercise. This doesn’t mean having to swim to China and back every day. Tai chi, for example, has been shown to improve balance. Originally developed for selfdefense, tai chi has evolved into a graceful form of exercise that incorporates gentle, flowing movements. Plus, stretching can help maintain and even improve muscle strength. Discuss with your healthcare team what exercise programs would be good for you and what are available in your community, on the web, or even on TV that you could access on a routine basis. And remember, once-a-week exercise really is not the most effective approach. Consider daily physical activity as much as possible.

Review your medications

It’s always a good idea to review what medication is needed and what is not, but in the context of benefits versus risks, the balance with any medical agent can change as we age. Also, remember to review your supplements and vitamins with your healthcare team. That tea you’re drinking at night might be something that could add to risk more than you think! And there might some supplements that could be helpful as well. Vitamin B12 deficiency has been identified as a major contributor to falls and vitamin D is important for optimal bone and muscle health. Ask your physician whether blood tests for these vitamins could be helpful to you. And ask about your sodium (salt) level. A low sodium level has been linked to an increased fall risk.

While the aging process is inevitable, by exercising caution and following easy-to-implement prevention measures, older adults can decrease their odds of fall-related injuries.