Health Tip: What Causes Older People To Fall, And How Can We Reduce Their Risk?

I am the rehab physician for a charming, ninety-year-old woman who is recovering from a broken hip. She is very sharp and independent, and had been living alone until her recent fall at home. She was hurrying to turn off her stove burner when she lost her balance and fell on the linoleum kitchen floor.

Weeks later she is almost pain-free from her hip replacement surgery, but as I watched her stand up from her chair to grab onto her walker, I felt very uneasy. She was still fairly weak and struggling to get up safely. I knew she was still a high fall risk, and we both worried about her falling again. My protective side wanted to keep her in rehab, but then again I knew that we couldn't exactly "hold her hostage" because of something that might happen in the future.

There's no way to prevent people from falling down 100% of the time. However, there are some interventions that have a proven track record for reducing fall risk. The CDC has a nice compendium of research describing what works. I thought I'd summarize it for you here:

1. Exercise - Many studies demonstrate that regular strength, balance, flexibility, and endurance training can reduce fall risks by 50-60%. Classes are often led by physical therapists and last about 60 minutes, 3 times per week to be effective. Tai Chi has also been proven effective for fall reduction. One Swiss study recommended piano music with varied rhythms to challenge stepping speed and balance, and another Japanese study used "Twister-like" colored blocks to improve stepping agility.
    
2. Winter Grips - One study showed that Yaktrax (a traction device that fits over the bottom of shoes, the way chains fit over car tires) reduced falls in snowy Wisconsin by about 60%!
    
3. Home Evaluations - When occupational therapists visit a person's home, they look for specific fall hazards (such as area rugs, cluttered hallways and bathrooms, stairs without railings) and recommend equipment (such as grab bars, walkers, and shower chairs) that can help to make people more steady during everyday activities. Just one visit (lasting an hour or an hour and a half) may reduce falls by 30-40%.
    
4. Stopping Medications - One study showed that stopping sedative medications (such as benzodiazepines for anxiety) reduced fall risks by 67%! It's very important to limit the medications that we take whenever possible. Another study suggested that formally reviewing one's current medication list with a primary care physician could also significantly reduce falls.
    
5. New eye glasses - A vision check by an optometrist, along with new glasses prescription, can improve poor vision and reduce this risk for falls.
    
6. Cataract surgery - Our eye lenses get cloudy as we age, and putting in fresh, clear lenses (a.k.a. cataract surgery) may reduce fall risk by 34%.
    
7. Vitamin D Supplementation- Since low Vitamin D levels can result in weak muscles and thinning bones, the American Geriatrics Society recommends Vitamin D supplementation of 4,000 IUs per day for adults over 65 with low Vitamin D levels.
    
8. Pacemakers - For those with slow heart rates or heart blocks, pacemakers can reduce dizziness from rhythm problems. If the heart is not beating normally, a pacemaker may prevent fainting and falling.
    
9. Foot Checks - One podiatrist visit (with a prescription for well-fitting shoes or sole inserts if needed) can reduce fall risks significantly.

Overall, regular exercise and limited medications are the two most important fall risk reduction strategies that we have. Enlisting the help of physical and occupational therapists, optometrists, ophthalmologists, primary care physicians, cardiologists, rehab physicians and podiatrists can further success!

References
https://www.cdc.gov
https://www.americangeriatrics.org
https://www.medscape.com/viewarticle/819047

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Health Tip: What Causes Older People To Fall, And How Can We Reduce Their Risk?

During the holiday season we often reconnect with our older relatives and friends, and may notice some new deficits in their ability to walk or transfer safely. For this reason, I think it's an opportune time to review a frequently overlooked health topic: are you or your loved one having falls?

Falls are one of the greatest health threats to people over the age of 65. An estimated 37.5% of those who fall sustain injuries severe enough to restrict their mobility or require medical treatment. A recent CDC report suggests that seniors are so embarrassed about their falls (or fear loss of independence), that they fail to report half of them. This can lead to sedentary behavior in an attempt to avoid further incidents. Unfortunately, skimping on exercise only makes the body weaker, which actually increases the risk of toppling over.

Why does our fall risk increase as we age?

1. Balance deficits. As we age, cells responsible for detecting where our bodies are in 3-D begin to die off. This affects the vestibular system in our inner ears, causing a decrease in body awareness during motion.
2. Slower reaction times. Our ability to react quickly to environmental stimuli decreases with age, probably as a factor of impaired vestibular systems, combined with poorer vision, and weaker muscles.
3. Muscle atrophy. Without sustained effort to avoid muscle loss, most people lose 3-5% of muscle mass per decade after age 30. Weaker muscles don't perform as well, particularly in getting up from low surfaces.
4. Neuropathies. Nerve damage is more common with age (especially for those with diabetes), reducing sensation in the feet and leading to stumbles.
5. Medication effects. The average American over age 65 takes about 5 prescription medications per day. Many of these have side effects (such as dizziness or low blood pressure) that can contribute to fall risk.
6. Vision changes. Our eye tissues are less flexible as we age, causing difficulty adjusting our focus (hence the need for "reading glasses.") Cataracts (cloudiness in the lenses of the eye) may also reduce our vision. In fact, internationally-speaking, cataracts are the #1 cause of blindness. We tend to need more light to see well as we age, due to light scatter from aging lenses and corneas or perhaps macular degeneration (vision loss due to cell damage in the back of the retina).
7. Blood pressure variability. As we age, our hearts are a little slower to compensate for changes in body position. So going from sitting to standing too quickly may cause dizzy feelings or fainting spells, leading to falls.
8. Clutter. Ok, this isn't really a factor of aging, but I can tell you that many of the patients I see in my rehab practice have tripped over area rugs or household clutter and fallen down. I suspect that since we tend to collect more worldly items as we age, our risk of falling may increase specifically due to that!
   

Now that we all feel somewhat depressed about the natural aging process and what we are all facing, I have some good news: we can take steps to reduce our (and our loved ones) fall risks. In my next post I'm going to review the CDC recommendations for reducing falls, and call out the practical things you can do that have been proven to work. So stay tuned…

References

https://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html
https://www.wsj.com/articles/falling-is-dangerous-for-the-elderlyand-often-preventable-1510542240
https://www.askdoctork.com/why-does-balance-decline-with-age-201306054928

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What Is Causing My Chronic Diarrhea, Gas, and Bloating?

A dear friend of mine has been suffering with abdominal discomfort for over a decade. She has undergone every study and procedure known to gastroenterology - including tests for infectious disease, autoimmune disorders, and allergies. She has had unremarkable colonoscopies, followed restrictive diets, and felt perpetual embarrassment regarding her ill-behaved intestines.

Although she still has no definitive diagnosis, the answer may be irritable bowel syndrome (IBS). An estimated 25-45 million people in the United States have IBS though many cases go undiagnosed. For those who are diagnosed it may take up to 6 or 7 years for a clinician to figure it out. The reason why it's hard to diagnose is that its course is so unpredictable (it comes and goes in severity, with no obvious pattern), and because embarrassment may cause people not to seek help.

But wait, it gets worse.

The truth is that doctors don't yet know what causes IBS for certain, and there is no reliable cure for it either. In fact, IBS is a general term for what might be several different underlying diseases, yet to be clarified by science and research.

What causes IBS?
We do have some theories, though. First of all, the intestines are stimulated to contract by a complex plexus of nerves. In some people, these nerves may be overactive or triggered by stress. It's not unheard of for people to lose control of their bowels when they are terrified. Imagine that a much smaller stimulus - say, stress at home or at work - could trigger a similar response in more delicate guts. IBS is known to be more common in people with anxiety, depression, or a history of sexual, physical, or emotional abuse.

Secondly, a lot has been learned over the last few years about the importance of gut bacteria. You've probably heard about "good bacteria" and "probiotics" and how important it is to consume foods like yogurt, kefir, or kambucha, especially after a course of antibiotics. Well, it's possible that people with IBS don't have the best bacterial micro-environment, resulting in excessive fermentation of food with gas production and bloating sensations.

Thirdly, some foods may trigger excessive bloating, constipation, diarrhea, and abdominal pain. This is not due to an allergic reaction, but simply an intolerance. Foods known to predispose to IBS symptoms include sugar, wheat, dairy, beans, cabbage, high fiber, artificial sweeteners, and fried foods. These foods are enthusiastically fermented by normal gut bacteria, but for patients with IBS, the action can be overwhelming.

So what can people do about IBS?
The first steps are to address the most common triggers: mental health and diet. If you have symptoms of IBS and know that there is a lot of stress in your life, or perhaps a history of anxiety or depression, start by treating the psychological condition(s). Some people are helped significantly by stress-reduction techniques such as meditation, progressive relaxation, or talk therapy. Others may benefit from medications.

The next step is to avoid foods that are known to make IBS worse. These foods include "high gas" foods such as: carbonated and alcoholic beverages, caffeine, raw fruit, and certain vegetables, like cabbage, broccoli and cauliflower. Some people are sensitive to gluten (without being allergic to it) which is found in wheat, barley, and rye. And others are sensitive to easily fermented carbohydrates. This is sometimes referred to as a low FODMAP (fermentable oligo-, di-, and monosaccharides and polyols) diet. FODMAPs are found in certain grains, vegetables, fruits and dairy products.

Finally, encouraging healthy bacterial colonies to develop may be as simple as taking probiotic tablets or drinking live culture fermented beverages (such as Kambucha). Yogurt may be a good idea, though the fact that dairy is forbidden on the IBS diet may give you pause. For some people, avoiding dairy may be more helpful than getting probiotics through yogurt.

The next level…
There are medications on the market that can help to speed up or slow down the transit time of food through the colon, depending on whether you have diarrhea-predominant or constipation-predominant IBS. Alosetron (Lotronex), and Eluxadoline (Viberzi) are approved for diarrhea-predominant IBS, and Lubiprostone (Amitiza) and Linaclotide (Linzess) are used in constipation-predominant IBS.

When all else fails…
Some studies suggest that slow release peppermint oil pills may help with IBS, and other studies support repopulating the gut flora with someone else's bacteria. This may sound off-putting (fecal transplantation?) but it makes some sense that good bacteria from a healthy gut could make a new happy home elsewhere.
In one small study, 70% of people with IBS symptoms that failed to respond to diet, medication, and mental health treatments, found relief or resolution after a fecal microbiota transplantation (FMT). More research would be helpful in clarifying exactly when this measure (harvesting and cleaning someone's stool sample and transplanting it through an enema to the IBS sufferer) is indicated.

And so, in the final analysis, it may be that the cure for years of intestinal misery (for my friend, or someone you know) is to simply receive a dose of someone else's crap.

I'm sure there's some deeper wisdom in there somewhere. I'd rather take the peppermint oil, though.

References
https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/symptoms-causes/syc-20360016
https://www.mayoclinic.org/diseases-conditions/irritable-bowel-syndrome/diagnosis-treatment/drc-20360064
https://gi.org/media/press-releases-for-acg-annual-scientific-meeting/fmt-ibd-ibs/

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