Suspect Falls

All of us are at risk of falling. That includes your patient, your family member, you, and me. Recognizing how significant falls can be and acknowledging our tendency to overlook them can raise our index of suspicion and minimize their consequences.

The World Health Organization noted that “falls are the second leading cause of unintentional injury deaths worldwide. Adults older than 60 years of age suffer the greatest number of fatal falls. In the world, 37.3 million falls are severe enough to require medical attention each year.” (World Health Organization, 26 April 2021)

I need only to look around me to see examples of people falling. One of my neighbors became dizzy and fell, having become anemic from the accumulated blood loss resulting from undiscovered gastrointestinal bleeding. Another neighbor tripped over the threshold of a doorway. My stepdaughter fell down a flight of stairs trying to negotiate them despite having a herniated disc. My wife was looking at her phone and holding a latte when she tripped over a street curb and fell.

Falling, I thought, happens to careless people, and I was too careful to fall. Then I fell. It was even more embarrassing because I fell out of bed while flailing around in my sleep. Eventually, it became clear that I had been drinking too much coffee near bedtime, which had lowered my glycine levels. Glycine is a chemical the brain uses during sleep to separate the part of the brain that dreams of moving from the part of the brain that actually makes the body move. So, glycine helps you dream about moving without actually moving. Now I have a small bed rail. I avoid drinking coffee too late in the day and eat pumpkin seeds, which are high in glycine. As a bonus, I’ve stopped accidentally hitting my wife at night as well.

I was lucky my fall was not more serious. Some falls may lead to concussions, which may not be detected right away. Bridging veins in the brain may have been broken, and there may be slow bleeding in the brain, so that the brain is slowly being compressed as intracranial pressure mounts and death could occur. This is why falls that result in head trauma need to be evaluated by a doctor and perhaps an MRI or brain scan to rule out subdural bleeding injuries. The seriousness of a subdural supports having a high index of suspicion.

Sometimes it is not the fall that is the issue, but what caused the fall. It can be a heart or stroke issue. The event may have preceded the fall. This would suggest a broader investigation is warranted to look for such things as cardiac arrhythmias, anemia, dehydration, chronic venous insufficiency, and postural orthostatic tachycardia syndrome (POTS).

Situations also put people at risk of falling. Certain blood pressure medications, antidepressants, and sedatives can cause what is called “postural hypotension”. When a person has postural hypotension and gets up too fast, and their blood vessels don’t constrict fast enough to overcome the effects of gravity, they may become dizzy and fall. It is recommended that a person taking these medications should get up slowly from lying down and sit on the side of the bed for a minute before getting up to the bathroom.

If a person drinks enough alcohol to have a blackout from drinking too much, they may not remember falling. When a person is already taking medication, it may not take as much alcohol to enhance the effect that alcohol has on balance. Older people are particularly susceptible to medication and alcohol effects because they metabolize medication more slowly, which may make the doses too high.

After menopause, women lose bone mass, making bones more prone to fractures. Orthopedic problems can contribute to missteps and instability. Additionally, visual impairments put people at risk of falls.

So, what can you do to prevent yourself, your patient, or family member from falling?  I found out the hard way that the first thing you have to do is to realize that you too can fall. I was at a retreat, practicing mindful walking around the meditation building, when I noticed a pile of wood sitting by the building. I started thinking about the wood attracting termites and slipped off the stone steps. Enlightenment had eluded me again.

When you are walking, pay attention to what you are doing. Don’t multitask. Be present and more mindful than I was about what you are doing.

Planning could help both you and your patient:

—Be prepared for slippery terrain from rain or ice.

—Watch out for friendly big dogs who can jump on you and knock you down.

—Consider making two trips to carry bulky packages inside.

—Reflect on whether an assistive device would help with balance.

—Ask someone to hold your drink when you get out of the car.

—Take your time and examine the surrounding obstacles to help determine how to negotiate your passage.

—Steer clear of throw-rugs that might slip.

—Think about getting new glasses to see uneven terrain better and be able to anticipate obstacles.

—Exchange your Crocs for tennis shoes.

Some prevention might also help. You might work on building strength in your lower body and have your doctor make sure your body has enough Vitamin D. Ask yourself if physical therapy might help you to improve your balance.

One characteristic of falls is that they often come as a surprise. By recognizing how serious falls can be and remembering what situations are likely to cause them, we can raise our index of suspicion about falls and hopefully prevent this unwanted surprise. After all, the only kind of falling any of us want is falling in love.