After Mom slips in the bathroom just before dawn, the first thing many families do is go to the market and buy a rubber non-slip mat. The mat goes down. Only when they take her to the doctor, and the doctor asks a few more questions, does the family notice that for several months Mom has needed both hands to push herself up from a chair, gets up two or three times a night to pee, still wears glasses from several years ago that have never been rechecked, and has often felt woozy in the mornings since she was prescribed an extra sleeping pill. The wet bathroom floor that day was only the last thing to happen.
The factors that tend to add up before a fall
Weak legs are an easy factor to see, yet few people pay attention to them. The thigh and buttock muscles weaken gradually with age and with months of moving around less, so when someone misses a step, the muscles cannot pull the body back upright in time.
The trip from the bed to the toilet at midnight is only a few meters. Someone who has just sat up still feels light-headed, the light is dim, the eyesight is poor and the glasses are old, so it is hard to see the edge of a doorstep or a puddle on the tiles. A front of the foot that does not lift in time also often causes tripping. If the toe of a slipper keeps scuffing the floor on one side, think of a cause that is often missed, seen in people with numbness on the top of the foot.
Fear of falling is harder to see. After one fall, many people become reluctant to leave the house, sit more, their leg muscles weaken further, and their steps become even more unsteady. Out of love, the children tell Mom to just sit still in one place, and without meaning to, they make that cycle turn faster. With brittle bones, a fall easily becomes a fracture, so osteoporosis and calcium for Vietnamese people who drink little milk need attention at the same time.
How much balance training helps prevent falls
At five in the morning, the paths around park lakes are crowded with older people out walking. Each year, at least one third of people over 65 living at home have a fall, according to the Cochrane review by Sherrington et al. (2019). The authors pooled 108 trials with 23,407 people. Exercise reduced the number of falls by 23%, with high-certainty evidence. Balance and functional exercises alone reduced it by 24%. Combining balance with strength training probably reduces it by up to 34%, and tai chi also has data showing fewer falls. Programs of walking only, dancing only or strength training only have unclear effects.
Balance exercises are movements that challenge the legs a little while the hands still have something to hold on to: standing on one leg beside the kitchen counter, walking heel to toe along a tile grout line, standing up from and sitting down on a chair without using the hands. It takes many weeks of regular practice before you notice a difference. Someone who has just fallen, is dizzy or has a lot of knee pain should let a doctor check them first before choosing exercises. The clinic teaches these exercises, including a few simple tai chi movements.
Review the medicines taken every day
Empty the medicine bag of someone over 60 onto the table and you will often find several kinds taken every day, each prescribed by a different place. Among them, antipsychotics, antidepressants and one group of commonly prescribed sleeping pills and sedatives all come with a higher risk of falling. Pooling 248 studies in people aged 60 and over, Seppala et al. (2018) found an increase of about 1.4 to 1.6 times by odds ratio, although results varied quite a lot between studies. A second review by the same group added strong opioid painkillers, antiepileptic drugs and taking many medicines at the same time. Ordinary anti-inflammatory painkillers did not clearly raise the risk.
The easiest step is to gather every medicine in the house into one bag, including medicines bought over the counter, supplements and traditional Vietnamese herbal remedies, and bring it to the appointment. People taking blood pressure medicine who often feel dizzy when standing up should also tell the doctor. Don’t stop any medicine on your own. Reducing or changing a medicine is a job for the doctor who prescribed it. If you want to rely less on sleeping pills, you can start with a few small habits for deeper sleep.
After a fall, which signs mean going to hospital
If after a fall there is pain in the hip area and the person cannot stand up or cannot put weight on that leg, take them to the emergency department for an X-ray; don’t help them up and wait overnight. Hitting the head followed by a headache that keeps getting worse, vomiting or drowsiness also means going to hospital right away, all the more urgently for someone taking blood thinners. If a fall comes with fainting, palpitations, weakness on one side of the body or difficulty speaking, call an ambulance, because the fall may then be the result of heart disease or a stroke.
Even without an injury, see a doctor if there have been two or more falls in a year, or if the family notices that the person is walking more slowly, taking shorter steps or needing to hold on to the wall. The 2022 world guidelines by Montero-Odasso et al. recommend that people at high risk of falling have an assessment covering many aspects, so they can have an individual plan.
What the doctor asks and checks when an older person keeps falling
Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine) usually asks in detail about the most recent fall: what time it was, what the person was doing, whether they felt dizzy just before. Then the doctor asks the person to stand up from a chair without using their hands, walk a few steps and turn back, to see whether the steps are short or long and whether the toes scuff the floor. The medicine bag is opened and each blister pack is looked at. After that, the doctor uses muscle testing on the buttock and thigh muscles on both sides, especially the buttock muscle that holds the hip steady when standing on one leg. One side weaker than the other often leads back to the pelvis, the lower back or an old injury. If a fracture, nerve damage or heart disease is suspected, the doctor recommends imaging, lab tests or a referral to a specialist first. Vitamin D is also recommended as a supplement only when tests show a deficiency.
Many people give up exercising because of knee pain, so treatment first aims to help the person be able to exercise. For someone in so much pain that they avoid walking, the doctor uses acupuncture to ease the pain first. If the pelvis or lower back is not working properly, it is corrected with Applied Kinesiology adjustment techniques.
Someone with tired, aching lower back and knees, weak legs and having to get up to pee many times a night is often placed by traditional medicine in the pattern of Liver–Kidney deficiency (肝肾亏虚 / 肝腎虧虛, gān shèn kuī xū), because the Liver governs the sinews (肝主筋, gān zhǔ jīn) and the Kidney governs the bones (肾主骨 / 腎主骨, shèn zhǔ gǔ). An herbal decoction to tonify the Liver and Kidney is prescribed only after the doctor has carefully reviewed the Western medicines being taken, that is, the very medicine bag brought along on the first day.
Worth keeping
- If you see a loved one needing their hands to push up from a chair, start them on leg exercises;
- Practice balance a few sessions a week, always with a table or a wall beside you to hold on to;
- Gather all the medicines being taken, including over-the-counter medicines and traditional Vietnamese herbal remedies, and bring them to the appointment;
- At night, turn on the light and sit on the edge of the bed for a few breaths before standing up to go to the toilet;
- Two or more falls in a year means booking a consultation, even if there has been no injury yet.
If you have osteoporosis or have broken a bone in a minor fall, tell the doctor before any work on the pelvis and lower back.
References
- Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE (2019). Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 1(1):CD012424. https://doi.org/10.1002/14651858.CD012424.pub2
- Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J et al. (2022). World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing 51(9):afac205. https://doi.org/10.1093/ageing/afac205
- Seppala LJ, Wermelink AMAT, de Vries M, Ploegmakers KJ, van de Glind EMM, Daams JG, van der Velde N (2018). Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: II. Psychotropics. J Am Med Dir Assoc 19(4):371.e11-371.e17. https://doi.org/10.1016/j.jamda.2017.12.098
- Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, van der Velde N (2018). Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others. J Am Med Dir Assoc 19(4):372.e1-372.e8. https://doi.org/10.1016/j.jamda.2017.12.099
