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Interviewer: Responding to an older adult's fall rehabilitation and next steps. Dr. Natalie Sanders is an expert in recovering from falls. She works at University of Utah Geriatrics Clinic. And Dr. Sanders I imagine this could be a little scary for someone and their loved ones because falls are serious especially the older you get. So I wanted to kind of provide listeners with a general overview of the issues so they can better understand what should happen and to ensure that the recovery is successful.

Causes and Risk Factors of Falls in Older Adults

So first of all I think understanding the fall would be pretty important because there's probably a spectrum of those. Is that an accurate statement?

Dr. Sanders: Yeah I think so. You know the biggest thing that I think about when an older adult has fallen is number one understanding the circumstances around the falls and then how many falls are actually happening. And then also try to emphasize when I'm talking with my patients really trying to emphasize that falls are really a marker of decline. And so not all falls are created equal it's true but they do tend to signal that things are not going as well as they should be.

Interviewer: Okay. That's interesting insight because I guess in my mind I was thinking of a fall somebody gets hurt and then there's rehabilitation you know maybe a bone is broken or something like that. But if falls are starting to happen more frequently that's a symptom. That's a sign that something needs to happen before it becomes serious.

Dr. Sanders: That's right. Yeah. And so that's why it's so important when you have a loved one who does have a fall to make sure that their provider knows about it. And even if they think it's something quite as simple as you know "Oh well mom just tripped over the sidewalk" that still probably needs to be brought up because then that should prompt questions of "Well how many times is this happening and what are the other circumstances around other falls?"

Interviewer: Got it. And because there is this continuum I suppose in this brief conversation it makes it difficult kind of talking about like what the next steps are. So let's talk about a less serious fall where maybe it's just I don't know is a slight injury even a thing when you get older and you fall?

Dr. Sanders: Sure. Yeah. Yeah. I mean I think that a slight injury you know a lot of times patients will have a slight injury or several falls before they have the big one that ultimately ends up with the hip fracture or the big injury. So even if you have a slight injury I think that, let's say, a slight injury as you fall onto your knees and you get an abrasion on your knees or your loved one gets an abrasion on their knee that's still important to bring up because again when you go in and talk with the provider then the provider can talk through some of the common risk factors for falls.

You know maybe one thing that might be helpful in kind of framing this is that I usually tend to think of falls in older adults as there's these underlying risk factors and then there's the precipitating event. So the precipitating event may be the crack in the sidewalk the curb that they miss whatever it may be. The underlying risk factors are really where the money is at in terms of trying to prevent these in the future and also rehab from the current fall. And those are the things that a provider should kind of dig into some more. And patients can be advocates for themselves about "Hey I think I have these X risk factors for these falls."

You know there are a million different risk factors for falls but kind of the big ones that I think about are if you have trouble with your walking and your balance. So if you can't stand or if your loved one can't stand on one foot for longer than five seconds without kind of tipping over then that right there is an independent risk factor for falling. So problems with your walking either by using a mobility aid or needing to hang on to somebody and then problems with your balance those are major risk factors for falls.

Other common things that I see are troubles with feeling in your feet, so neuropathy because really what that makes it difficult for people to do is to be able to tell where they are in space. So neuropathy is another common risk factor. Troubles with your vision. And then also medications that's a big one.

Interviewer: After somebody has identified either themselves or their loved one has some of the issues that you're talking about what should the next step be? Should they go see their primary care physician or is there a specialist they should see? Where should they go?

Dr. Sanders: I think it's always a good idea to first start with your primary care physician because they have a general sense of overall kind of all of the medical problems that may be going on. And then they can frequently send them to specialists. The ones that we typically get involved in are those kinds of less serious falls and even the more serious falls your primary care physician will likely send you to physical therapy. So our physical therapists here at the U are outstanding at helping to decrease problems with falling.

You know primary care physicians may also just say "You need to get more balance exercises or start to do more balance exercises at home." And there are lots of programs in the community that can help older adults achieve those goals as well.

Rehabilitation and Prevention Strategies

Interviewer: And what should somebody look for when it comes to going to a physical therapist to help them develop the skills or the strength to avoid a fall? So at University of Utah ÐÇ¿Õ´«Ã½ we're very fortunate here in Salt Lake City we have the Faint and Fall Clinic where there are experts that have been trained in this sort of thing. If somebody doesn't have access to that type of resource are there specific questions they should ask their primary care physician or their physical therapist when they are referred to ensure that they're getting somebody that can really help them?

Dr. Sanders: I think a common misconception is that when someone falls they think "Oh I need to get stronger." And yes that is true. Their lower extremities may need to get stronger. But it's clearly more important or at least just as important to really focus on balance. So if you're going to a physical therapist and you're wondering what they should be focusing on ask that physical therapist to focus on improving your balance.

Interviewer: And it sounds like it's a little bit of a team effort at times because it sounds like there could be a lot of underlying causes of falls. Who are some other professionals you might want to go to? Like if it's a vision thing obviously you're going to want to go to an eye professional right? Are there other healthcare professionals that people would want to look into depending on their situation?

Dr. Sanders: Like you said if it's a vision problem then going to an optometrist or ophthalmologist to make sure that that's not contributing. Things like cataracts or macular degeneration can be common contributors to falls. The other specialist that I tend to think of is neurology. Especially if there's an underlying neurological disorder like a previous stroke or Parkinson's disease or a Parkinson's-like disorder that is going to increase a patient's risk for falling.

The other thing that is really important to mention is that if you have a fall that is associated with loss of consciousness that takes us down a completely different pathway in terms of trying to think about falls. And so that's really important to mention to your primary care physician. And then oftentimes that will end up resulting in a referral to cardiology.

Interviewer: Let's transition into a more serious fall where perhaps there's a fracture or . . . When we say "more serious falls" what tends to be the case there? What tends to happen?

Dr. Sanders: So a lot of times even the "more serious falls" we really just call them more serious because of the injuries that occur with them. I think it's important to remember that all falls are very serious because they're kind of a miss. You dodged a hip fracture if you didn't get a hip fracture on the fall that happened where you just landed on your knees right? But with the more serious falls, I think things to watch out for or at least to be aware of is again if there's associated loss of consciousness that's really important to let the provider know or the person in the ER know who is evaluating the patient.

I think providers are pretty good about asking about these questions but you're thinking about things like preceding chest pain or other cardiac-related things and then also seizures. So assuming that none of those things happen and we are really dealing with an "accidental fall with other risk factors" then the treatment or the evaluation and treatment is focused on risk factors. And those are things like again vision gait and balance medications. Medications are huge.

Interviewer: And if somebody does experience a fall where they do break a hip or break some sort of a bone what is that rehab? That rehab process probably looks a lot worse than catching it early and working on balance and strength.

Dr. Sanders: That's right. So typically if someone has broken a hip we'll take that as an example then they end up in the emergency room and end up having surgery. And then rehab following hip surgery for a fracture oftentimes ends up involving a stay at a skilled nursing facility for at least a week or even two weeks while the patient is rehabilitating and then transitioning to home and doing home physical therapy or outpatient physical therapy.

Interviewer: Right. And how long is that healing process generally?

Dr. Sanders: I would say to be entirely healed from a hip fracture it is typically on the order of months. So I think the other thing that's really important to impress upon people is that when an older adult has a fall that results in a hip fracture less than a third of older adults that have that happen to them achieve the same level of function that they had prior to the fall. So what that means is that if you were living alone independently using a walker or maybe even a cane you were using a cane to get around and you fall and break your hip the likelihood that you're going to get back to that previous level of living is less than 30%.

Interviewer: If somebody has a serious fall where they do break a bone say a hip is there a way to avoid that 30% chance that you're not going to get back to the same physical level? Are there things that can be done to mitigate that or is that just going to happen?

Dr. Sanders: Yes there are things that you can do to help improve your likelihood of an optimal rehab right? So things like actually doing the rehabilitation so actually doing the exercises that's one. That's not always easy.

Interviewer: Yeah Right.

Dr. Sanders: And then also really pressing your providers to look into those other risk factors for falls. So asking them "Well what about my medications? How is my vision? Do you get a sense that there is any kind of underlying cardiac or neurological problem that contributed to these falls?" That's an important way that patients can advocate for themselves to make sure that they have a good outcome in rehab.

And then the other things are when they get out of rehab making sure that they are doing they meaning the patients are doing things to set themselves up for success for not falling again. So take a look around their house and make sure that they don't have a lot of clutter. Having hand bars or handrails installed in the bathroom. Not having a lot of rugs in the home. We have occupational therapists who can oftentimes come out to the home and do what's called a home safety evaluation and optimize the chances for a successful recovery.

Resources for Falls

Interviewer: Any final thoughts as we wrap up this conversation as far as the topic is concerned recovering from a fall? Like what should somebody know and what are the next steps?

Dr. Sanders: Probably the biggest thing that I would love to get across to people is that fall prevention is the best way to prevent a fall which sounds silly but doing all of these things like making sure you're trying to think about these risk factors for falls before the bad fall actually happens is really important and can make the difference between a loved one continuing to be able to live independently and age in place as opposed to having to live with additional help.

Interviewer: Are there additional resources you would recommend to somebody about this topic?

Dr. Sanders: Yes absolutely. So for people who have either experienced a fall or a near fall or are just curious about what they can do to prevent falls and what kind of exercises they can do, go to your local senior center or the Salt Lake County Aging Services or even if you're not in Salt Lake County the area agencies on aging they have a ton of resources on fall prevention and they actually also offer fall prevention classes for older adults that are free.