HEALTH: Aging; Finally, Doctors Ask if Brutal Falls Need Be a Fact of Life for the Elderly
Published: December 29, 1988
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Dr. Ray studied 1,021 Medicaid patients in Michigan who had hip fractures in 1981 and 1982, and compared them with 5,606 patients who did not. He found that the users of the medications had twice the risk factor. He later repeated his findings in a non-Medicaid population.
Dr. Ray explained that psychotropic drugs ''produce a residual sedation so the user will feel lethargy, confusion and loss of motor coordination the morning after taking them.''
In addition, some drugs that are used to lower blood pressure can foster postural hypotension, a sudden drop in blood pressure that causes dizziness and fainting.
Perhaps the most comprehensive approach has been taken by Dr. Mary Tinetti, an assistant professor of medicine at the Yale University School of Medicine. Her paper on risk factors was published today in The New England Journal of Medicine.
Like Dr. Wolfson, Dr. Tinetti surveyed two distinct groups of elderly people: nursing home patients in Rochester, N.Y., and community residents in New Haven. In both groups, complete physical, psychological and balance and gait assessements were performed with year-long follow-ups. About one-third of the subjects fell at least once during the project. #9 Risk Factors Among the nursing home residents, Dr. Tinetti found that nine risk factors distinguished people who fell from those who did not: balance and gait, vision, hearing, depression, dementia, back flexibility, postural blood presssure, the number of medications and the need for help with more than two basic daily activities.
''As the number of risk factors increased in any individual, then the chances of falling increased,'' she said. ''We found that none of the people with three or fewer risk factors fell. One-third of those with four to six factors fell, as did 100 percent of those with seven or more.
''We also looked at what the factors were that distinguished those who were injured in falls from those who were not and found that people with weaker lower extremities were more likely to be injured,'' she continued. ''In addition, women were more prone to injury than men, probably because osteoporosis is more common to women.''
In her follow-up study of 336 New Haven residents over the age of 75 who were living independently, she found six risk factors most closely associated with falling: sedative use, dementia or changes in mental status, any disability of the legs, signs of central nervous system disease, balance and gait problems or severe problems in the feet.
She said the researchers also looked at the circumstances of the falls; 10 percent occurred during acute illness and 5 percent while the person was doing something hazardous like standing on a chair. In 44 percent of the falls, something in the environment was a factor. For example, she said, the people tripped on a rug or fell in an area of dim lighting.
Compounding the problem are the attitudes of elderly people.
''The likelihood of falling is modified by what you choose to do or not do,'' said Dr. Stephanie Studenski, an assistant professor of medicine at Duke University who is director of rehabilitation at the Durham Veterans Administration. ''Those who restrict their activities because they feel unsteady may not fall because they don't do anything.'' Impact of Weeks in Bed
But Dr. William J. Evans said the tendency to do nothing can increase the risks. Dr. Evans is chief of the physiology laboratory at the Human Nutrition Research Center on Aging at Tufts University and an authority on strength in the elderly.
''I believe that most fall problems are due to profound muscle weakness from not doing anything,'' he said. ''The focus is to have the institutionalized elderly be as little problem as possible, so in many cases they are put to bed. Two weeks in bed can cause bone loss equal to that of a year in normal aging.''
It may be some time before the researchers find conclusive answers about the causes of falling.
Dr. Nevitt said, ''Though we can identify risk factors and predictors to tell us who will and will not fall, there is a lot of work that remains to be done sorting out what those risk factors mean in terms of cause.'' VULNERABLE PEOPLE
Studies of falls by the elderly are focusing on many factors. BRAIN
Mental changes such as confusion or dementia may increase risk. A new theory implicates deterioriation of white matter under the cortex of the brain, leading to an inability to coordinate vision, the sensations in the inner ear and the feet. CIRCULATORY SYSTEM
Cardiovascular or circulatory problems, especially an inability to adjust blood pressure to sudden changes in posture, can cause fainting and falls. MEDICATIONS
Anti-anxiety drugs, antidepressants and other sedating medications can raise the risk. DISEASES
Effects of diseases, such as the tremors of Parkinson's and the pain of arthritis, can cause falls. MUSCLES AND BONES
Muscular weakness can compromise balance and gait. Osteoporosis can weaken bones.
Photo of a special balance platform test being performed (NYT/Jim Estrin); drawing