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Fall Prevention Strategies for People Living with Parkinson's
By Sheree Loftus, Ph.D.
In 1817, when James Parkinson wrote his essay on the disease that would later bear his name, he observed that, “the patient, on proceeding only a very few paces, would inevitably fall.” Indeed, while aging may put us all at an increased risk for falling, people living with Parkinson’s disease (PD) have twice the risk of their peers. Falls can impact a person’s mobility and quality of life. Falls often result in injuries ranging from minor cuts and bruises to serious fractures and head trauma. It is also common for a person with PD to develop a constant fear of falling, which may become overwhelming.
What Contributes to PD-Related Falls?
While many people attribute falls to the motor symptoms of PD, and certainly these are often to blame, there are many other contributing factors. Being aware of these is a first step to preventing a fall.
The primary motor symptoms of Parkinson’s, such as rigidity (stiffness) and bradykinesia (slowness of movement), along with associated changes in posture, all contribute to risk of falling. Axial rigidity, which is reduced flexibility and adaptability in the neck and trunk, results in postural instability (loss of balance), increasing a person’s chances of falling. Problems with center of mass, or center of gravity, can also contribute to falls. A person’s center of mass is located just below the navel and the legs form the base of support. In PD, it is not uncommon for a person’s center or middle to move away from his or her base of support. This causes people with PD to lose balance during daily activities such as standing up; bending down or forward; turning sharply; and walking while turning the head, dodging obstacles or talking.
Falls may also occur due to impaired postural reflexes (a complex set of movements that we make automatically to maintain our balance when we stand up and walk); postural change (a propensity to lean forward, with stooped posture and shuffling gait); and freezing (the inability to initiate movement, as though one’s feet were stuck to the floor).
Another risk factor for PD-related falls stems from the problem some people with PD have with their vision. Some individuals experience double and blurry vision as well as changes in depth perception, making it difficult for them to scan ground surfaces while walking and to maintain their center of gravity and balance.
There are also nonmotor symptoms that can increase the risk of falls. For instance, it is common for a person with PD to experience low blood pressure when arising from sitting or lying down, which in turn produces lightheadedness and can cause a fall.
Then there is constipation, which increases the risk of bathroom falls because it can lead a person to strain for a bowel movement. This, in turn, can stimulate a vasovagal (drop in heart rate) response and increased or decreased blood pressure — sometimes resulting in dizziness and falls. Constipation also causes physical pressure on the bladder, which contributes to urinary incontinence. This can result in falls as a person rushes to the bathroom and/or slips on lost urine.
Fatigue and exhaustion due to the disturbed sleep or lack of sleep that are so common in PD, are also hidden risk factors, as are stress and emotional reactions to life’s events. While stress tends to worsen symptoms overall, many people with PD also develop increased and sometimes incapacitating fear and anxiety related to falls.
Lastly, there are problems with executive function — that is, the ability to select, inhibit, organize and sequence information and related functions — that is often impaired in PD. Impaired executive function leads to distraction and inattention, causing people with PD to become more susceptible to fall risk.
Medications and Surgery
While medications and surgery for PD will ease symptoms and improve mobility, they usually do not benefit stability and balance. Not only that, but taking four or more medications increases the risk of drug interactions and falls. Some of the complications caused by medications — dyskinesias (twisting and writhing movements) and retropulsion and propulsion (falling back and forward) — may also result in falls.
If a person has previously fallen, he or she is at risk for falling again. A person’s home, if not adapted for PD needs, may also present risks. This could be due partly to the presence of physical obstacles, such as furniture, or because the person is so comfortable at home that he or she is not attentive to the possibility of falling.
How Can PD-Related Falls Be Prevented?
Parkinson-related falls are not amenable to medical and surgical therapies, but there are some actions that people with PD can take to be aware of and lessen their risk.
Talk to the Health Care Team
The first step in prevention is for the person with PD to talk to his or her health care team, including a doctor, nurse and other professionals.
Understanding one’s own risk factors is a crucial fall prevention strategy. A health care professional can help a person assess whether medications, physical condition, stress and/or environmental hazards are contributing to the risk of falls. Correct detection and interpretation of any gait and balance disturbances is essential to planning optimal therapy. The health care team can evaluate balance using measures such as the Berg Balance Scale.
Lastly, a person’s current medication regimen may need assessment and adjustment. Generally, the prescription message when it comes to falls is, ‘less is best.’ An ideal plan includes careful titration (that is, small adjustments in dosages of medication, and/or timing of dosages) that will help to optimize a person’s function. It also includes consideration of decreasing the number of medications the person is taking to minimize adverse symptoms.
Exercise plays an essential role in keeping a person with Parkinson’s disease healthy and maintaining his or her ability to participate in activities of daily living.
For reducing the risk of falls, exercises that specifically challenge and strengthen a person’s balance, address axial rigidity and improve flexibility are ideal. They help a person maintain the postural stability and mobility needed to prevent falls. Exercise also enhances a person’s awareness of the location of his or her center of mass, which can improve balance.
Research has shown that enriched exercises — those that include attentiveness, concentration and focus on activity and movement — may not only be beneficial to balance but may also be neuroprotective, meaning they may slow down, stop or reverse the progression of PD. One such exercise is Therapeutic Qi Gong (pronounced chee gung), an ancient Chinese healing exercise that includes slow and well-designed physical movements that engage the whole body. Qi Gong teaches controlled breathing to reduce stress, slow stretching and self-massage. It works to improve balance and flexibility through weight shifting, axial mobility and walking. The exercises can be done standing, sitting or lying down. In pilot studies, Therapeutic Qi Gong has been shown to be effective in decreasing falls and improving balance in people with PD. It can also help with dyskinesias, freezing, retropulsion and propulsion.
Make the Home Safer
In the home too, there are certain adjustments that can protect against falls. Specifically, the use of adequate lighting and contrasting wall colors can help, as can the choice of patterns to follow in floor tiles or rugs. At the same time, it is good to eliminate glare and clutter, which can be distracting and dangerous.
In the bathroom, the use of non-skid surfaces, as well as the installation of grab bars, can reduce the risk of falls. Getting in and out of the bath and bed can be less cumbersome when a steady heavy chair is used. Raised toilets and low beds also help to reduce injuries when getting up and down.
It may be helpful to place furniture close together so while walking, there is a “touch path” that allows the person with PD to touch furniture to initiate movement, but does not impede the stride. Other tips are to properly maintain — and properly use — such ambulation aids as hand rails, grab bars, canes, walking sticks, wheeled walkers, scooters and wheelchairs. And one more tip: in selecting footwear, be sure to favor safety over beauty.
Fall prevention is an important component of living with PD and avoiding complications that can arise from even the most minor falls. By talking to the health care team, exercising and making the home safer, a person with Parkinson’s can decrease his or her risk of falling and ensure a better quality of life.
Sheree L. Loftus, Ph.D., is a gerontologist and nurse scientist in the Mirken Department of Neurology at Beth Israel Medical Center in New York. Dr. Loftus facilitates Manhattan PD support groups. Her research focuses on complementary care and quality of life in PD.