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Creating Waves of Awareness

Falls and ‘off legs’
If a person falls on ground suddenly, and is brought to you, it is very difficult to make the case history. Hereunder are given some important points to consider.
Points to assess in the case after a fall
• Circumstances of fall (e.g. place, time of day, witnessed)
• Symptoms before fall (e.g. presyncope/ syncope, palpitations)
• Injuries sustained
• Contributory factors (e.g. dementia, previous stroke, parkinsonism, lower limb joint disorders, foot disorders)
• Previous falls if any
• Previous syncope
• Usual effort tolerance (e.g. able to climb stairs; able to walk on flat; able to manage activities of daily living)
• Walking aids if used
• If fall at home, are there environmental hazards (ask family/carer), e.g. loose rugs, poor lighting, slippery floor?
• Current medications (e.g. sedatives, hypnotics, antidepressants, antihypertensives, multiple drugs)
• Alcohol history
• Social history: living at home or residential/ nursing home resident?

• Key observations and systematic examination
• Injuries sustained (head injury, fracture, joint dislocation, soft tissue bruising and laceration)
• Assessment of mental state (e.g. abbreviated mental status examination of the elderly
• If the patient does not have evidence of acute illness or injury, screening for neurological and musculoskeletal disorders with the ‘get up and go’ test: to ask the patient to stand up from a chair without using the arms, walk several paces and return: can this be done without difficulty or unsteadiness?

Further reading
• American Geriatrics Society, British Geriatrics Society and American Academy of Ortho-paedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatrics Soc 2001; 49: 664–72.
• Kannus P. Prevention of falls and consequent injuries in elderly people. Lancet 2005; 366: 1885–93.
• Parker M, Johansen A. Hip fracture. BMJ 2006; 333: 27–30.
• Falls and ‘off legs’


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Dear Dr Sharma,

In this thread is the main discussion the 'cause' of the fall and investigation into the etiology in order to treat the person? The way to prevent accidental falls when a person slips on a banana peel or a child's toy lying on the staircase are to pick things up off the floor and be careful where we step, but this discussion deals more with inciting factors for a natural fall. Thus, we may be looking at some brain malfunction, weakness or deterioration in some tissue, muscle, nerve or bone capacity?

The example above comes under the category of environmental factors. So, we should not take this causative factor lightly. Fear of falling has been a subject of concern for the elderly. At least one-third of all falls in the elderly involve environmental hazards in the home. The most common hazard for falls is tripping over objects on the floor. Other factors include poor lighting, loose rugs, lack of grab bars or poorly located/mounted grab bars, and unsturdy furniture. Go through the check list of suspicious areas inside and outside the home to reduce risk of falling.

For instance, we can attribute a number of falls to the sudden bone breaks from taking Fosamax and obvious sudden fall to the ground. Taking a close look at the medication a person takes as a contributing factor to falls.

Brittle and weak bones contribute to falls.

Lead toxicity effects the brain and perceptual functions, which could possibly lead to falls. Of the many effects of lead poisoning visuospatial/visual motor functioning leads to imbalances and vulnerability especially in children.

The familiar picture of those addicted to alcohol substance abuse show slurred speech and uncoordinated gate and easy falling leading to brain injury. Alcohol has a toxic effect upon the nervous system.

The elderly and women are most prone to falling. Falls are the leading cause of death from injury among people 65 or over

Impaired vision, inability to focus, cataract and glaucoma may obscure vision.

Sedantary persons who do not have muscle tone or coordination are prone to falls.

Arthritis causes a decreased range of motion, muscle pain and weakness, and joint pain and weakness. This can contribute to instability or pain while in motion—which may cause falling.

Impairments in cognitive processing and motor and sensory loss can disorient your loved one. This can contribute to confusion and falling.

Agitation, irritation, and lack of caring may cause your loved one to not pay attention while in motion. Decreased activity and lethargy may cause muscular weakness which can cause falls.

Symptoms associated with diabetes such as low or high blood sugar, cardiovascular disease, obesity, eye problems, and more, can contribute to falls.

Bunions, deformed toes, painful calluses, or plantar warts may all contribute to pain while your loved one walks, and can contribute to falls.

Abnormal gait, balance problems medication side effects and other symptoms may contribute to an increased chance of falling.
Thanks Debby. A few days back, an attendent of a patient felt down sudenly in my OPD and it was very difficult for me to find out the cause. The main discussion is to find out the causes and the treatment will depend on the cause.
Traditional or Non-Traditional Method to Assist the Elderly Improve Their Balance

The New York Times posted a study that shows how music, movement and exercise can improve balance and reduce risk of falls by half.

We all know the comparisons of infants and the elderly life cycle from birth to death, from needing care and loss of function first on the up-swing and then the down-swing. We learn that elderly who took a eurythmics class designed for young children improved their unsteady 'falling' legs.

We know that those who stutter can speak fluently when singing. Those who cannot speak, somehow are enabled when speaking in rhyme or singing. The Mozart connection of music, movement and language must fire off the parts of the brain that work toward stabilizing and steadying movement and language.

The 12-month trial recruited 134 people, average age 75, who were unsteady on their feet. Half were randomly assigned to weekly, hourlong eurhythmics classes for the full year, and the other half for just the last six months.
The program, developed by the early-20th-century Swiss composer Émile Jaques-Dalcroze, teaches movement in time to music, from Mozart minuets to jazz improvisations. Participants have to walk and turn around, stay in step with changing tempos, learn to shift their weight and balance, handle objects while walking, and make exaggerated upper-body movements while standing and walking.

The two groups were monitored outside of class to determine how many times they fell. In the full-year group, there were just 24 falls over the first six months, compared with 54 among those who were not taking the classes.

Even after the classes ended, the participants maintained their improvements in balance, walked with a more regular gait and enhanced their ability to walk while doing other things, like having a conversation. The study was published online in Archives of Internal Medicine on Nov. 22 and will be in the print edition on March 28.

The paper’s lead author, Dr. Andrea Trombetti of the University Hospitals and Faculty of Medicine of Geneva, Switzerland, said that despite the the striking results, it was still unclear how music affected people’s walking and gait.

Even though we "Don't know how it works" we can still utilize this phenomenal phenomena that supports and steadies a person on their feet. Let's institute more dance and music classes for the elderly so they can get into the swing of things. By providing this synesthetic experience they can get in touch with their bodies, move their muscles, tone up and feel better about themselves. Of course, since their greatest fear and concern is falling, just knowing that risk is reduced by half will give them a boost if they pick up their feet in song and whistle a happy tune. So many excellent benefits associated with music can be put to great advantage for both young and old. As we say with homeopathy, "It works!"

Cutting the budgets of cultural arts classes like music, art and dance makes no sense whatsoever. The cost in illness, accidents, loss of self esteem and more from removing these programs illustrates the poor vision to reduce the short term budget at the cost of long term goals of keeping the mind and body active for good health.
Thanks. Very nice one!


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