Ever heard the story about the sickly woman who makes a deal with the devil? “Give me one more year to walk this earth, unharmed, and then you may take my life,” she requests. He happily agrees. She is granted a year, free from injury, but there is no escaping it. Twelve months later, he collects.
Every time I give a walker to a patient who—until that precise moment—had traveled this verdant earth device-free. I feel like I have made a deal with the devil.
As a physical therapist, I have had the opportunity to work in a trauma hospital, a skilled nursing facility and in people’s homes. I have come to the conclusion that for many of these people, natural movement has narrowed to a 3×2 foot area.
Because of the fear of falling, there is no risk-taking behaviour: no lunges to grab the telephone, no lurching forward to catch the dropped car keys, no plopping down in the chair. There is, as a matter of course, no plopping down.
For these people, falls are a constant threat. This fear translates into an unwillingness to move without external support, and while a walker or cane may prevent a fall today, 2015 research shows that it sets up a tomorrow full of risk.
We have all seen the “shopping cart push” of a patient with a wheeled walker. Walker, left foot, right foot. Centre of mass maintained inside the (artificially widened) base of support. The patient moves in a constant linear manner, almost assuredly in a forward direction. So what happens when an accident or freak of fate forces that person’s mass outside the carefully maintained base of support? The body has no engram or natural protective mechanism off which to operate, and what often transpires is a fall.
Instead of making an easy choice—handing out that walker—nurses and physiotherapists need to step back and ponder the antecedent event: what changed? Why now? What is placing this person in harm’s way today that wasn’t present last week?
The Top 12 Fall Risk Factors
To do this, it always helps to have the facts in front of you, so here’s the top 12 fall risk factors for patients who are in hospital:
- Has a history of falls
- Needs an assistive device or a person’s assistance to ambulate
- Is underweight or obese
- Demonstrates confusion
- Experiences dizziness
- Is incontinent
- Has an order for hydantoin
- Has an order for benzodiazepine
- Has an order for anticonvulsant
- Has an order for haloperidol
- Has an order for tricyclic antidepressant
- Has an order for insulin
In hospital, the solution is often close supervision, physical assistance and tweaking of medications. But what about after discharge? What are the options to prevent falls once the patient is back in the community? For a precise answer, it never hurts to look to the Cochrane Database of Systematic Reviews.
Here are the fall interventions that actually work.*
- Group exercise programs and multifactorial interventions (including individual risk assessment) reduce the rate of falls, but not the risk of falling.
- Home safety assessment and modification interventions are effective in reducing the rate of falls and the risk of falling. These interventions are more effective in people at higher risk of falling, including those with severe visual impairment.
- When regular wearers of multifocal glasses are given single lens glasses, all falls are significantly reduced.
- Vitamin D does not reduce the rate of falls or risk of falling, but may do so in people with lower vitamin D levels before treatment.
- Pacemakers reduce the rate of falls in people with carotid sinus hypersensitivity, but not the risk of falling.
- First eye cataract surgery in women reduces the rate of falls, but second eye cataract surgery does not.
- Gradual withdrawal of psychotropic medication reduces the rate of falls, but not the risk of falling.
- An anti-slip shoe devices reduce the rate of falls in icy conditions.
*Notice anything missing? The walker doesn’t make the cut.
Physiotherapists are in the business of preventing falls and the natural solution to a balance deficit is to issue a walker. It’s a common choice. But it’s not enough–it’s never enough–to issue a walker. In fact, such an act may place the patient at a higher risk of injury… and even death.
Just ask the 47,312 older people who are treated annually in American emergency rooms for falls associated with walkers and canes.