Last week, while shadowing in a rheumatology clinic, I encountered a 76-year old man named Mr. OA. At his last visit a few weeks ago, Mr. OA presented with a large knee effusion (or fluid in the knee) that developed after he fell at home. After a complete evaluation, the rheumatologist diagnosed Mr. OA with osteoarthritis, a degenerative disease of the joints, and then removed a large amount of fluid from his knee in order to relieve his pain. The purpose of the return visit was to administer a steroid injection to further reduce the pain and inflammation in the joint.
When the rheumatologist left the room to get the necessary supplies for the injection, I had a few minutes alone with Mr. OA. He was impeccably dressed and wore a dark gray suit with striped shirt underneath, collar open. Despite his outward appearance, his age was readily apparent. Years of sun exposure had worn on his skin, and he sat with stooped posture, peering upward at me through bifocal lenses. He met the I-know-it-when-I-see-it definition of frailty, though he was certainly better off than many others in his age group.
Having a few minutes on my hand, I took the opportunity to ask Mr. OA about his fall. I learned that he had not fallen once but twice in the past month. Both times occurred at home, once on the stairs and once while carrying a heavy object. After a brief interview, I quickly assessed that his fall was most likely “multifactorial” — a combination of deconditioning, joint instability, and physiologic aging. I also assessed that Mr. OA was at high risk not only for falling again but also for serious harm from falling. Here in rheumatology clinic our role was to treat Mr. OA as a specialist and leave his non-rheumatologic problems to his other health care providers. But as a generalist, I could not ignore that his knee pain and falls were interrelated, and that his falls were potentially an urgent issue.
It turns out that falls are incredibly common in older people. About one-third of “community-dwelling” adults over age 65 have experienced at least one fall in the past year. In the nursing home population this rate nearly doubles to two-thirds. While we typically think of heart disease, cancer, and dementia as major diseases of older people, falls are also an important cause of disability and death in this population. Falls are the number one cause of accidental death in people over the age of 65 years and lead to a host of medical problems, including:
Fractures: Most of us think of fractures as nuisances, but in older people fractures are often disabling and deadly. The worse of these are hip fractures, 90 percent of which occur as a result of falls. One fourth of elderly persons who sustain a hip fracture die within six months of the injury. More than 50 percent of older patients who survive hip fractures end up in a nursing home, and most experience a significant decline in overall quality of life.
Head trauma: Falls can also lead to major head trauma. A patient I recently took care of in the hospital died from bleeding in the brain after a fall.
Psychologic distress: Most falls do not end in death. However, the psychologic impact of a fall or near fall is often disabling. Older adults that experience a fall often develop a fear of falling that may lead to loss of independence and self-esteem and in some cases depression.
I generally avoid being overly dramatic with patients, but I told Mr. OA that he was “one fall away” from a serious, life-threatening event. The two falls he had in the past month were near-misses, and should be viewed as ”warning shots” that without urgent action he risked serious injury or in the worst case death.
In my limited window of time, I thought of how to best intervene. Looking him over once again, I noticed that Mr. OA lacked a basic piece of equipment that might prevent him from falling again — a cane. Upon further questioning, I learned that he had been outfitted with a cane but seldomly used it. He knew how to use the cane and wasn’t embarrassed to use it. He simply was never told by a physician to use it.
My intervention however was cursory. He would benefit most from referral to a fall prevention program. As the causes of falls in the elderly are multifactorial so too are the solutions. A comprehensive fall prevention program would include proper evaluation for assistive devices (e.g., cane, walker), physical therapy, home assessment (e.g., removal of loose carpeting, installation of night lights), medication review, and vision assessment. At least one randomized clinical trial has showed that performing a detailed medical and occupational-therapy assessment of older people who fall and then referring them for the appropriate medical services reduces fractures by 50 percent.*
This case has gotten me thinking about falls, prevention, and health in general:
1. When are we going to take falls seriously? Falls are not a “sexy” medical disease. They are not caused by killer viruses nor do they typically affect young people and celebrities. They are also not treated with cutting-edge surgeries or blockbuster medications. Rather they are diseases of frailty and physiologic aging, best remedied through strength training and night lights. But, at the same time, falls are incredibly important and potentially treatable.
2. When are we going to integrate prevention into medicine? Although Mr. OA was seen in a specialty clinic, he benefited best from being viewed from a preventive health perspective. In my clinical rotations, I have seen smokers in a cancer clinic not counseled about tobacco cessation, sexually active women in gynecology clinic not advised to take prenatal vitamins, and people with obesity in an knee injection clinic not counseled about weight loss. I often find it ironic when doctors debate whether prevention makes sense or saves money. Putting it that way makes it seem that prevention is something outside of medicine, instead of something deeply ingrained within its practice.
3. When are we going to start putting health first? Medicine is becoming increasingly specialized. While this specialization has a number of benefits, it comes with limitations. One of these is the inability to view a patient as a whole person and not as a series of organ-based systems and ask, “How can we better the health of this patient?” Mr. OA is not someone who lacks access to medical care. He has a number of specialists and is on a number of medications. But between the lipid-lowering agents for his cholesterol, blood pressure-lowering agents for his blood pressure, colonoscopies to screen for colon cancer, we have lost sight of what matters most to the patient.
By sheer coincidence, I saw Mr. OA the following day in a department store while coming out of the elevator. As I stepped out into the corridor, I saw him, enjoying the weekend with someone who I imagine to be his wife. He was walking with his usual stooped gait, huge shopping bags in one hand, and to my delight, a cane in the other.
- Shantanu Nundy, M.D.
* Close, J et al. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet. 1999 Jan 9;353(9147):93-7.