1. Vestibular (inner ear) Disorders –Vestibular disorders can cause dizziness, vertigo, or loss of balance with certain movements and in certain environments.
2. The use of multiple prescription medications – When a patient is taking four or more prescription medications, the chance of an adverse reaction increases, and the ability to predict interactions between medications decreases.
3. The use of anti-depressant or anti-anxiety medications – These medications can affect reaction time, which is crucial when one is faced with a potential fall. SSRI anti-depressants may have fewer side effects, but it is not clear that they result in a reduced risk of falling compared to tricyclics and benzodiazepines.
4. A drop in blood pressure when standing –Some medical conditions such as diabetes, as well as many medications used to treat high blood pressure, irregular heart rate and bladder problems, can cause a sudden drop in blood pressure when a person is standing. This causes temporary lightheadedness and loss of balance. Postural pre-syncope associated with orthostatic hypotension may result in an increased risk of falling when one assumes the upright position.
5. Weakness or numbness in the feet or lower legs –Numbness, tingling, or feet that feel unusually hot or cold may be a sign of decreased nerve sensation in the feet and legs, a condition known as Peripheral Neuropathy. The sense of touch is an important contributor to balance and orientation. The stretch receptors in the legs, the finger tips, and the soles of the feet, all provide feedback for balance.
6. Degeneration of the Cerebellum– The cerebellum is the part of the brain mostly responsible for balance and coordination. Stroke, medications or aging can compromise the efficiency of the cerebellum and, therefore, the efficiency of the balance system in general. The integration of vestibular, visual and proprioceptive information takes place in the cerebellum. Cerebellar dysfunction can result in slow or inappropriate reaction to self-movement or external visual stimuli.
7. Visual disorders – Vision is an important contributor to balance, so any visual compromise can increase the risk of falling. – Vision plays an important role in balance, and patients with visual deficits have greater risk for falls. Visual problems associated with decreased postural stability include: visual acuity less than 20/50, asymmetric vision impairing binocular vision and depth perception, slow pupillary reaction causing increased adaptation time when going from a lighted to a dark room and vice versa, impaired peripheral vision.
8. Depression – The use of anti-depressants increases the risk of falling. Depressed patients may be more internally (therefore less externally) aware. The use of antidepressants and anxiolytics increase the risk of falling.
9. Impaired Cognition – Lack of awareness of surroundings can increase risks for falling. Patients with impaired cognition may be less aware of their surroundings or more likely to engage in risky activities
Management options for high risk of falling:
For most patients there is no magic bullet or single intervention that will make a significant impact. Identified risk factors may be treated, medications may be reviewed and adjusted, balance retraining therapy can improve postural and gait stability, living quarters can be modified to reduce exposure to fall hazards, and the patient can be educated to avoid fall risk situations. Comprehensive assessment for risk of falling may require examination by more than one specialist. Your primary care doctor should coordinate any assessment or treatment plan.
Credit must be given to Drs. Gary Jacobson and Devin McCaslin at Vanderbilt University for their pioneering work in developing fall risk assessment techniques. The above list is a modification of various risk factors discussed in the chapter (26) Assessment of Falls Risk in the Elderly from the book by Gary Jacobson and Neil Shepard, Balance Function Assessment and Management, Plural publishing.
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