Preventing Falls In The Elderly: Where DPMs Can Have An Impact

Douglas H. Richie, DPM, FACFAS

   Medications that physicians commonly prescribe for elderly patients can negatively affect all aspects of neuromuscular control of the body during gait. While the use of four or more medications from any category of drugs will increase the risk of falling, identifying certain drugs that can independently increase the risk is more difficult. In general, an increased risk of falling is associated with the following medications: serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents, benzodiazepines, anticonvulsants and class IA antiarrhythmic medications.10 Withdrawal of these medications becomes a complicated issue when considering fall prevention. Many times, the condition patients are taking the medication for is itself a risk factor for falling.

A Closer Look At Lower Extremity Risk Factors For Falling

Most of our elderly patients experience a decline in balance and muscle strength. The combination of this decline with visual and vestibular compromise increases the risk of falling. What, if anything, can we as podiatric physicians do about this?

   Helfand voiced a call to attention for podiatric physicians to realize their role in fall prevention in 1966.11 Few paid notice, especially outside the podiatric profession. Beginning in 1991, the emergence of significant research conducted by a group of Australian podiatrists started a movement that has now placed podiatry in an esteemed position in the role of fall prevention in the elderly.12 As a profession, American podiatric physicians owe a debt of gratitude to Lord and Menz as well as all of their students and collaborators for their monumental contributions to our understanding of foot health and fall prevention in the elderly. Their findings have elucidated four general areas of podiatric risk factors.

   Toe deformity. While previous studies have reported an association of “foot problems” with an increased risk of falls in the elderly, Menz and Lord were the first to attempt to measure the effects of specific foot deformities on balance and functional abilities in older people.12-14 Then these researchers were able to make a connection between foot health and fall risk by showing that people with a history of multiple falls had a significantly higher foot problem score than those who had not fallen.15 These foot problems included (in order of prevalence): hallux valgus, lesser toe deformities, plantar calluses and corns on the toes. The presence of foot problems was associated with decreased performance on functional ability tests such as stair ascent and alternate stepping. This suggested that certain forefoot deformities could compromise balance in elderly patients during dynamic gait.

   Range of motion and toe flexion strength. A series of studies have demonstrated certain physiologic or clinical markers from a foot examination that could be clues to fall risk in the elderly. The first paper on this subject showed that ankle flexibility, plantar tactile sensitivity and toe plantarflexor strength were significant and independent predictors of balance and functional test performance, explaining up to 59 percent of the variance in these measures.16

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