Falls are a leading cause of morbidity and mortality in the elderly population and frequently contribute to the need for nursing home placement (Smallegan M, 1983; Tinetti ME, Speechley M and Ginter SF, 1988). Falls have been reported to occur in 68.3% of PD patients over a one-year period (Wood BH et al, 2002), and more commonly in patients with advanced PD (Aita JF, 1982). As such, many patients who have falls are already wheelchair-ridden or bed-ridden, thus necessitating admission to nursing home. Injury from falls is “a serious medical problem” because it may be fatal. About 10% of falls in elderly people result in injuries such as fractures of the hip or other bones, subdural haematoma (bleeding in the brain) and soft-tissue injury (Nevitt MC, Cummings SR and Hudes ES, 1991; Sattin RW, 1992; Tinetti ME et al, 1995).
Despite these observations, falls remain one of the most commonly overlooked problems of sufferers of Parkinson’s. Very often, when a sufferer of Parkinson’s returns to the clinic for follow-up, the busy doctor does not have time to enquire whether there have been falls at home. I have seen many patients who have lost confidence in walking after falling and as a result, they chose not to walk. This has contributed to the patients’ poor quality of life at home. Thus, falls are a very important problem that needs to be identified and treated accordingly.
What are the causes of falls and how to deal with them?
Falls can be due medical factors (PD itself and concomitant medical disorders), home environmental factors and patient factors:
A) Medical factors
a) PD itself
i) Advanced PD
During the advanced stage of PD, the symptoms such as slowness of movement and stiffness of legs are no longer effectively controlled by medications. As a result, when the patient attempts to walk, the body goes forward but the legs cannot “catch up” with the body. This leads to a change in the centre of gravity (poor balance) and subsequently, the patient falls. Another common scenario is when a patient tries to turn while walking. Again, the body turns but not the legs. Needless to say, what happens next is a “loud bang”.
In this case, the patient is advised to seek treatment of specialists. The dose of drugs should be increased and new drugs may need to be added. In addition, brain surgery should be considered.
ii) Postural imbalance
This usually occurs in many patients during the later stage of PD.Unfortunately, there is no effective drug treatment for postural imbalance. Brain surgery (pallidotomy and DBS) has been shown to improve postural balance to a certain extent. Physiotherapists can also help by teaching the proper technique on how to walk around safely (gait training) and improving the balancing of body.
This refers to an episode of “getting stuck” on the floor that lasts several minutes. Typically, it occurs when a patient is trying to walk through a narrow passage such as a door or gate. Some patients may lose their balance and fall.
Sometimes, freezing can be overcome by increasing the dose of Parkinson drugs. Other helpful methods are employing different ways to move, such as pretending to march, and using mental cues – imagine that there are horizontal lines on the floor and trying to step over these lines, counting one to ten, etc.
b) Concomitant medical disorders
As PD and stroke are usually diseases of the elderly, it is not surprising that many Parkinson patients also suffer from stroke. The weakness and unsteadiness caused by stroke adds to the physical disabilities of patients.
ii) Low blood pressure and heart disorder
These have been discussed in the previous articles.
iii) Visual and joint problems
Some elderly people develop cataract, a disease of eye lens, which causes loss of vision. Consequently, they may trip over an object and fall down. Elderly people are also at higher risk of getting knee joint problems (osteoarthritis) that can cause unsteadiness of legs while walking.
These problems can be overcome by consulting the relevant specialists. Cataract surgery is a simple and safe procedure that
Picture 1. The “double-level” entrance to a house is a common cause of falls – it can be easily rectified by building a ramp that enables patients to walk into the house without tripping over.
improves vision. Patients with joint problems can go for replacement surgery.
B) Home environmental factor
Home environment is another area that is often overlooked by both doctors and patients. Sometimes, patients fall simply because of “unfavourable” home environment. This could be a “double-level” floor (Fig. 1), lack of fixtures which patients can hold on to while walking, poorly illuminated rooms, slippery floor, etc. This can be overcome by “home visits”, which aim to “modify” the home environment to prevent falls.
C) Patient factor
Some patients have a tendency of carrying out “risky” maneuvers that can lead to falls, such as turning the body when standing on the same point on the floor. This could be due to unrealistic expectation of patients; most often because they cannot accept their illness.Thus, it is important that doctors try their best to explain the limitations to the patient and the drug treatment in PD.
Falls are a serious problem that is often unrecognized by doctors.The underlying cause of falls should be identified in order to prevent bodily injury and improve the quality of life of patients. Strategies to prevent falls should include home visits and referral to physiotherapists and occupational therapists. It has to be emphasized that as long as a Parkinson’s patient is having falls at home, the management of PD is considered incomplete.
Aita JF. Why patients with Parkinson’s disease fall. JAMA 1982; 247: 515-516.
Nevitt MC, Cummings SR , Hudes ES. Risk factors for injurious falls: a prospective study. J Gerontol 1991;46:164-170.
Sattin RW. Falls among older persons: a public health perspective. Annu Rev Public Health 1992;13:489-508.
Smallegan M. How families decide on nursing home admission. Geriatr Consult 1983; 1: 21-24.
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among the elderly persons living in the community. N Engl J Med 1988; 319: 1701-1707.
Tinetti ME, Doucette J, Claus E, Marottoli RA. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995;43:1214-1221.
Wood BH, Bilclough JA, Bowron A, Walker RW. Incidence and prediction of falls in Parkinson’s disease: a prospective multidisciplinary study. J Neurol Neurosurg Psychiatry 2002;72: 721-725.