We know that medication which lowers the blood pressure can cause falls.  This would typically occur on standing up from sitting, with a sudden drop in blood pressure causing a fall.  We also know that medication which affects the brain, such as sleeping tablets or antidepressants can cause falls.  This seems logical as they may cloud the full function of the brain, nerves and blood pressure.

What seems less obvious is the result of a large research study which found that taking four or more medications was a risk factor for falling.  To understand this a bit more, I will explain the study itself.  Approximately 1280 older people were followed over the course of a year.  At the beginning of the study period, various observations were made, including details of the medications and other medical problems.  Different measurements were taken over the course of the year.  At the end of the study the researchers explored the data to see if they could find any way to predict who was more likely to fall.  They found that people who were taking four or more medication were more likely to fall.

This study is over 10 years old now and the types of medication we take now are very different.  The study is not able to tell us why it is the particular number 4.  But let’s not fixate on why it is 4 and not 3 or 5 or 10.  Let’s use this information to help people.  We can see who is more likely to have a fall and therefore who would benefit from a falls assessment.

Some people have questioned whether being on four medications is a sign of frailty and whether it is the underlying medical problems that are causing the falls.  This is a fine theory.  But other studies have proven that reviewing medication and stopping anything that is unnecessary can prevent falls, which implies (but does not prove) that it is the medication and not the underlying condition contributing to the falls.

 

As we have learnt in week one, even just agreeing on a definition of a fall has been challenging.  So you can imagine all the other difficulties we face in trying to perform research into falls.  For example, falls are under-reported, several risk factors contribute to falls and people often have a complex mix of underlying conditions and medications.  So where we do not have the proof from large, well-conducted studies, we must draw upon the evidence from smaller studies, clinical experience and expert opinion.

The issue is not about reducing a person’s medications to less than four, it is about using the information to recognise and help those at risk.

Tromp AM et al.  Fall-risk screening test: A prospective study on predictors for falls in community-dwelling elderly.  J Clin Epidemiol 2001; 54: 837-844 – abstract available

Leipzig, Cumming and Tinetti Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc. 1999; 47(1):40-50.

In vari-focals, the lower part of the glass contains the lens for reading and the upper part contains the lens for long distance.  In vari-focals the two lenses merge across the glass without the distinct line which we see in bi-focals.

The problem arises when we are up on our feet and need to look down to the ground, the best example is when going down the stairs.  As we look down, our vision looks through the lens for near vision/reading.  This distorts our depth perception and the judgement of where we place our feet, increasing our risk of falls.

As we have seen from the discussions, many people use vari-focals with no problems at all, but other people have difficulty adjusting to them.  We are not asking everyone to stop using their vari- or bi-focals if they like to use them.  What we hope for, is that people can be aware of the risk.  For people who are comfortable using their vari-focals, have an awareness that if falls do become troublesome in the future you could consider changing to single lenses.  The biggest risk is for people who use them outdoors.  For people who are considering using vari-focals, feel confident enough to ask your optician what all of your options are.

Vari- and bi-focal lenses are a well recognised risk for falls among experts. This is based on the results of well conducted clinical trials, small observational studies, clinical experience and expert opinion.  But it remains up to each and every individual to decide for themselves whether to use them, or use separate glasses for distance and near vision.

If you would like to read more about this and make up your own mind, you may find the following links interesting:

The college of optometrists report on falls  

The British Geriatrics Society: why it is important to assess vision for falls prevention

A paper from the British Medical Journal looking at falls:  BMJ 2010; 340 doi:  (Published 25 May 2010, accessed 3 December 2014)

Why do we feel embarrassed when we fall?

For a moment, it seems as though all the eyes in the world are focussed on us, just as we are feeling particularly vulnerable, lying on the ground.  Given that almost everyone who has ever walked on the earth will have experienced a fall at some point in their life, why is it so embarrassing to fall in public?  In fact, we can all probably empathise with someone in this position, having been through it ourselves.

That intense emotional feeling of discomfort which appears immediately on hitting the ground can stay with us for days or even weeks.  In the immediate moments of embarrassment we may try to divert attention away from ourselves by laughing and turning the situation into a humorous one.  Or, we may become angry and to place blame, shifting the focus of attention, and the uncomfortable feeling, away from ourselves.

There is a theory that the feeling of embarrassment is protective in some ways.  It gives us feedback, in a similar way to pain, that the situation is bad for us.  This could make us change our behaviour in order to prevent being in the same situation again.  If we fall in a particular place outdoors, do we change our behaviour at that spot? And if so, do we change in order to prevent injury, or is it to prevent embarrassment?

Previous research has shown that people, who do not experience the emotion of embarrassment, tend to partake in more antisocial behaviour.  So embarrassment may actually serve us and protect us from risky behaviour or putting our heads above the parapet.

Blushing is just one of the physical characteristics of embarrassment.  It is an uncontrollable reflex that makes us very visible to those around us.  Charles Darwin found it fascinating and even wrote a whole book chapter about blushing, describing it as

Blushing arises because the blood vessels in our cheeks react differently to blood vessels in other parts of our body when under stress.  So while our hands might go pale and clammy, our cheeks may turn ruddy.  However, this effect wears off with advancing age and is usually limited to younger people.

Some psychologists believe that blushing is a very useful tool to have in social situations.  It provides an immediately recognisable signal that we know the situation is awkward, that we are able to react emotionally to social situations and that we are not prone to antisocial behaviour.

Will understanding these theories make falling in public any less embarrassing?  Probably not.  But maybe we can accept that sometimes embarrassment may be useful, it may help protect against falls and we shouldn’t be embarrassed by being embarrassed!

We’ve invited course participants on Ageing Well: Falls to tell us the three words they associate with falls.  It’s made fascinating reading, thank you to everyone who has contributed so far.

You can see the most frequently used words in the word cloud above and we’ll be updating this during the course – so it’s not too late to have your say.