fall prevention in parkinsons, falls in parkinsons, parkinson's disease, Parkinson's Health

Treatments for Frequent Falls in Parkinson’s Patients: By Dr. De Leon

“Most important thing in life is learning how to fall.”
Jeannette Walls, Half Broke Horses    

 

There are many reasons people with Parkinson’s fall so it’s important to identify the cause correctly in order to solve the problem and prevent fractures and hospitalizations which only increase mortality and disability.Image result for free images of falling

Every patient can experience all these factors at one time or another but is important to note that there is usually one predominant cause which must be addressed if hope to continue mobility and maintain independence.

I believe the reason why sometimes patients don’t seem to get better is because we tend to lump all the causes together and assume that is all due to PD so we don’t get to the root cause. I hope that this will help you guys find the best treatment for your falling issues.

 

One of the reasons patients fall is due to freezing. There you are walking and suddenly your feet are stuck to ground as if super glue had been added to the bottom of your soles. Now you can’t move stuck and there you go down like a log because the center of gravity has shifted forward. How to combat this problem?:

1) Increase Parkinson’s medicines- especially since under medication can cause severe muscle rigidity making legs feel weak and difficult to pick up during normal stride.

2) Physical therapy

3) Visual aids- shoes with laser, laser canes, striped floors…

laser-cane-parkinsons_t

4) AthI7J1FZ3Luditory aids- listening to marches or metronomes

 

 

Second reason why people with PD fall is due to loss of balance. There are many causes for this from neuropathies to decrease visual acuity and everything in between.

  • It is important to note the time and quality of balance issues such as;
  • Is the balance loss sudden?
  • Does it happen when you first start walking?
  • Does it occur after you have been walking for a while?
  • Does it occur in confined spaces?
  • Does it happen when light is dim?
  • Does it occur after going to the bathroom?
  • Is the room or you spinning?
  • Do you feel light headed or swimming headed?
  • Is it related to dyskenesias?
  • Does it happen in uneven terrains?
  • Does it occur when medicine wear off?
  • How do you improve this problem?

As you can see this is a more intricate problem than the first one and requires a good detailed history in order to find the right solution. In order to lead the doctor in the right direction and minimize the guess work is for you to take the initiative and answer these questions.

1) Make sure visual and auditory acuity is good

2) Rule out neuropathies caused by b12 deficiency and diabetes among other things

3) If starts at the onset of gait – make sure not orthostatic – check the blood pressure sitting and standing if drops more than 10 mmHg when standing then you have a problem – few solutions …arise slowly from sitting, elevate one leg when standing  use Ted hose, use meds for low blood pressure (e.g. northera, proamantine) if orthostatic symptoms are severe. Consult cardiology to rule out cardiac disease particularly if blood pressure unstable or if fall or pass out after going to bathroom.

4) Physical therapy – especially Tai-chi, walking on sand, water aerobics in water, walking backwards, and yoga help core balance also improve posture which may contribute to stoop ness causing increase likelihood to fall.

5) Adjust or increase meds- these can help with vision, dyskenesias, and actual balance- in case of Azilect.

6) Make sure hearing is intact and not causing the imbalance problem.

7) Klonopin (clonazepam) for swimming head. May also require vestibular therapy

8) Walking devices especially for uneven terrain

9) If balance problem not cause by any of above but due to PD – I have found Azilect to work great for this issue.

10) If posture is a significant problem besides therapy consider using a back brace or Botox injections if dystonia is involved.

11) Declutter your commonly used living spaces.

12) Make sure walking area is well lit particularly at night.

 

Third reason why people fall is impulsiveness and getting in a hurry while standing, turning, and walking

1) Physical therapy.

2) Occupational therapy

3) Aricept (donepezil) – studies have shown improvement in falls due to improving impulsivity not balance necessarily.

references:

Donepezil May Reduce Parkinson’s-Related Falls – Medscape – Oct 08, 2010

copyright-2017

all rights reserved – Maria De Leon MD

fall prevention in parkinsons, falls in parkinsons, parkinson's disease, Parkinson's Health

Tips for preventing falls and hip fractures in Parkinson’s patients: By Dr. De Leon

First let’s look at the general population in order to understand how big a problem this is and how to avoid falling if possible.

The number of falls increase with age. The reason for this increase is due to a number of contributing factors such as poor vision, decrease hearing, loss of balance, dizziness, and medication effects to name a few. Among older adults, falls are the leading cause of death especially over the age of 65 since in this age group yearly there is a report of 1 out of 3 people fall. These falls often result in emergency room visits due to lacerations, head injury, and fractures commonly of the hip. Older white men are not just more likely to fall and break a hip and die as a result. Although, women have a higher incidence of fractures particularly twice as much as men death rate not associated with them as for men.

Now, add Parkinson’s disease to this equation where the typical Parkinson’s patient still is a white older male; we are really setting ourselves for a whole lot of troubles unless we begin to recognize the risks and begin preventive measures to avoid and minimize not just falls but serious injuries such as hip fractions. Parkinson’s as we all know is a chronic progressive disease which means most of us will live with it for at least 20 years. Even if we have YOPD at some point we will reach and possibly surpass that age limit for which we become at higher risk for falls. If falls occur later in life after age of 75, studies have shown that individuals are more likely to then be admitted to long term care facilities usually indefinitely.

RISKS For FALLING:

  • Advancing age
  • Gender-male
  • Advanced disease stage
  • Freezing
  • Dyskenesias
  • Orthostatic Hypotension
  • Loss of balance
  • Stiffness
  • Visual problems
  • Stooped posture- it tends to put the point of gravity forward making it easier to lose balance and go head first.
  • Dizziness (vasovagal reflex)
  • Medications-(especially using more than 4)
  • alcohol
  • Problems with executive function- forgetting how to walk- consider getting chairs with lap buddy.
  • Sleep disturbances
  • White male
  • Housebound
  • Lives alone
  • Difficulty rising from chair- get one of those self lifting chairs
  • Use of assistive walking devices
  • Previous falls
  • Foot problems- e.g diabetic neuropathies, neuromas, arthritis, gout
  • Environmental hazards
  • Risky behavior-impulsive- consider alarm systems
  • Confusion/cognitive problems –i.e., dementia

As you can see there is an extensive list predisposing PD patients to falls but in general advance in age, with advanced disease plus poor vision, and cognition are primary players in determining risk of falls and hip fractures. Our goal is to learn to recognize these symptoms so they can be treated in order to reduce risk most are modifiable behaviors except for age, ethnicity, gender, and disease state.

Steps in reducing the risk of falls / hip fractures:

  1. Eliminate external factors which can increase falls – open spaces for walking, decluttering, and use floor designs with horizontal pattern to aid in movement. Avoid standing on ladders/chairs. Increase lighting throughout living areas and use night light using only non- glare 100 watt or greater incandescent or fluorescent bulbs. Get glasses with tint in them to help with contrast. Staircases should have non slip surfaces and if needed a stair lift placed. Consider medical alert bracelets- many to choose from. Remove rugs. Wear appropriate walking shoes- do not go barefooted. Make sure assistive devices are the right length. Remove any cords. Use bath aids and rails installed in shower and in toilet area- this is one of the most common areas PD people fall especially in the night!the reason sometimes is due to a vasovagal reaction/passing out. often with meds modified problem is solved but sometimes have to add things like midrodine to raise BP or in rare cases place a pacemaker.
  2. Improve home support- do not be alone.
  3. Increase socialization- join a water aerobics class/ tai-chi/ senior centers, support groups This includes getting into a regular exercise regimen – having a friend join you while you walk or swim is much better!
  4. Modify Medications-**** most important**** –since medication side effects can cause a lot of the risk factors for falls like confusion, sleepiness, dizziness, low blood pressure. Periodically need to review ALL medicines this includes over the counter and natural supplements!!
    1. Keep diaries of times when stiffer, dyskenetic, having any other problems so meds can be adjusted accordingly and may even need to consider surgery such as deep brain stimulation for dyskenesias if that’s the main cause of the falls.
    2. there are many new medications used to treat low blood pressure /orthostatic hypotension such as midrodine, florinef, northera along with compression hose and other tricks to prevent pooling of blood in lower extremities- can be taught by PT/OT
  5. Provide ancillary services –such as PT to improve balance, OT to modify home; both can recommend aid like visual aids or walking devices, helmets to protect brain/skull, etc.  
  6. Involve all of the medical team- multi-specialty. Check for other medical illnesses (strokes, diabetes, high blood pressure, heart disease, cancer, and inflammatory illnesses like arthritis). Evaluate vitamin D levels since these are usually low in PD and can cause confusion and lead to increased risk of fractures due to an increased risk of osteoporosis. Evaluate B12 levels these too are commonly low in Parkinson’s patients which can lead to fatigue, muscle weakness, dementia, and neuropathies. Women may need hormone replacement to increase bone density. Remember that there is an increase in hospitalization and recovery and slightly worse prognosis for PD patients who have hip surgery. MUST prevent at all cost!

Sources:

http://www.pdf.org/en/fall09_fall_prevention

http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

http://www.aafp.org/afp/2000/0401/p2159.html