Balance and gait

If you find yourself bumping into things more often than you used to, or stumbling occasionally and reaching for something to hold on to in order to maintain your balance when you walk, this may be more than the occasional clumsiness that can afflict anyone. Many factors can contribute to poor balance and gait as people grow older. Loss of muscle strength, slower reflexes, and changes in proprioception can all affect balance (see "Physical changes with age," above). You can slow some of this decline by exercising (see "Improve balance and strength," below) and by investing in sturdy footwear that fits properly. Some medications can affect your balance and flexibility (see below).

Medications

Certain medications have side effects that may increase your risk of falling. Taking four or more medications for various conditions — as many older people do — also increases risk. Granted, people usually take medications for very good reasons. But if you are taking multiple medications and are experiencing dizziness or poor balance, it may be time to work with your doctor to reassess which ones are truly needed or whether any can be replaced with something that is not a medication. If you have trouble sleeping at night, for instance, it might be possible to taper the dose of your medication and learn relaxation techniques and other methods to help you fall asleep. One study found that gradually lowering the dose and finally discontinuing psychotropic medications such as sleeping pills and antidepressants reduced the risk of falling by 39%. That's almost twice as effective as removing home hazards such as loose rugs, which another study found lowered risk of falling by 20%.

Antidepressants. Two categories of antidepressants may increase your risk of falling: tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs). Tricyclic antidepressants once were the mainstay of depression treatment but are now a second- or third-line treatment because of concerns about side effects. Tricyclics include imipramine (Norfranil, Tipramine, Tofranil), amitriptyline (Elavil, Endep), nortriptyline (Aventyl, Pamelor), and desipramine (Norpramin). People who take tricyclics are 50%–200% more likely than others to fall and injure themselves, mainly because of side effects such as motor impairment, orthostasis (a drop in blood pressure when you stand up, which can cause dizziness), blurred vision, and daytime drowsiness. The newer SSRIs include citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). SSRIs treat depression as well as the tricyclics but tend to have fewer side effects — and were also thought to reduce the risk of falls. However, a 1998 study of nursing home residents reported that SSRIs increased the risk of falling by 80%, similar to the risk posed by tricyclics. It is not clear why, as SSRIs do not cause motor impairment or orthostasis. It may be that the likelihood of falling increases because of the underlying depression, which itself is known to cause motor impairment and clumsiness, or from a neurologic or medical condition that may precipitate depression, especially in an elderly person.

Heart medications. Certain types of anti-arrhythmic medications, which treat irregular heartbeats, may increase the risk of falls — although it is not clear if the medication or the underlying arrhythmia is to blame. Class 1A anti-arrhythmic medications, also known as sodium-channel blockers, have been most strongly linked to the risk of falling, perhaps because they make some people lightheaded and dizzy — but so can the underlying arrhythmia. Common sodium-channel blockers include disopyramide (Norpace), flecainide (Tambocor), procainamide (Procan, Procanbid), propafenone (Rythmol), quinidine (Cardioquin, Quinidex, and others), and tocainide (Tonocard). If you are on one of these anti-arrhythmic medications, talk to your doctor about alternatives.

Neuroleptics. Originally developed to treat psychotic disorders such as schizophrenia, neuroleptics are also used to treat movement or tic disorders such as Huntington's disease and Tourette's syndrome. Although effective, neuroleptics increase the risk of falling by about 50%. Older neuroleptics such as fluphenazine (Prolixin) and haloperidol (Haldol) are known to cause muscle rigidity and impair movement, which might contribute to falls. The newer generation of neuroleptics such as clozapine (Clozaril) and risperidone (Risperdal) have less of an effect on motor function, although it is not clear if they reduce the risk of falling. It may also be that the underlying disorder is to blame.

Sleeping medications. Medications known as benzodiazepines increase the risk of falling by anywhere from 32% to 48%, depending on the type used. Benzodiazepines include diazepam (Valium), lorazepam (Ativan), and temazepam (Restoril). These can cause clumsiness or unsteadiness, dizziness, lightheadedness, and drowsiness, all of which can contribute to falls. Although newer types of sleeping medications are available that have fewer side effects, their effect on falls has not been studied. It's wise to be aware that any sedative or sleeping medication may make you more susceptible to a fall.

Cognitive impairment

Cognitive impairment increases the risk of falls, but probably does so in different ways depending on the type of impairment. Some types of impairment make it difficult for people to process new information or to shift their attention rapidly from one thing to another. Others might develop problems with visual-spatial function, making it hard to walk without bumping into things. Complicating matters still further, cognitive impairment can result from a range of conditions and factors, including everything from nutritional deficiencies to medications to stroke. If you or a loved one is experiencing cognitive impairment, talk with a doctor about what may be causing it and then determine what you can do to alleviate it — and reduce the risk of falling.

Orthostatic hypotension

If you notice that you get dizzy when you stand, discuss this with your doctor and take a blood pressure test to determine whether you have orthostatic hypotension (see "Blood pressure," above). Review all the medications you are taking to determine whether the dose should be adjusted or the medication stopped. Make sure that you are drinking enough water, as dehydration can worsen the problem.

You can also take practical steps to enable your body to better adjust blood pressure as you move from one position to another. For instance, elevate the head of your bed or add a pillow so that you're not lying completely flat. Rise slowly from your bed in the morning by taking it in stages: Sit up slowly and rest a minute, and then stand up. Wearing pressure stockings at night may help to maintain blood pressure. When you get up from a chair, do so as slowly as possible and hold on to something to steady yourself. Try exercises to improve the flexibility of your ankles, so that you can more readily push up to stand (see "Improve balance and strength," below).

Osteoporosis

Osteoporosis does not increase the risk of falling, but it does increase the risk of suffering a bone fracture following a fall. The bones most often broken are those in the hip, wrist, and spine.

Ask your doctor whether you should have a bone mineral density test, which is recommended for women over age 65, younger women with multiple risk factors for osteoporosis, and for all people who have already suffered a fracture or take medications such as corticosteroids that significantly increase the risk of suffering one.

You can also take steps to prevent or at least slow bone loss, primarily by consuming sufficient quantities of calcium and vitamin D (see Table 2), exercising regularly (see "Improve balance and strength," below), and maintaining a healthy weight. Also ask your doctor about medications that can prevent or treat osteoporosis, such as alendronate (Fosamax) and risedronate (Actonel).

If you already have osteoporosis, or if you are at greater risk of hip fracture because you have lost fat that serves as a natural cushion, you may want to ask your doctor about hip protectors. These plastic or foam cushions, embedded in special undergarments, protect the hip during a fall by absorbing some of the impact. In one study, hip protectors reduced the risk of fracture by 56%.

Vision problems

Many of the vision changes associated with aging (see "Vision," above) can increase your risk of falling. In particular, visual acuity that is less than 20/60, cataracts, decreased depth perception, and reduced contrast sensitivity — all of which can be detected in a standard eye exam — contribute to falls. Although you are probably most aware of your eyes when you try to read something, vision also contributes to how well you can maintain balance. Your eyes convey information directly to your nervous system about where you are in relation to household objects, supplementing other sensory information and your inner sense of proprioception. (If you doubt this, try closing your eyes while lifting your foot off the floor. Most people sway and need to grab on to something to steady themselves.) That's why an annual eye exam and corrective eyeglasses are important in preventing falls (see "Eye examination," above). Installing sufficient lighting, without glare, will also help.

If you need reading glasses, use them only when reading, cooking, shopping, and in other cases when you need to switch your focus back and forth between objects that are close at hand and those that are far away. Bifocals, trifocals, progressive lenses, and other reading glasses can be hazardous when you walk across the floor. If you are looking straight ahead as you walk, the lenses blur objects that are scattered on the floor, thereby partially blinding you to potential hazards. One study found that people who wore reading glasses regularly were twice as likely to fall as those who did not wear such glasses.