Elderly woman walking with a walker looking at a mural

Falls in the elderly

Falls are common in the elderly and their frequency increases with age. They are a leading cause of injury, hospitalization and institutionalization and therefore have a significant financial impact. Falling can be a significant burden for individuals, their families, and society in general.

Balance and gait require a coordinated interplay of several systems in order to achieve planning, execution and control of movement. All senses come into play and give the information to the central nervous system regarding the environment and the surroundings. The coordination of the neurological and muscular systems is paramount in order to achieve postural control and safe movement. Age-related changes such as muscle weakness, decreased sensory input (poor vision and hearing, decreased proprioception etc) impair the performance of the systems responsible for gait, balance and movement. 

Common risks for falls include intrinsic and extrinsic factors that can occur alone or in combination and contribute to the increased frequency of falls. Some important intrinsic risk factors are cognitive impairment, malnutrition, low blood pressure on standing, Parkinson’ s disease, previous falls, depression, urinary incontinence etc. Some extrinsic risk factors include various medications (antihypertensive, psychotropic, diuretics), poor lighting, loose rugs, slippery surfaces, tripping hazards, lack of handrails, ill-fitted footwear etc. 

Almost 10% of falls result in a fracture or head injury and a significant percentage of fallers suffer from moderate or severe injuries that reduce mobility and functional independence. Falls are a risk for premature death and the 12-month risk of mortality after being hospitalized for a fall is approximately 50%. Even if a fall does not result in serious injury, it may still have serious implications for the subject and his family. The fear of falling can result in social isolation, increase feelings of loneliness and also increase the risk of another fall. Half of those who fall do so repeatedly.

Many people and even health professional accept falls as a normal part of aging. This wrong attitude may not allow careful assessments and interventions that may decrease the health, social and financial implications of falls. Falls should be considered as symptoms of frailty and not as a disease themselves. Early identification of changes in gait, movement, functional performance and fall risk factors, allows the timely implementation of individualized interventions to maintain or improve mobility and functional independence and reduce fall rates.

Since the cause of falls is multifactorial, the interventions required should be multifactorial as well. Most interventions are simple and cheap. A careful review of prescribed medications and the elimination of the ones that may contribute to falls is a first step that needs to be done by the physician in charge. Use of the correct walking aids, home safety alterations like rails, good lighting, removal of loose rugs, the positioning of ramps to even out various levels etc are some of the measures required to reduce the risk of falls. Physical exercise, Tai Chi or yoga may also help coordination and confidence. The overall aim is to maintain or improve mobility and functional independence and reduce fall risk and fall rates.

/by
Elderly couple with eyeglasses talking in front of a laptop

Caught between habit and change

Surviving cognitive decline

The onset of cognitive decline can be frightening. It often involves feelings of loss of control and helplessness coupled with anxiety about the future. It may be a time of struggle and desperation for many people but it can be turned into an opportunity for reflection, preparation and planning for a future that’s more enjoyable than frightening. In the face of cognitive problems, instead of quitting, one should redouble their efforts to sustain a fulfilling and meaningful life.

The first step is assessing one’s limitations with the help of relatives and health experts. Though they may seem insurmountable at first, the effects of most limitations can be overcome to a large extent. Changes in everyday life, the use of technology and also support from family and friends can help people adjust and mitigate the effects of cognitive decline on their everyday life. Sometimes even simple solutions like using a digital pill box with reminders for each medication or enlisting the help of friends and relatives when engaging in complex activities such as planning a vacation can make the difference between remaining active and abandoning favorite activities.

Often, even when cognitive decline has begun, people can maintain their daily schedule with relative ease. This is due to the fact that habitual actions rely on well-established neural pathways that are more resistant to decline as they have been reinforced by continual activation throughout our lives. Furthermore maintaining our preferred daily schedule also has psychological benefits as it provides us with a sense of control and continuity over our lives. Thus we must focus on maintaining our daily life and habits with some help from our loved ones when needed.

The reliance on familiar routines can help mitigate the effects of cognitive decline but it should not come at the expense of adjustability and learning new things. At the same time one must be realistic about the amount of change they can incorporate into their lives. In essence it is a question of where one should invest time and effort. As cognitive decline limits the ability to learn, time and energy should be expended in changes that can bring tangible benefits to one’s life. Remodeling an already comfortable house may be a waste of effort while learning to use a messaging program that allows one to communicate with their children who are living abroad may bring joy to their lives.

It is said that aging is both natural and universal thus we should embrace it and accept what it brings into our lives. Instead of treating the challenges of old age as insurmountable obstacles we should treat them as opportunities to adjust by maintaining a balance between reliance on old habits and willingness to learn and try new things.

What can I do? 

  • As an older adult: Be vigilant for signs of cognitive decline. Ιf they appear talk to your doctor and relatives in order to get the necessary support for mitigating any negative effects in your daily life.
  • As a relative: Offer help and guidance to your loved ones. Sometimes they may need your assistance in order to be able to keep doing some of their favorite activities.
  • As a nursing home / assisted living owner: Make sure that you offer services that allows older adults to mitigate the effects of cognitive decline and continue to engage in activities they enjoy.
/by
Grandmother and grandfather holding their grandchildren on their lap

Urinary Incontinence in the elderly

Urinary incontinence in the elderly is a big issue as it affects the quality of life, causing isolation, depression, infections, institutionalization and physical handicap.

Urinary incontinence increases in frequency as age advances with its prevalence ranging from 30-60%. A third of women over the age of 65 suffer from an overactive bladder and a third of those is associated with incontinence. There is a general acceptance amongst sufferers and doctors that incontinence is a normal consequence of aging and the most common management method seems to be the use of incontinence pads.

There are various types of incontinence which are related to different causes and have varying characteristics. Stress incontinence is defined as loss of a small amount of urine during coughing, laughing, sneezing and various conditions that increase the intraabdominal pressure. Most of the time stress incontinence is related to weak pelvic floor musculature.  

The second type of urinary incontinence is urge incontinence, which is characterized by small amounts of urine leaking before the person can reach the toilet. A person suffering from urge incontinence is unable to postpone voiding after the sensation of fullness. The cause in urge incontinence seems to be an overactivity of the bladder muscle and this can be related to either neurological problems such as dementia, Parkinson’s disease, spinal core injury or structural problems of the bladder such as tumors, stones etc. 

Overflow incontinence is leakage of urine (usually in small amounts) that occur due to overextension of bladder due to retention. Common problems causing overflow incontinence are amongst others an enlarged prostate in men, a contractile bladder due to multiple sclerosis, spinal cord injuries etc. 

Finally, functional incontinence is usually related to physical (e.g. mobility problems, arthritis), cognitive impairment such as severe dementia or other neurodegenerative diseases or psychological unwillingness such as depression and others. Essentially in patients suffering from functional incontinence, the problem lies in getting to and using the toilet when the need arises.

The assessment in cases of incontinence is focused in careful medical history taking, evaluation of related risk factors, physical examination, urine analysis and some more special tests which will help to ascertain or exclude possible causes of the incontinence. Depending on the type and possible causes, various interventions may help to improve or correct the incontinence. Cognitive and behavioral therapy have good results especially in the elderly patient with good function, by changing their toilet habits and retraining them to adopt more suitable routines for their problem. The benefit of behavioral therapies is that there are no side-effects, but they do require motivated and cognitively able patients. These kinds of approaches are not recommended in overflow incontinence patients.  

Physical therapy in the form of pelvic flow exercises is used to optimize sphincter function and urine retention. This kind of approach is best suited to patients with stress incontinence. Pelvic floor electrical stimulation can represent a possible treatment for patients who can not perform pelvic floor exercises however these treatments can be uncomfortable or cause occasionally urinary tract infection. 

Drug therapy is used to treat patients with incontinence but the adverse effects associated with the various medications may hinder their use in the elderly. Diapers and pads can be used as a sole intervention or to aid other interventions mentioned above. As a last resort, indwelling bladder catheters can be used with potentially serious problems related to infection and therefore should be used with caution. 

In general specialist advice is recommended most of the time for the management of urinary incontinence and a multidisciplinary approach is preferred. Physicians, urologists, gynecologists, physical therapists, psychologists and specialist nurses are all required to work as a team to help the patients and their carers for this distressing problem. 

/by