Friday, March 30, 2012
Falling: We have nothing to fear but fear itself
By Moses Znaimer, Zoomer Magazine Toronto
I need to regain my balance. —Tiger Woods
Whenever I hear or think about the word “Falling,” the associations that flash into my mind are not all bad. There is, as it happens, a positive, exciting version of “Falling” to counteract the more mundane negative one. I’m speaking about love, of course, and the mysterious human mechanism that renders Vertigo in that realm (“falling in love”) sufficiently intoxicating that we seek it out, no matter how reckless or illogical the situation. Listen to Leonard Cohen’s “Crazy to Love You”, a cut on his just-out late-life masterpiece album, Old Ideas, and you’ll see what I mean. “Had to go crazy to love you,” he sings. “Had to let everything fall.” The singer has no choice in the matter, and neither – fortunately, I’d argue – do we. In matters of the heart, I’m all for the risk and passion of Falling. In matters physical, on the other hand, I’m far more pragmatic; and my watchword is Balance.
This year, if current trends continue, about a third of Canadians over the age of 65 who are still living at home will suffer a fall. Half these people will be injured in one way or another; 25 per cent of them significantly and, 20 per cent of those badly enough that they’ll end up in the hospital. They won’t be alone – almost 62 per cent of all injury-related hospitalizations for seniors are the result of falls. (Second only to car accidents, falls are implicated in an amazing 29 per cent of all injury-related hospitalizations for all Canadians.) Nine out of 10 hip fractures suffered by Canadians are caused by falls; and one out of five who break their hips will die within a year of the accident (U.S. figures, even more dire, suggest that a full 50 per cent of seniors who are hospitalized in that country because of falls will not be alive after a year). In other words, dangerous falls are tantamount to an epidemic in the aging population. The conventional reasons given for this are widely known: our bones become more brittle as we age, our muscles weaker and our spatial orientation (the sense of where we are) is diminished. But as undeniable as these deficits are, they’re more the cause of the injuries we suffer when we fall than the cause of falls themselves. The vast majority of the falls are actually the result of the malfunction of a critical “sense” with overtones as metaphysical and poetic as love: our sense of Balance.
Balance is defined physiologically as “the ability to maintain equilibrium against the force of gravity.” Essentially, to function smoothly in everyday life – let alone during athletics or exercise – it’s important that we not tip over. What grants us equilibrium is our ability to process stimuli from our inner ear, our eyes, our legs and our feet simultaneously. It’s an intricate enough process for a nine-year-old; for a 90-year-old, it can be a nightmare. This is because, as we age, the integration mechanisms we use to orient ourselves in space tend to break down.
This breakdown comes in different forms, says Dr. Bruce McFarlane, a 67-year-old family practitioner in Collingwood, Ont., who’s been involved in the study and treatment of balance issues for nearly 20 years. First are conditions associated with aging that can restrict blood flow to the brain and affect balance – “strokes, carotid artery blockage.” Then there’s diabetes, which “can result in a loss of sensation in the feet, which in turn can cause a loss of balance”; and medications themselves, “which we take more of as we age, particularly anti-infection medication like antibiotics.” Deteriorating vision can also affect balance, as can an erosion of our actual position sense, which lets us know, for instance, where our hand is in the dark. “When you reach a certain age,” says Dr. McFarlane, “you’ll notice that when you get up in the middle of the night, it’s way more difficult to get where you’re going than it used to be. Balance again.”
If that’s not enough, our muscle strength does indeed deteriorate as we get older (“It peaks at 40 and goes over a cliff at 60”), as does our flexibility, which restricts our ability to throw out an arm or hand to restore balance when we’re about to lose it. So it’s a tipsy world we’re contemplating, one that without intervention may only get unsteadier. That’s the bad news. The good news is there’s something we can do about it.
One of the most interesting and counter-intuitively simple treatments for a loss of balance is something called the Epley manoeuvre. The Epley is used specifically in cases of the inner ear disorder BPPV, or benign paroxysmal positional vertigo. The absence of balance is always paired with the presence of dizziness. In BPPV, which is more prevalent in older people, the spinning feeling occurs when the sufferer changes the position of his or her head, an action that can disrupt the fluid in our inner ear, which maintains our equilibrium.
In the Epley manoeuvre, the individual sits up straight, then lies back on her back, holds her head in a centred position, then turns to the right and to the left, and then moves back to a sitting position. Each pose is held for approximately 30 seconds and is intended to dislodge calcium particles called otoconia that adversely affect the inner-ear fluid. In romantic Vertigo, this would be like dislodging the object of our infatuation to regain emotional equilibrium. Both involve a kind of “rebooting” of our sense of balance. Success rates for the Epley in treating physical Vertigo due to BPPV range from 80 to 90 per cent.
More widely known in the treatment of balance problems in older people is Dr. McFarlane’s chosen discipline: the 108 moves, often beautiful and hypnotic, that make up Taoist tai chi, a martial arts-exercise discipline that dates from the second century AD. The moves come under a variety of evocative names: Hold the Ball, Turning the Wheel, Step Back to Repulse Monkey and Partition of the Wild Horse’s Mane. As New-Agey as the names are, several studies have shown the marked efficacy of tai chi in easing dizziness and aiding balance. (Of course, the Chinese have known about the therapeutic value of tai chi for millennia, but the sceptical Western mind generally demands “harder” data.)
The most renowned tai chi study was published in 1996 in the Journal of American Geriatric Society by Stephen Wolfe et al. One group of 200 subjects, average age mid-70s, did tai chi for 15 weeks, while another 200 people used a “balance plate,” a tilting platform that required subjects to shift their weight in order to keep a visible line in front of them level. The balance plate portion of the study, which was relatively expensive, tedious and required one-to-one supervision, resulted in no reduction in falls in the six months following the study. The tai chi portion which, with one instructor for a large group, was inherently cheaper and more fun, resulted in a 47 per cent reduction in falls over the next six months. The findings have been replicated several times over the past 15 years. Older people who do tai chi consistently experience less dizziness, more steadiness and improvements in all the balance-building factors: flexibility, lower body strength, position sense and alignment.
But when it comes to one of the greatest risk factors in our susceptibility to falls, our actual fear of falling itself, it’s helpful to return to the idea of “romantic” falling to understand the remedy. It seems reasonable for us to be more aware of the increased dangers of falling as we get older and to exercise extra caution to try to minimize the chances that we will fall. Concern and caution, you’d think, makes sense! But studies show that the more we give in to the Fear of Falling, the greater the likelihood that we will fall. Collected under this general apprehension is the fear of being hospitalized, of being embarrassed, of losing independence and, most acutely, the fear of having to move from home. The result, says Aysha Bindar, an advanced practice nurse currently working on balance treatment at Baycrest Home for the Aged in Toronto, is that people limit their activity. “They may not drink as much fluid as they need to,” she says, “so they don’t have to go to the bathroom as often. They avoid social gatherings, where there may be large numbers of people and furniture to trip over. The fear of falling isolates people and makes them less physically active, which leads to muscle atrophy and depression, which, of course, then puts them at greater risk for falling. And this happens not just in retirement homes but in the community at large.”
So by attempting to overprotect ourselves, we leave ourselves open to greater injury. Isn’t this precisely what happens in the emotional world? The more we attempt to insulate ourselves from the hazards of love – romantic or platonic – the more we leave ourselves open to emotional atrophy and greater depression.
In other words, in trying to keep ourselves safe, we court a fate worse than what we fear. To stay “upright” in this life, we need to cultivate two kinds of balance: physical and emotional. Without risk, we risk falling more and living less, forfeiting the ever more precious moments that make our lives worthwhile.
As Mary Pickford, the Canadian-born America’s Sweetheart of the silent screen, once said: “You may have a fresh start any moment you choose, for this thing we call ‘failure’ is not the falling down but the staying down.”