Dizziness and Fall Prevention: Interview with Lynn S. Alvord PhD
Douglas L. Beck, AuD, speaks with Dr. Alvord about dizziness and vertigo and the medical, behavioral and other causes of falls.
Academy: Good Morning, Lynn. Thank you for your time.
Alvord: Hi, Doug. Thank you, too.
Academy: Your book does an excellent job of explaining and reviewing the vestibular and other systems that contribute to balance, as well as excellent and detailed explanations of screening versus comprehensive balance assessments.
Indeed, I believe that when audiologists think about dizziness and vestibular tests and functions, they tend to think about VOR, vertigo, dynamic posturography, ENG, Frenzel lenses and many other important diagnostic issues and concerns – but we rarely get involved in falls assessment and prevention, and these are key themes of your book. I’d like to focus our discussion this morning on falls and fall prevention.
Alvord: Excellent. We tend to view the situation and the patients through their vestibular, visual, and somatosensory systems, too—but applying that knowledge to the patient’s day-to-day life, helps get us to falls and fall prevention, and arguably, this is the most important part of what we do for the patient.
Academy: Yes, that seems to makes sense from the patient’s pragmatic viewpoint. To the health-care professional, we’re looking for the differential or primary diagnosis, but to the patient, the feeling of vertigo or dizziness, and the disability that presents, as well as how to not fall and get injured are likely much more important!
Alvord: Exactly. I’m glad you brought up the “differential of primary diagnosis” issue. To me, it’s so important to realize that virtually every patient out there is “multifactorial.” When I see or hear “multifactorial” as the diagnosis, I believe it’s a relatively weak statement. Again, yes, it is true, but as diagnosticians, we should be able to give a more exact and comprehensive analysis as to why the patient fell, or why they have an increased risk for falling. In other words, as part of the multispecialty health-care team, we should be able to say something specific about this particular patient…perhaps a vestibular system failure, maybe blood pressure or orthostatic hypotension issues, a visual problem, cognitive issues, peripheral neuropathy. I’d like us to be able to answer the questions—What is the most likely reason the patient fell? Or perhaps, what is the most important thing the patient can do to avoid falling in the future?
Academy: I agree. From the patient’s perspective, the key is pragmatics. And, so, perhaps our responsibility is more than diagnostics and does include an analysis of the potential and likelihood of a fall, as well as falls prevention? You say in the book there are only two reasons we fall. One, is we’re not aware we’re tipping, and two, we’re not able to prevent tipping from becoming a fall.
Alvord: Exactly. To prevent a tipping episode from becoming a fall requires strength, quickness, and coordination. Many of our fall patients simply don’t possess the ability to stop a fall once it’s been initiated, as they are often older people, or they have medical issues that inhibit strength, quickness, and coordination.
Academy: Very interesting and thought provoking. You also say that falls can be medical, behavioral and/or environmental, and you boldly state that behavioral is quite often the problem. Please tell me more about that?
Alvord: Yes. It seems many of us think medical issues would be the primary problem, and of course, medical issues are clearly very important, but perhaps more often, people fall because they do things that cause problems. For example, they turn off the light in the hall and then go up or down the stairs, maybe they shower or bathe without a secure handrail available in case they do get dizzy, maybe they turn too quickly or they stand up too quickly, maybe they rush to answer the door or the phone. So they may indeed have Meniere’s Disease, but they fell because when they felt dizzy or vertiginous, there was nothing to hold on to in the shower. Or maybe they have multiple sclerosis, and they spend most of their day in the wheelchair, but the reason they fell was that as they were getting out of the wheelchair, the railing around the toilet pulled off the wall!
Academy: Yes, that makes good and intuitive sense. So regardless of the primary or differential diagnosis, the patient typically has to address the behavioral issues, to avoid the tipping and the fall.
Alvord: Of course. So whether the patient has dizziness or vertigo, imbalance, poor vision, dementia, weakness, blood pressure issues, cardiovascular issues, neurological disorders, neuropathy, or other medical issues – he or she still has to be very careful to not let behavioral or safety issues initiate a fall.
Academy: And I might add that in the book, page 173, you list quite a number of unsafe items in a “fall-prone” home, such as throw rugs (even the ones taped to the floor); wet surfaces; slippery surfaces; absent handrails and grab bars (stairs, toilets, showers….); pets underfoot; lack of light and night lights; switches on top and bottom of stairs; carpets that are buckling, loose, or too thick; uneven floor surfaces and more.
Alvord: Yes. That’s the essence of it. Fall prevention is the goal, and it’s always the preferred activity, particularly when compared to rehabilitation for a broken hip! So throughout the book, because falls are so expensive with regards to health, money, time and pain, I detail in the book that most falls can be prevented, and I explain how to go about accomplishing these goals.
Academy: What can you tell me about the term “Falls Clinic?”
Alvord: Good question. Many vestibular labs have used the term “Falls Clinic” but I like to state that (to me) a Falls Clinic involves and addresses more than diagnostics. It must extend to rehabilitation and falls prevention, too, across multiple body systems, not just the vestibular system. Further, as we touched on earlier, a falls clinic should involve multiple specialties, medicine, physical therapy, audiology, and more.
Academy: Thanks, Lynn. This really is an exciting and common sense approach to falls and fall prevention. I think your book arguably takes our knowledge of the vestibular system to the next level—one of pragmatics from the patient’s perspective.
Alvord: Thanks, Doug.
Lynn Alvord, PhD, is the director of the Falls Prevention Clinic, Henry Ford Hospital in Detroit, Michigan, and author of Falls Assessment and Prevention—Home, Hospital, and Extended Care, published by Plural Publishing.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.