By Laura Plantinga, PhD, Bernard Jaar, MD, MPH, and C. Barrett Bowling, MD, MSPH
Why are dialysis patients at particular risk for falls?
Studies show that approximately one-quarter of dialysis patients fall every year, meaning that they are about three times more likely to fall in any given year, compared to the general population. While older age certainly plays a role, there are several other factors that put dialysis patients — regardless of age — at higher risk for falls. In fact, most falls probably result from a combination of factors, usually a combination of long-term “predisposing” risk factors and short-term “precipitating” factors. For dialysis patients, predisposing factors include health conditions like nerve damage from diabetes, weakness from heart failure, or poor circulation in the legs and feet due to peripheral arterial disease; reduced vision; long-term medication use; and reduced physical functioning and/or frailty. Precipitating factors include environmental factors in your home or neighborhood (or even in the dialysis clinic); slippery and/or dark conditions; and low blood pressure and dizziness after dialysis or in response to starting a new medication (see PDF of Table).
What are the consequences of falling?
Falls can damage more than just your ego! Of course, not all falls result in injury, but a pattern of even minor falls suggests that there are underlying issues that should be addressed to prevent future falls. Additionally, even minor falls can create a vicious circle, in which frequent falls result in a fear of falling, which can then reduce physical activity and functioning, which then makes future falls — and associated injuries — even more likely. For dialysis patients, falls are more likely to result in broken bones (fractures), since end-stage renal disease is associated with bone mineral metabolism problems that can result in bone softening (osteopenia). Additionally, fractures that do occur may take longer to heal. Falls are also associated with increased risk of other unwanted outcomes, such as emergency room visits, hospital admissions, nursing home admissions, and even death. Therefore, it is critical to address falls and their underlying causes as soon as possible.
What can you do to decrease your risk of falling?
The most important thing you can do to reduce your risk is to report any falls, “near-misses,” or risk factors for falls to your nephrologist, primary care physician, and/or other providers, as appropriate (see Table). While your doctors are likely aware of any major underlying medical conditions, it is unlikely that they will know about gradual changes in vision, physical performance (strength, balance, walking ability), or environmental conditions. Remember that they most often see dialysis patients in the clinic and sitting still, making it hard to distinguish the patient who easily walked unassisted into the dialysis clinic from the patient who needed help getting in and out of the chair. In some cases, it might be helpful to ask the dialysis clinic nurses, social workers, or dietitians if they can help you access services, rather than wait for doctors, whom you may see less frequently. Note that most of the sources of help listed are at least partially covered by Medicare; your social worker can also help navigate these issues.
While falls assessment is common in geriatric medicine, it is rarely done by busy dialysis clinic providers, who have many competing demands on their time. Thus, advocating for personalized, effective falls prevention for yourself or loved one is important. Preventing falls will help you or your loved one maintain and maximize quality of life and independence.
Laura Plantinga is an epidemiologist and health services researcher at Emory University in Atlanta, Georgia, whose work primarily focuses on improving the equity, quality, and patient-centeredness of U.S. dialysis care. Bernard Jaar is a nephrologist and clinical researcher at Johns Hopkins University in Baltimore, Maryland. He serves as the medical director of a dialysis clinic and his research interests include epidemiologic studies of chronic kidney disease and end-stage renal disease and their related complications. C. Barrett Bowling is a geriatrician at the Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), and Duke University, Durham, North Carolina, whose research focuses on patient-centered care that optimizes function and quality of life over traditional disease-based approaches, particularly in patients with chronic kidney disease.
