Falls and dialysis

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The recent death of the actor Gary Coleman after a fall in his home brought to mind the issue of falls in dialysis patients. Gary was best known for playing the role of Arnold in the TV show Different Strokes. He had congenital nephrotic syndrome and had two renal transplants, in 1973 and 1984. Over the last few years he had been on regular hemodialysis. He had dialysis on the morning of his fall and one of his friends reported that he had been feeling very weak after the session. Unfortunately, he fell at home that afternoon and suffered a head injury from which he did not recover.
There are only a few papers that directly address the issue of falls in dialysis patients. One study prospectively followed 308 dialysis patients of all ages for 8 weeks and found that 13% of patients fell at least once with 80% of the falls occurring at home. In the 12 months after the close observation period ended, 4% of patients suffered a fall-related fracture. Falls were independently associated with polypharmacy, increasing age, diabetes, use of anti-depressants and, unsurprisingly, failing functional tests at the beginning of the study period.
Another study divided 78 dialysis patients into younger (less than 65yrs) and older age groups and followed them for 6 months. Rates of dizziness (80%), pre-syncope (50%) and syncope (20-30%) were similar in the two groups but falls were much commoner in the older cohort (38% v 4%). The rate of falls in the older patients was 1.76/patient/year, which is higher than the rate recorded for elderly nursing home residents.
These falls are not without serious consequences, the rate of hip fractures is 3-4 times higher in dialysis patients than in the general population. Some of this risk is related to reduced bone mineral density but some is related to the increased risk of falls. The one-year mortality for hip fracture in dialysis patients is 40-60%.
So what can we do to prevent falls in our patients? The first thing is to identify patients at risk, particularly those who have a history of previous falls. Avoid overly aggressive fluid removal and reduce the number of medications the patients are taking if possible. Randomized trails have demonstrated the effectiveness of a multidisciplinary approach to falls in non-dialysis patients. This includes review of medications, strength and gait testing with targeted training, assessment of the home environment and measuring visual acuity. These strategies are likely to be effective in dialysis patients also and could help reduce the morbidity associated with falls in this vulnerable population.

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