January 3, 2022
The Health Care Blog
Dr. Henry Mahncke

More than one in four senior citizens fall each year, making it the leading cause of both fatal and non-fatal injuries in older adults. Anyone with a loved one at high risk of falls can tell you it creates constant worry and curtails many of life’s pleasures. And, if that loved one has fallen and broken a hip, too many of those caregivers can share the oft-told tale of how that break was the beginning of the end.

As our population grows and ages, the costs of this widespread risk multiply.  However, recent breakthroughs in the science of brain health demonstrate that we could be taking relatively low-cost, highly scalable, steps to reduce these risks.

Our narrow focus on physical factors is misguided

When we think about the causes of fall risk, we tend to focus on physical factors in our environment, such as trip hazards or unexpected changes in terrain. We might also think of physical factors in our health, like muscle strength, bone density, impaired vision, or medications that cause dizziness.

As a result, most programs to reduce fall risk involve physical things like someone coming to the house to remove trip hazards and add grab bars, and, maybe, a review of medications, suggestions of treatments to strengthen bone density and muscles, and advice to update eyeglass prescriptions.

Those are good actions to take! But they don’t fully address the problem. Right before you fall, there is a moment – just a split-second – when you either regain your footing or fall to the ground. What happens in that moment is all in your head – and addressing that risk may be the most important factor in preventing falls.

What happens when you fall … or you don’t

During that split-second when you go from your upright walking position to hit the floor, there has been a failure in at least one of three systems that keep you on your feet: (1) The “vestibular” or “balance” system which uses hair-like structures in your inner ear – balance sensors –  to monitor your head’s position in space; (2) the musculoskeletal sensory system, which uses posture sensors throughout the body to monitor your body’s position in space; and (3) the visuospatial system of your eyes and brain, which detects changes in the visual scene as you move through space. These three systems constantly send information to the brain when you are walking, so you can make tiny split-second adjustments to your posture, which keeps you on your feet and walking confidently.

Now, visualize yourself walking and then suddenly beginning to stumble into a fall. As you begin to fall, your head begins to move from its balanced upright position to a position at an angle – and that movement activates your brain’s visual motion systems, letting your brain know that some unusual and risky movement is happening. Meanwhile, balance and posture sensors activate, sending information to your brain that something unusual – and probably bad – is going on.

In most cases, your brain takes in all this information in an instant and makes appropriate split-second commands to the body to adjust your posture, so you stay on your feet – but sometimes that split-second information doesn’t get processed quickly and accurately enough… and down you go.

It’s long been well-documented that brain processing speed and accuracy decrease with age – increasing fall risk. It is now also well-documented that by training on appropriate brain exercises both processing speed and accuracy can be significantly improved, even at an advanced age.

Neuroscientists have learned a lot about the role of the brain in falls

Recently, scientists have been interested in whether brain function might explain a lot about fall risk. And it turns out it does. This is particularly true for cognitive performance related to visual processing speed and attention. Studies from the early 2000s showed the connection of visual cognitive abilities to personal mobility, including predicting fall risk and gait issues in walking.

Improving brain function reduces fall risk

Since people with better brain performance have lower fall risk, it might make sense to work to improve brain performance to see if that lowers fall risk. Researchers at the University of Illinois at Chicago had that idea, and they conducted two randomized controlled trials using brain exercises from the commercially-available BrainHQ app — to target the improvement of visual processing accuracy and speed.  The two studies were conducted in very different populations of older adults. One study involved predominately white, residents of up-scale retirement communities aged 70+, and the other involved  African-American, residents of Chicago’s South Side, aged 65+. In both studies, the researchers found the brain training significantly improved standard measures of fall risk and gait with large effect sizes, and, in the latter study, pulled users away from the cusp of high fall risk. These studies show that sharpening cognitive function with brain training – helping the brain process information more quickly and accurately – helps people stay on their feet.

Strengthening brain speed and accuracy to reduce fall risk

Whatever circumstances give rise to a fall, it’s that split-second moment at the beginning of the fall – when your brain can quickly process information and order adjustments to prevent the fall – that makes the final determination of whether you fall or not. The brain exercises targeted the outcomes of that moment by strengthening the speed and accuracy of split-second reactions to lower fall risk. At the time the studies were conducted, in 2013-2015, this was a novel approach.

A new NIH grant

A new grant from the National Institute of Aging (of the National Institutes of Health) has been awarded to carry this research one step further.  The previous studies provided in-person brain training classes (requiring all participants to visit an academic medical center, three times a week), and measured balance (to estimate fall risk). The new study will be conducted entirely remotely using an online version of the brain exercises with telehealth coaching —meaning people across the country will be able to participate. Study participants will be issued an Apple Watch® to directly record any falls that they actually experience, as well as measure other aspects of walking and balance.

What the future holds

The program to be used under this new grant – online, with telehealth coaching – makes sense in the age of COVID, where telehealth has become commonplace. But it also makes sense in the post-COVID age, because this program can be rolled out to people across the country – in urban centers and rural areas – without requiring participants, who may be at risk for falls, to travel to engage in a program that lowers fall risk and improves mobility. We’re finally starting to see the promises of digital health technologies – inexpensive, accessible, and effective – deliver benefits to people from breakthrough technologies.