It’s important to realize that falls among older persons, with their staggering physical, emotional as well as economic consequences, have the potential to impact not only patients, but all members of a family.
In fact, The White House Conference on Aging, held earlier this month, provides an ideal forum as a lead-in to this important topic.
And, as we recently read about George Bush Sr.’s fall and resulting fracture to his cervical spine earlier this month, we are reminded how such injuries can potentially lead to paralysis, immobility, and resulting downstream medical issues that were triggered by the fall. Luckily, Mr. Bush required only a special neck brace to stabilize his fracture to promote healing.
The circumstances that lead up to falls can be related to numerous factors including progressive muscular weakness, compromised neurologic function, poor vision, safety issues, as well as the possibility of fear itself compromising normal movement and activities.
As a start, healthcare providers should have a frank discussion with their patients about falls and their negative downstream consequences. Focusing on primary fall prevention can be one of the best ways to begin to attack the problem.
“We need to be proactive!” emphasizes Gisele Wolf-Klein, M.D., Director, Geriatric Education, North Shore-LIJ Health System, New Hyde Park, New York. “Physicans and health care practitioners need to talk to their patients about falls.”
Falls are more common than you would think. According to the most recent data from the CDC, about one third of older adults over the age of 65 fall each year, Wolf-Klein explains.
And she explains that every year in the U.S., more than 2 million older adults present to the emergency department (ED) because of falls. In fact, according to CDC data, more than 700,000 of these patients were hospitalized, resulting in medical costs exceeding $30 billion dollars.
Breaking it down further, it turns out that falls are the leading cause of both fatal and non-fatal injuries among older adults.
In 2013 alone, the CDC reports that 2.5 million non-fatal falls were treated in ED. In the same year, about 25,500 older adults died as a direct result of a fall.
Wolf-Klein explains that it’s also critical to understand that the death rates related to falls have increased sharply over the 10 years. She alludes to data indicating “that older men are 40% more likely than women to die from their fall, and older white patients are 2.7 more times likely to die form a fall than black or Hispanic patients.”
The STEADI Initiative
Wolf-Klein also touches on the fact that patients’ often do not want to talk about falls and may not be willing to “share such information with their family members or their physicians.”
As Wolf-Klein explains, “The STEADI initiative (Stopping Elderly Accidents, Deaths and Injuries) encourages adhering to a RITUAL, consisting of Reviewing the self-assessment CDC brochure, Identifying risk factors, Testing gait and balance, Undertaking multifactorial assessment, Applying interventions and Later, follow-up.
The medical consequences of falls in older persons are serious, according to Wolf-Klein, and include hip fractures, arm and wrist fractures, subdural hematomas, skin lacerations and bruises.
“Over 95% of hip fractures are caused by a fall,” she explains. “These injuries may require hospitalizations and surgeries, may change forever the functional status of the patient from ambulatory to wheelchair dependent and may trigger permanent long term institutionalization.” In the end, “death may result from a fall,” she added.
“Perhaps the most concerning unspoken consequence is the permanent fear of falling resulting from the fall, which will change the quality of life of the older adult,” explains Wolf-Klein. Wolf-Klein emphasizes that “because they have sustained a fall, they will become hesitant about carrying on with their normal activities, and start avoiding family gatherings, social events.”
They may not share their fear with their family members, she explains, “which could provoke a decision to change their living environment and encourage their sons and daughters into placing them into assisted living.” And it’s possible for family members to also “witness a sudden, inexplicable change in their mother or father activities pattern, refusing for instance to go out on the weekend to visit a beloved grandchild for fear of falling,” she adds.
The Stark Realities Of Aging
“Falls are a common concern for older adults,” explains Laurence Z. Rubenstein, MD, MPH, FACP, Professor and Chairman, Donald W. Reynolds Department of Geriatric Medicine, The Donald W. Reynolds Chair in Geriatric Medicine, The University of Oklahoma Health Science Center. “Our bones weaken over time and any number of factors common to old age—from taking more or certain types of medication to managing poor vision or issues with balance—may predispose us to falls later in life.”
Most falls “only cause bruises and scrapes,” Rubenstein describes, “but up to 30% result in cuts, broken bones, head trauma, or other serious injuries requiring trips to the emergency department.”
Rubenstein further explains that death rates due to falls “seem to be on the rise among older adult populations, but we need more research to determine whether that’s because of an actual increase in falls or some other factor, such as greater sensitivity to reporting fall-related deaths.”
According to Rubenstein, a large percentage of the precipitating risk factors for falls can be treated or corrected, with a strong focus on fall prevention. “A regular review of your progress with fall prevention is part of standard care, and a doctor, nurse, or other healthcare professional can and should evaluate your personal situation at least annually to determine what can be done to lessen your risk for falling,” he added.
“Some easy interventions,” Rubenstein suggests “can include adjusting your living environment to ensure that you have proper lighting, a path for walking clear of obstacles, and tools like grab rails in problem areas like the bathroom.”
“Staying physically active by exercising when you’re able to is also a great way to strengthen muscles and improve your balance. For people who have fallen in the past or who are at high risk of falling in the future, a healthcare professional may also be able to identify an underlying medical cause,” added Rubenstein.
An an example, he explains that you may have a newheart problem that puts you at risk of fainting or “passing out”, “a nerve or joint problem that you weren’t aware of, or a foot disorder that makes walking difficult.” Many of these conditions are manageable, but that can only happen if you speak up about your health history and health concerns, cautions Rubenstein. “One of every three older adults falls each year, but less than half talk to their healthcare providers about it,” he added.
High Risk Patients
Rubenstein’s strongest word of advice is this: “If you or someone you’re caring for is at high risk of falling, consider seeing a geriatrics healthcare professional.”
“These are doctors, nurses, and many others with advanced training in the care of older adults. Through professional groups like the American Geriatrics Society and its Health in Aging Foundation, they can have access to expert advice on how to manage, treat, and prevent falls. New solutions such as the Stopping Elderly Accidents, Deaths, & Injuries (STEADI) initiative announced by the CDC at the White House Conference on Aging held earlier this month can give patients and healthcare providers new ways to approach this serious public health issue.”
“STEADI is valuable,” Rubenstein points out, “as it can provide educational tools to healthcare professionals to help identify individuals at risk for falls and effective options for falls prevention.”
And caregivers and patients alike can learn more about the causes of falls and best practices for falls prevention through websites such asHealthinAging.org.
“They can also help you find a geriatrics healthcare professional in your area who can assess your risk for falls and work with you on strategies to keep you mobile, active, and healthy for as long as possible,” he added.
Take Home Pearls
Practicing primary prevention for falls is critical for providing the best care for patients, according to Deb Houry, MD, MPH, Director,National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
Houry recommends the following approach:
1. ASK patients if they’ve fallen in the past year, feel unsteady, or worry about falling.
2. REVIEW medications and stop, switch, or reduce the dosage of drugs that increase fall risk.
3. RECOMMEND vitamin D supplements of at least 800 IU/day with calcium.
4. New online continuing education is available to help providers ask the right questions. Log in or create an account on CDC TRAIN, then search for “STEADI”.
Economic and Medical Realities
According to Houry, “1 out of every 5 falls results in a serious injury such as head trauma or a fracture with the direct medical costs for fall over $34 billion dollars annually.”
“Long term consequences, including limited mobility and reduced quality of life.” represent important long term effects of falls. “Unintentional falls are the leading cause of both fatal and nonfatal injuries among people age 65 and older,” she added.
The take home message according to Houry is this:
The number of deaths from falls and fall death rates are increasing.
During 2000–2013, she explained “age-adjusted death rates from unintentional falls increased steadily for both men and women aged ≥65 years, with consistently higher rates observed among men. During this period, death rates from falls increased from 38.2 per 100,000 population in 2000 to 67.9 in 2013 among men and from 24.6 to 49.1 among women.”
“A big influence on fall death rates is probably the health of the rapidly aging population. U.S. life expectancy has increased and people are living longer with chronic conditions such as diabetes mellitus, arthritis, and cardiovascular diseases. Along with advancing age, these conditions and the medications used to treat them can reduce older adults’ functional abilities and increase their risk of falling. Such frail older adults are more likely to die if they experience a fall injury.”
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