When Dick Van Dyke on his sitcom tripped, then sprawled each week over the living room ottoman, his audience hooted. The slapstick comedy and pratfalls of the Three Stooges, the Marx Brothers or Abbott and Costello have been used as medicine to give very ill patients a few needed belly laughs. And who hasn't chuckled when a cartoon guy, gazing at the sky above, falls into an open manhole.
But in real life, a fall is not the least bit funny. And when an elderly person takes a tumble — even a short one from a curb or a standing position — the chain of events that follows can be catastrophic, the cost to our health care delivery system is huge.
A Big, Costly Problem
One in three adults older than 65 fall each year. Not all hurt themselves and fewer than half of them even mention it to their doctors. But in that age group, falls are the most common cause of admissions to hospitals from trauma. In the decade between 1993 and 2003, fatal falls in that age group increased by 55 percent.
In 2009, 2.2 million falls among elderly people were treated in emergency rooms, with more than half a million of those patients admitted to hospitals at a cost estimated to be more than $28 billion. All too often, falls are fatal. In 2008, more than 19,700 older adults died from an accidental fall.
The odds that a fall will result in a serious injury increases with age. People older than 85, for example, are four times more likely to be seriously injured from a fall than those 65 to 74 years old. And those 75 and older are up to five times more likely to be admitted to a long-term care facility for a year or more following a fall than "younger" seniors.
Frail and Vulnerable
Even when people fully recover from the damage done by the fall, a spill can cascade into events that can culminate in a premature death, which may have very little to do with the actual tumble.
For older people, the possibly deadly progression is the result of bodies that are so frail that coping with everyday tasks, like rising out of bed and getting to the bathroom, are sometimes all they can handle. The trauma of a fall, atop normal frailty and likely pre-existing conditions such as heart disease or diabetes that come with age, seriously challenge muscles and organs, especially among the very old. A 20-year-old likely will spring back up after slipping on a wet tile floor, dusting off and suffering little more than momentary embarrassment. But when a team of researchers analyzed what happened to more than 57,000 people, 4.5 percent of those who were 70 or older and suffered the same kind of ground-level fall, died compared to 1.5 percent of non-elderly individual; only 22 percent of the over 70 group were able to function on their own after they left the hospital.
Hospitals and Nursing Homes
For older people, hospitals and other institutions can be hazardous. Even if the original problem, such as the broken bone of a fall, is successfully treated, the "ordeal" of bed rest takes a toll.
Older people begin hospitalization with some serious strikes against them. They already have lower muscle strength and less aerobic capacity than younger people. They may have a tendency toward urinary incontinence and reduced appetite, simply as a result of aging. A few days in bed makes this all worse, far worse.
Most of us have in our lives heroic elderly friends and relatives. By heroic, I mean people who struggle mightily, and successfully, to manage daily activities. It takes them painful minutes to get out of bed in the morning, many hours to complete their morning chores. They cook simple meals, apply lipstick or manage a shave, toss laundry in the washer and dryer, use walkers to navigate their homes and gratefully ease themselves into lift-assist chairs. With a little help from loved ones, they manage to remain in their homes. For very old people, those struggles are a kind of modest workout and part of what keeps them going.
But just a few days in a hospital bed can change all of that. After three to four days of almost no activity, many elderly patients never get their former level of strength back due to rapid deconditioning. Treatment for the consequences of the fall may have been successful, but the patient can go on to a lingering life of diminished quality.
It's a common story, and indicates some of the true hazards of a fall, especially for a very elderly person. A hip fracture repair can be technically perfect and uncomplicated, yet the decline is set in motion. The injury and the treatment interfere with the aging body's need for daily doses of exercise, no matter how modest. As we age, we have fewer physical reserves to draw from. Under normal conditions, older people make accommodations (a cane, a walker, a lift-assist chair) to keep moving. But a simple fall can send a senior over the threshold and into a future of functional disability.
The Interaction of Aging and Inactivity
Muscle mass and muscle strength go down with age. So does aerobic capacity. To maintain even this reduced strength, people need to move. The efforts of the very old to keep moving can look difficult because they are. As many in their 80s and 90s know, getting old isn't for scaredy-cats. In the absence of such efforts, muscle strength diminishes at the rate of 5 percent a day. Even young, healthy men lose muscle strength at the rate of 10 percent a week when they are confined to bed. What's worse, it takes a whole lot longer to get that strength back than it did to lose it in the first place. So a long period of rehabilitation is required, a difficult task because strength in the legs is the first to be lost.
Bed rest also leads to a loss in plasma volume, which can lead to a feeling of dizziness or actual fainting when a person stands. And it leads to reduced oxygenation of the blood, which can result in confusion. Combine the loss of muscle strength, especially in the legs, with a greater chance of dizziness and confusion, and you can see how dangerous it can be for an older person to attempt to get out of bed and stand. Add to that a combination of pain medications and sleeping pills, and it is no wonder that confusion and disorientation is a common occurrence in the elderly. This increase in confusion helps explain why many older people do attempt to get out of bed, even with the obstacle of bed rails in their way. If the patient is in a hospital because of a fall or any other reason, the hospitalization itself can be a perfect storm of events leading to yet another fall, disability and the need for skilled nursing care.
Strategies to Reduce Falls in Institutions
Hospitals and institutions are very aware of the problems of falls. Health care providers care deeply about their patients. But institutions, since 2008, also have a huge financial stake in reducing falls. They no longer receive payment from Medicare for treating injuries caused by in-hospital falls. Along with bed sores and catheter-associated bloodstream infections, such falls are considered serious preventable events, or, in the jargon of Medicare payment, "never events."
Institutions along with patients and their families can work together to help reduce falls. Hospitals and nursing homes should emphasize the importance of using a call button to ask for help in getting out of bed, going to the bathroom or walking around the room or hallways. Nonslip socks or footwear are now standard in hospital garb — about as flattering as the much-hated open backed hospital gowns, but useful for safety.
The bed should be lowered to a safe height (100 percent to 120 percent of the patient's lower leg length) for getting into and out of bed. Once, hospital personnel thought that a raised bed rail and a bed cranked up to an intimating height would keep people in their beds. They, and patients, learned the hard way that it just increased the damage from a fall as determined patients scaled the rail to make the leap to the floor. Patients, or their family members, should be encouraged to let caretakers know if medicines make them feel light-headed or confused.
Preventing Falls at Home
I've talked a lot about hospitals and other institutions. But there are a lot of things elderly people and their loved ones can do to help avoid a fall in their homes or communities.
Exercise, exercise, exercise. As we age, we should never stop paying attention to daily exercise. It may change in intensity and form, but it never stops being part of a healthy routine. To help reduce the chance of a fall, exercises that strengthen the legs, like walking, are good. And tai chi has been shown to be particularly good for improving balance.
Fall-proof a home by removing tripping hazards such as slippery throw rugs; adding grab bars to showers, tubs and next to toilets; adding stair railings; and improving lighting.
Lighting can improve vision, but older people may need new glasses to help them avoid falls. A lot of elderly people wear bifocals, but bifocals or trifocals can be hazardous in some circumstances, such as looking down to walk down stairs. Make sure vision prescriptions are up to date, and consider single distance vision for some activities.
Cataracts can also impair vision. A recent study for the first time connected cataract surgery to a reduced incidence of hip fractures. Researchers examined records of more than a million Medicare recipients 65 and older who had cataracts. Those who underwent cataract surgery had a 16 percent decrease in hip fractures in the year after the procedure.
Dizziness and drowsiness can lead to falls, and they are two common side effects of a lot of medications. If you or an elderly loved one has such symptoms, it may be time to review medications with a doctor or pharmacist to try to identify drugs that may be causing the symptoms.
And when you're outside walking, take time to smell the roses and notice the sky above. But don't forget the cartoon guy who fell down the open manhole, and notice the beauty around you while you're standing still. While falling down a manhole is unlikely, a lot of urban and suburban neighborhoods have broken or buckling concrete sidewalks just waiting to trip you up.
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