More than a half million older Californians have fallen more than once during the past year, according to new research underscoring the severity of a national public health trend with medical costs exceeding $2 billion annually.
A new study from the UCLA Center for Health Policy Research names falls as “the leading injury-related cause of death and of medical care use among older Californians.” The study’s author and the center’s associate director Steven Wallace urged greater awareness about the risks of falling. He also encouraged health practitioners to ask questions and make recommendations to patients to help prevent future falls.
“It’s a bit horrifying when we consider the number of older Californians who fall repeatedly every year,” Wallace said. “An older person who falls should be regularly counseled by a health care practitioner.”
Wallace’s research found that in 2012 among older Californians falls caused:
- 1,819 deaths;
- More than 72,000 hospitalizations because of injuries; and
- More than 185,000 emergency department visits.
The high California numbers echo similar increases in national falls numbers. Nearly 24,000 people over age 65 died from falls in 2012, according to CDC statistics. CDC data also show falls as the leading cause of death from an injury for older Americans.
Stopping Falls Before They Start
Falls cause a litany of injuries including hip fractures, which can ultimately be fatal, according to the CDC.
Besides obvious physical injuries, falls diminish self-esteem and confidence, fueling a vicious cycle in people who are embarrassed, worry about falling more and subsequently move less. Obesity and diabetes risk increases, plus reduced mobility increases risk for pressure sores, lack of sound sleep and osteoporosis — putting a patient at an even higher risk for fracture.
Diminished mobility also reduces social interaction and independence. An unattended person who falls can languish for long periods of time with dire consequences including death.
“Most falls are preventable if the risk factors are treated early,” said Debbie Rose, co-director of the Fall Prevention Center of Excellence at California State University in Fullerton and director of its Institute of Gerontology.
“It’s always disturbing when primary care physicians don’t address this on a regular basis since falls are one of the highest public health priorities in the 65+ population,” Rose said. “Clearly, you don’t just turn 65 and start falling, but people develop underlying clinical impairments and we need to intervene earlier to identify them.”
Adults may start to notice sensory system changes such as impaired vision as early as age 40, she said. “They’re surprised when they fall right after getting a new prescription for corrective lenses, for example. And muscle weakness doesn’t just begin at age 65, but occurs earlier without regular exercise. Lower body weakness is an important risk factor for falls.”
“We can’t eliminate falls, but we can do something about them,” said Jocelyn Montgomery, director of clinical affairs for the California Association of Health Facilities, a not-for-profit organization representing long-term care providers.
“In an institutional setting you can control some variables, but not all.”
She suggested starting by educating families. “They may say, ‘We don’t want Mom to fall. We expect you to restrain her so she can’t get out of bed.’ The state has come a long way in terms of our decreased use of restraints that actually create a downward spiral for the patient. Issues like instability, balance or poor judgment become worse with restraints.”
Injury risk also can be reduced, she said. “We want to perform a complete analysis of causes, for a fall is not just a fall and each is unique. We do ‘detective work’ and consider the person’s supervision at the time of the fall, what was going on when they fell, where they were, and how they landed.”
More Than an Ounce of Fall Prevention
In his report, Wallace listed fall prevention factors such as:
- Evaluating the relationship between medications and dizziness;
- Improving gait, balance and strength through physical therapy and exercise programs;
- Using assistive devices like canes or walkers to further support balance;
- Making home modifications to reduce “slip and trip risks”; and
- Modifying high-risk daily routines like wearing inappropriate footwear or walking on uneven pavement.
A senior’s first point of contact in the health care system can evaluate the need for those recommendations, said Dan Osterweil, founder of S+AGE or Specialized Ambulatory Geriatric Evaluation in Sherman Oaks, a teaching site for the UCLA School of Medicine’s geriatrics department. Osterweil also is CEO of the California Association of Long Term Care Medicine.
Simply asking a patient who signs in at the front desk, “Have you fallen in the last month?” can really help, he said.
He seconded the UCLA study’s finding that physicians should evaluate a patient’s medication regimen if they fall. “Patients may have hypertension, diabetes, congestive heart failure and be taking multiple medications that increase risk for falls,” Osterweil said.
He recalls once treating an elderly patient who woke up on the floor with no apparent reason for a fall. He later found the patient was taking several sedatives, an antidepressant and drugs for blood clot management, and that the medication mixture likely caused the fall.
“We need to look into our own souls to determine whether prescription medicines we prescribe, or a colleague prescribes, are contributing to falls,” he said. “Also, we shouldn’t assume that when we give advice to a patient today that it’s remembered and followed tomorrow.”
Medicare Benefit for Counseling Would Help, Experts Say
Wallace found that even when older Californians seek medical care for their multiple falls, about two-fifths received “no advice on reducing their risk of falling.”
Rose lamented that the annual “Welcome to Medicare” exam has been a sorely underutilized benefit for all beneficiaries for the past three years. “It’s an ideal opportunity to discuss fall prevention,” she said.
The total number of Medicare beneficiaries is approximately 49 million, Rose said. “With only 1.4 million having used the benefit since 2012, that number equates to only 3% of the total number eligible to receive it,” she said.
Understandably, doctors under pressure to do a lot in less time during a patient visit focus on billable activities, said Wallace.
“A Medicare benefit for counseling those with falls would incentivize providers to be more aggressive in falls assessment and counseling,” said the authors of a 2006 study in the journal Gerontologist.
For providers, Rose suggested resources like the CDC’s Injury Center and its STEADI Tool Kit with resources to help assess and address fall risk in older patients.
The Orange County Healthy Aging Initiative, co-chaired by Rose and infectious disease specialist Helene Calvet at the Orange County Public Health Agency, just developed an annual wellness visit toolkit. The kit includes easy falls screening tools for primary care physicians and other providers eligible to administer those visits, Rose said.
Anyone can use the resources of the Fall Prevention Center of Excellence, she said, a multi-institutional collaborative for fall prevention services and programs in California.
Sharing Responsibility for Fall Prevention
The responsibility for falls education isn’t confined to primary care physicians, said Martin Gallegos, senior vice president of health care policy and communications at the Hospital Association of Southern California.
Gallegos noted that the UCLA study found that just under 60% of people who sought care in an ED and just more than 64% who received hospital-based care reported having conversations about falls.
“From a hospital standpoint, we know the health care delivery system is changing as hospitals become part of integrated delivery networks or IDNs,” Gallegos said. The term defines a network of facilities and providers that work together to offer a continuum of care to a specific geographic area.
“As IDNs cover the entire continuum of care for patients, they also will generate improved communication among all providers, whether pre-op or pre-acute, post-acute or rehab,” he says. “Many in health care believe an integrated network will reduce fall rates and consequences of other chronic conditions, since theoretically, risk factors will be spotted early on. Hospitals will no longer just ‘do their share’ and discharge a patient who simply moves on.”
Additionally, as the Affordable Care Act advocates for more monitoring of patients in their home — including remote monitoring — to reduce hospital readmissions and expenses, hospitals can send providers such as nurses, nurses’ aides or licensed vocational nurses to the patient’s home to assess it for fall risk, Gallegos said. “That’s especially relevant since most falls occur inside the home.”
“We need to change the entire culture surrounding falls and reporting them,” Rose said. “We can create an atmosphere in which older adults feel they can do something about this rather than feeling falls are an inevitable consequence of getting older.”