It’s one of the most stubborn health care problems in the United States. Every year, it costs the nation tens of billions of dollars, inflicts physical and psychological damage on individuals and their loved ones, robs people of their independence and not infrequently kills them. Yet it has failed to capture the public imagination with marches, high-profile campaigns, or fundraisers.
The problem is falls among people over the age of 65. They numbered 29 million in 2014, leading to some 2.8 million emergency department visits, 800,000 hospital stays and 27,000 deaths. The Centers for Disease Control and Prevention calculated that in 2015, direct and indirect costs of falls totaled $50 billion – about a quarter of that borne by patients and their families.
As the population ages, these numbers are likely to increase. So aren’t there urgent calls to prevent falls?
“It isn’t sexy,” said Dr. Tyson Oberndorfer, assistant professor with the University of Colorado School of Medicine’s Division of Geriatric Medicine. “There is no one single thing you can do to prevent falls. It’s a lot of small things, not magic pills.”
Get it (up)right
But Oberndorfer, who practices in the Seniors Clinic at UCHealth University of Colorado Hospital on the Anschutz Medical Campus, believes the dismal statistics can be improved. He spearheaded the launch last year of the UCHealth Fall Prevention Clinic, which brings together geriatrics, occupational therapy, physical therapy, pharmacy, and social work in common cause to reduce the number and frequency of falls in the highest-risk patients. It’s the first clinic of its kind in Colorado and one of only a handful around the country.
The clinic, which presently sees patients one half-day every other week (Oberndorfer hopes soon to expand the clinic to one half-day weekly) addresses an issue that has for years hidden in plain sight. It’s standard policy in outpatient clinics for medical assistants to ask patients, regardless of age, whether they have fallen in the last six months or are afraid of falling. If the answer to either question is ‘’yes,’’ it’s recorded in the electronic health record. All too often, the information goes no further.
That rankled Dr. Robert Schwartz, director of the Division of Geriatric Medicine at CU, who had long recognized that providers needed processes to treat patients who answered the questions affirmatively. Schwartz brought the problem to Oberndorfer and asked him to find a solution. Oberndorfer’s clinical interest in frailty in the elderly dovetailed with Schwartz’s determination to systematically address fall risk.
“We’ve needed a place in the outpatient setting for patients to be purposefully treated for falls,” Oberndorfer said, “and this multidisciplinary clinic is a venue for that.”
Patients referred to the UCHealth Fall Prevention Clinic by their primary care providers or by specialists first get a medication review from a pharmacist who specializes in geriatrics, including the use of multiple medications, an important contributor to fall risk.
“When somebody has had a fall, the first thing that any physician should do is look at their medications and ask which ones may have contributed to that fall,” Oberndorfer said.
Patients meet face-to-face with an occupational therapist and physical therapist, each of whom assesses their fall risk. After the assessments, the team gathers to review each case and craft a personalized care plan. Oberndorfer then discusses the plan with each patient, gives them a copy, and sends another copy to their primary care physician.
This process takes time: Oberndorfer, for example, schedules 40 minutes for his patient visits but he builds in extra time to accommodate more complex cases. The team approach is critical, he added, because evidence shows that while falls may be caused by a single event – tripping over a rug, say – they are nearly always the result of multiple factors. For example, that trip could be attributed not only to an area rug, but also to poor vision, weak physical condition, harmful medication interactions or side effects – or a combination of all of these things.
The strategies for preventing falls are low-tech but carefully considered. The team’s occupational therapists, for example, interview patients and their caregivers to understand the layout of their homes, the routine tasks they perform, and the seemingly harmless items – like that area rug – that present risks.
“We look at how a person fits into the physical and social environment, based on their current abilities, and how we can sometimes tailor that to keep them safe and engaged,” said Marie Andrews, lead occupational therapist with the clinic, who also specializes in geriatrics.
The protections against falls might be grab bars and no-skid strips for the shower; pads to give height to toilet seats; contrast tape on the stairs to aid vision; recommending eye exams and medication reviews; or shoes that fit firmly to prevent trips. Andrews also recommends community resources that help patients with tasks like yard work or transportation.
There are no cookie-cutter solutions, she said. “There are a lot of questions around literally the structure of the home, such as how the bathroom is set up, socially who is available to assist you, which tasks seem to be the most challenging and demanding,” she said. “The clinic is a forum for patients to talk and problem-solve.”
Physical therapy is another key component of the clinic’s fall-defense approach. It stands to reason that building physical strength is a bulwark against falls. But Oberndorfer also points out that poor conditioning often traps people in a “vicious cycle” that steadily increases fall risk, he said.
“If you don’t exercise, you get deconditioned,” he said. “That weakness further increases your risk of falls. And then, after that first fall, you’re afraid of falling and avoid exercising even more than before.”
Jessica Elliott, a board-certified specialist in neurologic physical therapy and lead physical therapist for the clinic, uses a battery of tests to assess each patient’s mobility, strength, endurance, and balance. She then gives patients specific recommendations for how to exercise, modify their homes and use equipment, such as walkers, to reduce their fall risk. The clinic’s physical therapists also help to coordinate follow-up therapy or community classes and resources to decrease fall risk, she noted.
“We’re trying to give people tools to be more active and figure out how to maximize their quality of life and minimize their risk of falling over time,” Elliott said.
The exercises to reduce fall risk might include slow marching, standing with feet apart and together with eyes open and closed, and standing on one foot. These might sound simple, but for patients at risk of falling, they can be dangerous without proper precautions, like standing in a corner against a wall, Elliott explained.
People can have trouble accepting recommendations, like the necessity of using a walker, Elliott conceded. She counters by describing the long-term benefits.
“Just because we recommend a walker now, it isn’t necessarily forever,” she said. “It’s to be safe in the short term while we address these other factors that contribute to fall risk. And a lot of the physical things, like strength and balance, can really improve with exercise.”
Count Elaine Bindel among those who had some trouble with the notion that she needed a walker to get around outside the home. Bindel, 81, overcame a childhood bout of osteomyelitis in her hometown of Akron, Ohio, and worked straight out of high school as a dental assistant and in other jobs in the medical industry, including a stint as a certified nursing assistant at Craig Hospital in Denver. Along the way, she raised four kids.
Falling wasn’t a concern for Bindel until 2003 in Montrose, Colorado, where she and her husband had settled. Walking their dog, Bindel crossed an innocent-looking patch of water running across the sidewalk. It concealed slippery mud, and she went down heavily, shattering her left elbow.
“It was really a horrible break,” said Bindel, who also broke her left wrist in the fall. “It really scared me from then on.”
Several years later, Bindel said she suffered another nasty fall during a restaurant stop with her husband on their way back from Arizona. It had snowed, but the wooden steps she mounted to a porch were clear. When she reached the top step, though, she lost her balance and grabbed for a heavy trash can that fell on and bruised her left side. A year or two later, Bindel, now living in Denver, was walking the dog when she tripped over a raised piece of sidewalk and tumbled onto a patch of grass, unharmed but shaken up again.
Reducing the risk, facing fear
Bindel’s geriatrician, Dr. Hillary Lum, with the UCHealth Seniors Clinic, referred her to the Fall Prevention Clinic. There, her occupational therapist recommended installing grab bars and non-skid strips in the shower and tub, improving lighting in her apartment – Bindel was recently diagnosed with age-related macular degeneration – and discarding throw rugs. Her physical therapist provided exercises, with pictures, designed to improve her balance. She also uses shoes that provide traction to guard against slipping if she has to walk across snow and ice.
Oberndorfer incorporated these and other suggestions in Bindel’s treatment plan and also caught another potential problem: a periodic fast heartbeat. He referred her to a cardiologist who had her wear a heart monitor and is continuing to evaluate her condition.
“I appreciated so much their input about what I personally need,” Bindel said of the clinic team. “Dr. Oberndorfer looks you straight in the eye and tells you everything he wants.” She said the clinic team has helped to reduce her fear of falling.
But about that walker. Bindel cheerily admits to being vain and confesses she only reluctantly stowed her “beautiful high heels.” She initially resisted her physical therapist’s advice that a walker was her best protection against another fall.
“I didn’t want to give in to that,” she said. “But my physical therapist told me a cane is no help for someone with a balance problem like mine. I discovered I felt more secure with a walker and could walk a little bit faster.”
For Jessica Elliott, stories like Bindel’s can dispel misunderstandings about falls.
“People see falling as a normal part of aging,” she said. “It’s common, but I don’t want people to think of it as normal. People think of it as something that just happens as you get older and there’s nothing you can do about it. I want to let people know that there is a lot that you can do to prevent falling.”
UCHealth also offers an evidence-based fall prevention program called Stepping On.