Pulse
Fatal Missteps
More older Minnesotans are dying from falls, but physicians and other experts have sure-footed advice on how to reverse that trend.
Last November, the National Center for Injury Prevention and Control issued a wake up call of sorts to public health officials and those who work with the elderly across the United States. Even when adjusted for age, significantly more Americans age 65 and older—a total of 13,700—died as a result of falling in 2003 than a decade earlier. The fatality rate for men increased 45 percent (to 46 per 100,000) between 1993 and 2003. For women, the corresponding increase was 59.5 percent (to 31 deaths per 100,000), according to researchers from the Centers for Disease Control and Prevention who conducted the study.
The problem is particularly serious in Minnesota, which ranks fourth among the states in the number of fall-related deaths—about twice as many per capita as the national average.
What makes that steep increase in mortality so striking, of course, is the fact that it happened during a decade of advances in the prevention and treatment of osteoporosis, as well as increased public health efforts to identify and treat elderly individuals with brittle bones. (Interestingly, the same report, published last November in the Morbidity and Mortality Weekly Report [MMWR], also said the hospitalization rate for hip fractures decreased 15.5 percent between 1993 and 2003.)
In addition, fall-related deaths are only part of the problem. More than one-third of individuals 65 and older fall each year, with 10 percent of those falls resulting in serious injury. More people 65 and older are hospitalized as a result of falling than any other type of injury (66,149 in Minnesota between 1998 and 2005, compared with 3,677 people in the same age group who were injured in car accidents). And, individuals who have fallen once are also much more likely to fall again.
What happened (or didn’t happen)? The MMWR report wasn’t designed to explain why the increase in mortality occurred, although the authors suggested a possible cause: More Americans are living with chronic diseases that put them at greater risk for falling and make them less likely to survive injuries.
No Simple Misstep
The reasons why people fall are as numerous and complex—and intertwined—as the documented risk factors: arthritis, depression, low blood pressure when sitting or lying down, muscle weakness, poor vision, impaired cognition, poor balance, medications, impaired gait, and bone disease. “Older people’s bones are so much more fragile. That’s a natural part of aging; peak bone mass is established by the age of 30. After that, we all lose bone mass. The trick is to try to slow that loss through good nutrition, exercise, and osteoporosis medication, if necessary,” says Julie Switzer, M.D., an orthopedic surgeon at Regions Hospital in St. Paul, who has done extensive research on geriatric trauma.
“Usually, the cause [of a fall] is multifactorial—a little weakness, a little joint disease, a little less balance potentially as a result of many different kinds of illness and medicines—all conspire to diminish the ability to recover from a slip, trip or stumble,” says Lawrence Kerzner, M.D., chief of geriatrics at Hennepin County Medical Center in Minneapolis.
Screening Patients
According to the Minnesota Falls Prevention Initiative website, affirmative answers to the following questions have strong value in predicting falls. Physicians and others who care for older adults should use them to screen patients on a regular basis:
- Have you fallen in the past year?
- How many times have you fallen in the past year?
- Are you afraid of falling?
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Why so many Minnesotans fall is in some respects as obvious as the weather. “When it’s cold, snowy, icy, we see a big jump in major falls—in fractures,” says Paul Takahashi, M.D., an internist and board-certified specialist in geriatrics at the Mayo Clinic in Rochester.
Indeed, the fall-related mortality rate here is similar to that of neighboring states in the Upper Midwest.
But severe winters also have an indirect effect on older Minnesotans. Says Kari Benson, project manager for the Minnesota Falls Prevention Initiative: “Older adults may limit their activities in terms of going outside and being active because they’re afraid of falling. Because winter lasts so long, they limit their activity for a long period of time. That decreases their lower body strength and balance, which are key risk factors for falling.”
Staying Upright
There are ways to prevent falls. “It’s not an inevitable part of aging,” Switzer says. The most successful intervention strategies begin with a broad assessment of risks “followed by interventions targeting the identified risk factors,” according to a 2003 review by Yale University researchers published in the New England Journal of Medicine. One study found the gradual tapering and discontinuation of psychotropic medications, including antidepressants and sleep medicines, resulted in a 39 percent decrease in the fall rate.
Takahashi says he devotes much of his time to assessing the medications that his elderly patients take. “People are taking more medications than they were 20 years ago,” he notes. “Which ones aren’t making you live longer, or even more important, better? My major objective is to make sure you’re really having a good quality of life—living at home, spending time with family, being mobile.”
Another example of what might truly work is a model program being developed by Switzer’s colleague, Michael McGonigal, M.D., director of trauma services at Regions, that would treat every fall-related injury to an elderly person as a “sentinel event” that triggers a cascade of questions and evaluations. Does this person have osteoporosis? Has his vision been checked recently? Might he eliminate some medications? Says Switzer: “It makes a fall … an opportunity to shore up care and provide resources.”
The Minnesota Board on Aging is also trying to reduce the number of fall-related injuries and deaths. In October 2005, the board received a three-year, $100,000 grant from the U.S. Administration on Aging to develop the Minnesota Falls Prevention Initiative in concert with the Minnesota departments of Health and Human Services, and public and private partners. Its goal is to increase awareness of the risk of falling both among the general public and health care professionals; to prompt more thorough assessment of individuals’ risk of falling; and to promote evidence-based interventions aimed at reducing falls, fall-related injuries, and deaths. The initiative’s website (www.mnfallsprevention.org) was launched in August.
Whether this nascent effort will have an impact remains to be seen. But if it is to be effective, it clearly demands involvement from—and coordination of—many different specialists. “As orthopedic surgeons,” Switzer says, “we think about fixing the bone. As internists, or endocrinologists, we think about addressing osteoporosis. We forget that we can do some pretty simple things to prevent falls. Because if you don’t fall, usually your bones don’t break.”—Frank Clancy