“I’ve fallen and I can’t get up” has long been part of the American lexicon, a staple of late-night comedians for generations.
But for older adults – and California’s fragile healthcare system – falling is no laughing matter.
One in three adults 65 and older falls every year. Falls are the number one cause of injury – and death – for seniors in California and across the nation. They are also the largest single contributor to nursing home admissions – a staggering financial burden for both families and governments who shoulder the high costs of assisted living.
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Yet a number of experts and programs around the state are helping California become a leader in fall prevention awareness and training. In a state whose over-65 population is expected to be more than 10 million by 2040 – nearly one in five citizens – this is welcome news.
“Fall is a dirty word,” says Debra Rose, co-director of the Center for Successful Aging at California State University, Fullerton. “Nobody wants to address falls.”
Rose and her colleagues have trained more than 500 instructors under the center’s FallProof certification program using a wide-ranging curriculum that combats the common stereotype that falls are caused simply by physical frailty.
In truth, falls are caused by a combination of risk factors: medications, the surrounding physical environment, poor footwear and age-related decay – which includes vision and hearing.
“People want to find a quick fix for falling, and it’s just not that simple,” says Rose.
Many of Rose’s students are physical therapists or fitness instructors.
“This just adds one more element of expertise to their burgeoning bag of tricks,” she says.
FallProof graduate Kelly Ward, who has trademarked the name “The Fall Prevention Lady,” was once a personal trainer to high-tech firms like Intel. Over six feet tall, lean and muscular, Ward is a striking contrast to seniors nearly a foot shorter in her elder mobility class at a Sacramento Presbyterian church.
Ward steps the 60 and 70 year-olds through a rigorous series of toe lifts, marches, step-ups, and heel-to-toe walks to improve balance and strength. Students use resistance bands for upper body strength, then face a challenging obstacle course.
“They’re not going to get this at senior centers,” jokes Ward, who typically sees improvements in the third week of her six-week program. “The choices you make in your 60’s will determine your vitality and independence of your 70’s.”
Aileen Nitta has taken Ward’s beginner class, and is now in the intermediate course.
“I went hiking in Sedona and hiked two times a day and am glad I had that prep,” she says. “My legs didn’t buckle. And I watched where I was going.”
Low-risk seniors who’ve never fallen can pursue several health-promoting physical activities: walking, biking, tennis, yoga, pilates, and tai chi.
But adults who have already taken a tumble “need a program that specifically targets balance and strength,” says Rose. “You can’t refer them to an aerobics or yoga class.”
In 2009, there were 1,851 deaths and more than 81,000 California seniors over 60 hospitalized due to falls, says Barbara Alberson, chief of the State and Local Injury Control Section. About one-quarter of seniors who suffer hip fractures die in the year following a fall.
The nation’s pioneer in fall prevention is Mary Tinetti, director of the Program on Aging at Yale University, whose early work paved the way for California’s two-day “Targeting Falls in Older Californians” conference nearly a decade ago.
That event spawned creation of the Fall Prevention Center of Excellence, a comprehensive resource both nationally and internationally headquartered at the University of Southern California’s Andrus Gerontology Center.
Center co-director Jon Pynoos says that that physical environments – both indoors and out – are implicated in nearly 40% of falls.
Pynoos describes most contemporary homes as “Peter Pan housing” – built for families who never grow old.
“What I really hate are the modern houses in Architectural Digest with floating staircases, and no hand rails,” says Pynoos. “They’re beautiful designs but disastrous for anybody with disabilities.”
Many falls occur on stairways, which often suffer from dim lighting, worn carpets and single-side hand rails. Pynoos says the best indoor improvements include bathrooms located in the ground floor, walk-in bathtubs, grab bars, non-slip tiles, raised toilet seats, and glare reduction. Older adults need up to three times as much lighting as their counterparts.
Outdoors, Pynoos says cities can do plenty: fix uneven sidewalks, add hand rails, or improve lighting by replacing bulbs or adding new LED or halogen lights. Timed walkways also help seniors cross safely.
Falls can also result from the dizziness and confusion produced by medications – prescribed or over-the-counter.
Dr. Laurence Rubenstein fingers plenty of chemical culprits: anti-depressants, anti-psychotics, blood thinners, or any drugs that modify behavior.
“Drug side effects are a big risk factor in old people.” says Rubenstein, chairman of the Department of Geriatric Medicine at the University of Oklahoma College of Medicine.
Seniors taking six or more medications are at higher risk for falls “even if they don’t include the culprit meds,” he adds.
The drug store can be just as dangerous: sleeping pills, sedatives, Tylenol PM, and antihistamines such as Benadryl or Chlor-Trimeton can all increase the risk of falls.
Experts say proper footwear is also crucial. Seniors should wear non-stick shoes and avoid thick soles.
Around the state, several counties are leading the effort against falls with unique initiatives.
“Tai Chi: Moving for Better Balance” is a streamlined set of eight tai chi forms (simplified from 108) taught for a San Diego County pilot program to more than 60 seniors over six months.
“It’s not as overwhelming to learn but it has all the essential elements for improving balance and reducing the risk of falls,” says Kristen Smith, health promotion manager for San Diego County’s Aging & Independence Services.
Developed for older adults by the federal Centers for Disease Control and Prevention, the program is now being adopted by the San Diego Community College school district.
“Stepping On” is a seven-week fall prevention workshop for 12 seniors covering the full range of fall prevention topics: medical conditions, drug interactions, physical health, and the environment.
“The program is really instilling long-term behaviors,” says Smith.
Though both programs have lost their federal funding, the county says seeds have been planted for future growth.
At Stanford University Medical Center, the Farewell to Falls Program began in 2005 to assess patients who had suffered a recent fall.
Conceived by Ellen Corman, supervisor for injury prevention, the program significantly reduced repeat falls and helped combat the number one cause of hospital admission at its level one trauma unit. It now extends to any at-risk older senior.
StopFalls Napa Valley has sent an occupational therapist into more than 300 homes to conduct a full-scale home assessment spanning physical hazards and health. Fall prevention coordinator Naomi Dreskin-Anderson follows up to ensure social services or materials, such as hand rails, are provided.
“The vast majority of these clients have not had another fall,” says Dreskin-Anderson.
Silverado Senior Living, headquartered in Irvine, houses older adults with dementia and Alzheimer’s disease in six states.
Each of its 23 communities offers mobility training to improve range of motion and gait. Residents are also assessed for medications, dehydration, or infections of the ear or urinary tract – all of which can cause falls.
Rather than confining residents, Silverado has instituted a “dignity in risk” policy that allows residents to roam freely despite potential hazards.
“We allow them to do a lot of wandering inside and out,” says Joann Fetgatter, vice president of quality care.
Silverado’s policy addresses a key irony of elder falls: seniors who are afraid of falling restrict their activities – leading to eventual falls.
Many Silverado residents also wear “hip protector” underwear with additional padding that can reduce fall injuries by 50%. At night, many sleep in low beds above cushioned “landing pads.”
For Silverado, these policies pay off. Fetgatter claims only 4% of residents who fall are injured, and less than 1% of falls result in fractures.
While plenty of fall detectors and alarm systems exist on the market – 43% of California’s in-home caregivers use fall detection technology – prevention experts say they don’t solve the root problem of falls.
“The real thing is to prevent them in the first place,” says Pynoos.