Reducing the Economic and Physical Impact of Older Adults' Falls

By Jamie Santa Cruz

Falls are a common part of aging: approximately 30% of individuals older than 65 fall each year, with about one-half of these falls resulting in injury.1-3 Although many fall injuries are not serious, the consequences in some cases are dramatic, in both an economic and a physical sense.

From an economic perspective, a new study has found that the medical costs associated with falls among older Americans reach $50 billion per year. According to the report, Medicare absorbs the largest share, paying out nearly $29 billion for medical costs related to nonfatal falls in 2015. (By contrast, Medicaid paid out $8.7 billion, and private and other payers spent $12 billion.)4

Other research predicts that the number of falls—and their associated medical costs—will increase substantially. One study has estimated that costs will reach $100 billion per year by 2030.5

Aside from the economic impact, falls frequently also have a debilitating physical impact.

"Falls play a very big role in the physical decline of older people," says Jan Busby-Whitehead, MD, division chief of geriatric medicine at the University of North Carolina School of Medicine. "For starters, there's the injury. If people are lucky, they fall and they don't break a bone. But if they do (and older folks are particularly prone to breaking bones), this can be devastating. Hip fractures are the most common type of traumatic injury that leads to hospitalization of older adults."

It's not only the initial injury that is problematic. Older adults who have suffered a major fracture often lose enough strength and mobility while in the hospital that they're not able to return home, Busby-Whitehead says. Instead, they go to a rehabilitation facility or end up in long term care.

Despite the advances in medical care, says Gisele Wolf-Klein, MD, director of geriatric education at Northwell Health, it's not always possible to fix a hip fracture or a wrist fracture entirely. "So one may be left with a limp or a deformity or may never actually succeed in relearning to walk the same way as in the past."

Some fractures, especially spinal fractures, cause chronic pain and result in the need for pain pill prescriptions after the initial event. Opioid medications are commonly prescribed, but because they are addictive, it may be hard for a clinician to taper down and discontinue them. Opioids can cause confusion as well as balance and gait problems, which can lead to additional falls and fractures, Busby-Whitehead says.

Ultimately, the experience of a significant fracture puts individuals at a substantially increased risk of mortality. Indeed, older adults who suffer a severe fracture as a result of a fall have a 1 in 4 risk of death in the year after the fall, compared with only a 4% risk of death for older adults without a severe fracture.6

Factors That Contribute to Fall Risk
One of the most significant factors that play into an individual's risk of falling is medication use. As patients age, they tend to develop multiple comorbidities, most commonly high blood pressure, cardiac issues, and diabetes, Wolf-Klein says. Each of these conditions is typically treated with medication, many of which—both individually and in combination—can increase risk of falls, she adds.

Hypertension, for example, affects more than two-thirds of individuals older than 65,7 but the challenge with medication is making sure the patient is receiving a sufficient dose to drop blood pressure without dropping it too low and increasing fall risk.

A similar problem occurs with treatment of diabetes. "Quite often we see older adults who start eating less or differently or who skip a meal but are still taking their blood sugar medication," Wolf-Klein says. "If you haven't eaten and you take your blood sugar medication or your insulin injection, you can get low blood sugar and that's going to make you feel wobbly and make you fall."

Medications for insomnia, pain, and depression also significantly increase fall risk. Drugs in these categories are known to increase sleep cycle problems and/or cause confusion, Wolf-Klein says.

Nor are prescription medications the only problem: alcohol and certain nonprescription drugs also increase risk. According to Busby-Whitehead, these include diphenhydramine (Benadryl), which older adults often take for sleep.

Aside from medications, a variety of physical conditions can also increase fall risk. According to Busby-Whitehead, these include arthritis (which can make it difficult for older adults to maneuver around their environments), diabetes (with attendant peripheral neuropathy), neurological diseases such as Parkinson's, cardiac arrhythmias, and bad vision.

Older adults' changing lifestyle patterns, particularly with respect to nutrition and hydration, also contribute. Older adults tend to eat less regularly than do their younger counterparts, Wolf-Klein says, in part because driving to the store and actually making food can both become more of a challenge with age. Dehydration is likewise common among older adults—particularly in summer months—and is yet another factor that increases fall risk.

Although both men and women are at risk of falling, women are more likely to sustain a fracture in a fall, Wolf-Klein says. This is largely because osteoporosis is more common in women, but it's also partly due to the type of footwear common among women. While men tend toward wearing comfortable shoes that provide good support, women sometimes continue wearing heels or more fashionable footwear, even if they have an unsteady gait, Wolf-Klein says.

The Provider Role in Mitigating Fall Risk
Fortunately, there are a number of steps providers can take to help their patients reduce the likelihood of falls. Such steps include the following:

1. Ask patients to bring a brown bag with all their medications to their office visits. According to Wolf-Klein, physicians should encourage older adults to bring in everymedication they are taking—including over-the-counter medications, supplements, and any medications borrowed from a spouse or partner. Providers should then evaluate whether there are any kind of adverse side effects from the combination that might contribute to the risk of falling.

When discussing medications, ask about alcohol use. "Alcohol is a hidden concern of which many clinicians are not aware," Busby-Whitehead says. "Patients don't always tell you that they're drinking alcohol, and they don't always share how much they're drinking. You can miss that risk factor, which can cause confusion and gait instability."

2. Take the patients' blood pressure both standing and sitting. Providers need to know both in order to prescribe medication at an appropriate dose, Wolf-Klein says.

3. Assess patients for—and treat—the variety of physical conditions that can precipitate falls. The number of conditions that influence fall risk is large, but providers should be on the alert for the more common ones (such as diabetes and neurological problems) and treat them as well as possible, Busby-Whitehead says. And because bone loss puts older adults—especially women—at higher risk of fracture, providers should make sure to assess for and treat osteoporosis.

4. Consider a Timed Up and Go test to assess fall risk in clinic. In cases where clinicians are not able to do the test in the office, a physical therapist can be recruited to conduct the assessment. For patients who don't perform well, Busby-Whitehead says, physicians should do their best to address the patients' risk factors before a fall occurs.

5. Ask explicitly about fall history. According to Wolf-Klein, patients often won't bring up past fall experiences on their own. Thus, providers need to ask directly. "The very frequent answer that we'll get is, 'Oh yes, I've had a couple falls, but I haven't broken anything, so I haven't mentioned it to anybody,'" she says. "That's a huge problem because if they don't mention it to us, it's impossible for health care professionals to start looking at the reasons for these falls and to take a proactive action to stop the falls from occurring."

6. Evaluate the patients' footwear and eyewear. Any patient at risk of falling should be encouraged to wear athletic shoes, which have good support in the arch and toes. As for eyewear, Wolf-Klein recommends that patients avoid bifocal lenses unless they are extremely comfortable with them because bifocals can distort older adults' depth perception and cause them to trip.

7. Talk with the family or with patients themselves about the patients' home situations.Specifically, providers should make some effort to determine whether a particular patient has any tendencies toward hoarding. "A cluttered home is a dangerous home," Wolf-Klein says. It can be hard to gauge hoarding tendencies by asking the patients directly, so Wolf-Klein suggests asking patients to take photos of their living room, bathroom, and kitchen to bring in to an office visit. "Patients of course never recognize themselves that they are hoarding," she says, adding that "it's a problem that we see in the elderly and that needs to be addressed."

Aside from clutter, three other aspects of the home environment deserve particular attention: lighting (bad lighting increases risk), throw rugs (which pose a trip hazard), and bathroom design. Older adults often have trouble getting off of the toilet and out of the shower, Busby-Whitehead says, so it's advisable to have the toilet seat raised and install bars that older adults can grab for support.

8. Raise the possibility of an assistive device. Older adults are often very reluctant to use assistive devices, but it's important to encourage their use if a patient is at risk, Wolf-Klein says. She suggests recruiting the assistance of a physical therapist and/or social worker for the conversation if necessary.

Patients should also be encouraged to wear a life alert device such as a bracelet or necklace. "One of the big dangers with a fall is that you break your hip and you cannot get to the phone or to the door to summon help," Wolf-Klein says. "You do not want to lie on the floor for a day … because you couldn't reach out to anybody."

Finally, Wolf-Klein says, patients simply need to know that it's safe to talk about falls. Many patients are embarrassed, she says, so they need to hear reassuring messages from their physicians: "Falling is common, so don't think it's something weird that doesn't happen to anybody else," she says. "The sooner you tell us about it, the sooner we can help you fix it. Let's not wait until you get a hip fracture and you're hospitalized to discuss a fall."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References
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3. King MB, Tinetti ME. Falls in community-dwelling older persons. J Am Geriatr Soc. 1995;43(10):1146-1154.

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5. Houry D, Florence C, Baldwin G, Stevens J, McClure R. The CDC Injury Center's response to the growing public health problem of falls among older adults. Am J Lifestyle Med. 2016;10(1):74-77.

6. Coutinho ES, Bloch KV, Coeli CM. One-year mortality among elderly people after hospitalization due to fall-related fractures: comparison with a control group of matched elderly. Cad Saude Publica. 2012;28(4):801-805.

7. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572.