When a Fall Changes Everything

“I’m sorry ma’am – your father is unresponsive. You will have to meet us at the hospital.” These are words no family member wants to hear. Yet, similar circumstances are all too common when falls take place. According to the Centers for Disease Control and Prevention (CDC), one in four falls occur in older adults, and injury and death as a result are on the rise (Division of Unintentional Injury Protection, 2017)

This statistic is just as shocking as the experience itself. Even as a healthcare professional, knowing what I know, I was taken aback when my father, at age 72, fell victim to a fall. We had no idea why it happened and no knowledge of ways in which we could have potentially prevented it. His unintended fall led to a fractured femur, a surgical procedure and rehab. Within two months of that procedure, he experienced a blood clot that resulted in a brain aneurysm that ultimately led to his death. What most people don’t realize is the high percentage (in some instances as high as 50%) of adults who will pass away within six months of their surgical procedure due to an unintended fall (Liem et al., 2013). That is what happened to my dad and countless other older adults, leading me to wonder—how did this happen so quickly?

There’s Hope

Believe it or not, falls are not a normal part of aging, yet so many accept this as an inevitable  stage. As the strategic manager for a national in-home care agency, ComForCare Home Care, I contributed to the recent development of Gaitway—our approach to helping older adults understand more about why falls occur and what they can do about it. Our goal is to help reduce the risk of falls and injury, and we believe that starts with education and, most importantly, understanding what can be done regarding fall risk. Most of the older adults we support nationally who experience a fall cannot tell us why it occurred when asked. This level of uncertainty tells us a lot about awareness and resources that aren’t getting into the hands of the population most vulnerable to related risks. Unless we know why falls are happening, they’ll continue to occur, and older adults and their families will continue to experience fear and anxiety about the possibility of an eventual fall.

We need to look at ways to truly empower our older adults by starting difficult conversations, routinely screening for fall risk, and intervening to address risk factors that are specific to each individual we support. When we do this as a collective whole, we truly believe we will see a reduction in falls in older adults.

Why Do Falls Occur?

So why do they happen? All older adults are at risk, but the data tells the story that falls do not impact all older adults in the same way. Those who are younger or living independently in the community (defined as community dwelling older adults) are at a far lower risk of injury or death from a fall than those who are older, more frail or institutionalized—requiring assistance or support (Bergen et al., 2019).

Those adults who are more frail are the most likely to experience a serious injury, fracture, traumatic brain injury or death from a fall than any other age group. There are numerous reasons why older adult falls are complex. Falls are considered a “geriatric syndrome” or a multifactorial health condition common in the elderly that is associated with morbidity and poor outcomes. Examples of common geriatric syndromes include falls, delirium, incontinence, functional decline, and pressure ulcers. Geriatric syndromes are often seen in adults who are older and have cognitive impairment, functional impairment, or impaired mobility in combination with the additional risk factors unique to older adult falls.

To put it simply, falls are often consequences of multiple medical conditions (also known as risk factors) and/or inactivity during the aging process. With the appropriate preventative action, it is possible to lessen the likelihood of a fall.

Fall Risk Factors

When an older adult falls, it is common for them or their family to not really understand what could have led to the fall in the first place. The person who fell may feel they are clumsy, but when it comes to falls in older adults, there are further considerations that typically come into play. Knowing what risk factors lead to falls, and how to manage them properly, can help decrease the risk of falling. Some of the most common risk factors in (primarily community dwelling) older adults include:

What Can You Do?

First, I believe our role as healthcare professionals is to help older adults and families to begin accepting that falls are not a normal part of aging. If an older adult is falling, there is almost always a reason why. If the reason(s) can be determined, you can address the issue(s). Managing fall risk requires that the older adult, caregiver, and health care provider all work together to manage risk. We’ve all heard how silos exist in healthcare and they’re real. The impact of a fragmented system leads to poor outcomes and increased falls in our eldery population. Connecting the clinical and community providers is the zone of opportunity to reduce falls and create safer communities.

Secondly, older adults and their caregivers should be educated and empowered to think about fall risk as a “chronic disease.” This means that risk should be assessed often by the older adult and the health care provider. Think about blood pressure—older adults expect their pressure to be taken every time they see a healthcare provider and are often educated to monitor their pressure at home. The same model can and should be applied to fall risk. Once someone starts thinking about falls like a chronic disease, they have a framework within which they can manage an older adult’s risk in an evidence-based way to assess individual risk factors.

The actions older adults and their families can take to identify their individual risk factors are called “interventions” and are proven strategies/approaches to reduce the chances of a fall.

What Can an Older Adult Do?

There are six actions (or interventions) we recommend taking to reduce a person’s fall risk. These each require professionals who work with aging adults to educate, and ultimately, they require the older adult to engage in their own health and well-being management. As health care partners, we have a tremendous opportunity to empower older adults by encouraging them to take action on a suggestion and nurturing other approaches. Part of a successful approach to change is knowing you have a support system and champion who will help encourage you to try something new.

Consider sharing all or one of the following six actions with older adults you support.

1. Understand the Reality of FallsShare with an older adult that if a fall has occurred, it is crucial to understand the root cause. It is important that older adults accept that falls are not a normal part of aging, and if they are falling, there is almost always a reason why. Managing fall risk starts with helping older adults with acceptance and understanding. It is important to realize what can and cannot be done. Discussing noticeable changes with a physician is a great way to identify underlying causes. Encourage a relationship with a primary care physician if they don’t have one. It’s also important to understand that not all risk factors need to be managed by a medical healthcare provider. Others can help with certain aspects of care such as ensuring medications are taken at the right time, addressing home safety issues like clutter, and assessing daily activity.
2. Become a Fall Risk ManagerOlder adults and their families should start to think of themselves as fall risk managers. Assuming this role may feel abrupt, but it is a solid step toward a more stable future. The primary role as a fall risk manager is to pay attention every day. Regularly screening for risk factors will allow for early identification and intervention. Taking action to prevent falls before they occur is an excellent way to improve outcomes.Here are a few things to consider as a fall risk manager.
   • Screen for falls regularly. Use the CDC Stay Independent brochure (2017). It was created specifically for older adults to engage in fall risk screening routinely. Find it through the CDC’s Older Adult Fall Prevention program, STEADI (Stopping Elderly Accidents, Deaths & Injuries) (www.cdc.gov/steadi).
   • Know your Stay Independent brochure score. A score of four or greater on the brochure means there is greater risk for falling. Based on this score, empower the older adult to understand resources available in their community that support their needs to modify a risk factor (like knowing a pharmacy that will presort medications and deliver straight to the door). Over time, we want to see this score go down.
   • Decrease distractions in the home. This can be as simple as turning off the TV or not talking to an older adult as they’re standing up or walking.
   • Keep things consistent. If anything changes, change it slowly.
   • Set up a regular time to exercise. If appropriate, suggest engaging in an evaluation with a physical or occupational therapist who can provide a specific routine based on abilities and needs. Here is a simple exercise to consider doing for leg strength: Sit in a chair. Now stand up. Repeat as many times (slowly) as you can in 30 seconds. And for balance: Stand on one foot for 10 seconds and then the other foot for 10 seconds. Hold something for support if needed.
3. Manage MedicationsOlder adults and their families need to know that many medications can increase the risk of falls and other problems. The rule of thumb is to start low, go slow, and avoid medications that cause confusion or sleepiness. The CDC recommends stopping medications when possible, switching to safer alternatives, and reducing medications to the lowest effective dose.Taking too many medications is referred to as polypharmacy. Many older adults have multiple medical conditions which result in too many or the wrong kinds of medications. To manage, encourage the older adult to:
   • Keep a list of all medications.
   • Make note of any changes that occur with a new medication and report them to a health care provider.
   • Try to minimize the number of medications being taken.
   • Ask a pharmacist if they are all necessary.
   • Get pills out of bottles and into compliance packaging where a virtual pharmacy provider can deliver medications in pre-set packing straight to the door. This helps promote single-use pharmacy and can help eliminate medication errors. AdhereRX.com is a great provider to consider if you aren’t aware of a local service.
   All of this goes back to a point I often make: you can’t talk about falls and not talk about medications. This is because some medications should not be prescribed to older adults as they can increase the risk of a fall. These can include medications that help with: sleep (sedatives), mood (antidepressants), pain (prescription pain medications, opioids), or anxiety (benzodiazepines, anti-psychotics). Always talk with prescribers about side effects that may increase fall risk, and consider asking for alternatives. In addition, many non-prescription medications can increase the risk of a fall, and these medications are often not tested on older adults. Because of this, it’s important to bring over-the-counter medications and supplements when discussing medications with a pharmacist or doctor.Also, keep in mind that vitamin D plays an important role in keeping muscles and bones strong. Believe it or not, older adults, even those who are frail or weak, will develop stronger muscles and fall less with adequate levels of vitamin D (Uusi-Rasi et al., 2015). Studies support that taking a daily dose of vitamin D can help improve osteoporosis—a condition that leads to brittle, weak bones (Avenell et al., 2014). Taking vitamin D in combination with calcium can enhance its positive effects (Lips et al., 2014).
4. Manage Nutritional StatusOlder adults’ nutritional needs change, and many don’t realize that. Older adults need to understand that as they age, they must manage nutrition to help keep their bodies strong. The better they eat, the more energy they’ll have to engage in the activities that keep them strong and steady on their feet. Unfortunately, older adults are particularly vulnerable to nutritional issues as aging can bring along changes in appetite and food intake. Early satiation, diminished taste and smell, lifestyle changes, medical conditions, and changes in the home environment can all contribute to reduced food intake. Older adults actually need more protein than those under 65. Without enough protein, a person can become undernourished, which can lead to weakness, frailty, adverse health, and an increased risk of falls (Landi et al., 2016; Ruiz et al., 2019).Here are a few suggestions you can bring up to help those you support manage nutrition.
   • Make sure there is enough protein in the daily diet. Questions can be addressed with a registered dietitian as part of Medicare or a Medicare Advantage plan.
   • Reference MyPlate as a guide to understand daily nutritional requirements (www.choosemyplate.gov).
   • Suggest eating small meals throughout the day that include protein at each meal.
   • Stay hydrated! Limiting fluids for any reason, whether due to illness, lack of thirst or choice, will put a person at risk of dehydration. Dehydration can cause confusion, dizziness, and falls. Dehydration can also increase the risk of urinary tract infections which can also cause falls. Ask how many fluids they drink and if they like water. If the answer is “I don’t know” or “no” then you can adjust your approach to suggest ways to consume more.
5. Increase ActivityMost older adults lead sedentary lives. The more we sit, the more likely we are to experience a fall due to lack of strength and poor balance. In fact, weak legs and difficulty walking are some of the top reasons why older adults fall (Sherrington et al., 2017). Older adults who participate in regular exercise, particularly exercise that challenges balance, experience a protective effect against a fall. In research studies, these individuals fell 21% less than older adults who did not exercise (Tinetti & Kumar, 2010). The effect was found in individuals of all age groups and all levels of ability, including those who were frail. It’s possible to build leg strength and improve balance at any age, even at over 100 years old!Most daily physical activity can be done at home. Suggest that an older adult focus on:
   • Leg strength and balance.
   • Standing positions if at all possible.
   • Finding ways to incorporate activity into the day such as doing squats while unloading the dishwasher or standing on one foot at the kitchen counter.
6. Consider Home SafetyHome is one of the safest places to be; however, it’s important to educate older adults to continually monitor for fall risk factors and make minor modifications as needed. You can consider making the following suggestions.
   • Use walking aids correctly. Just because an older adult looks unstable does not mean they need a cane or a walker. Suggest only using a walking aid if a healthcare professional has evaluated an older adult, recommends an aid, and trains both the older adult and caregiver on how to use it properly. If this has been completed and you notice that the older adult is forgetting to use the aid or trips over it, contact a provider for another assessment.
   • Complete a home safety checklist with a home care provider. ComForCare offers a complimentary comprehensive checklist that can be completed to ensure all areas of the home are considered for modification that can lead to greater safety. Home care professionals like ComForCare can assist in identifying potentially problematic areas and coordinate a handyman service if needed.
   • Keep a home fall-proof by examining areas such as:
     • Kitchen: Place daily use items within reach and avoid the need for ladders.
     • Bathrooms: Ensure clear pathways are available to the toilet and shower. Ask if grab bars have ever been installed. If not, suggest a handyman who can provide this service.
     • Bedroom: Ask if the height of the bed makes it easy to get in and out of. Find out if lights are reachable or, better yet, suggest installing a device like Alexa that is automated with movement.
     • Pathways: We like to suggest that handrails are installed on both sides of the stairs. Of course, you also need good lighting, and hallways and walkways clear of any items that could trip someone. You also can’t forget about the outdoors—search for uneven surfaces that could lead to a fall.
   Asking is one thing, but it is another to visit the home and truly evaluate safety. Working with a home care provider like ComForCare can make this an easy process for an older adult.

Next Steps

We realize that for older adults, learning a new way of doing anything can feel overwhelming and may be a lot to take in. Older adults may wonder if they can really benefit from completing a fall risk screening.

Remember, most of us don’t like change. But if older adults want to feel safer, they can with the right support. We always like to share that when thinking about fall risk, you should not try to do this alone. Caregiving and managing chronic conditions is a team sport and it’s important to find the right “teammates,” such as a home care provider.

To get an older adult started, determine if they have ever fallen and who, if anyone, reported it. The fear of such an event is real and often impacts their lifestyle, so they may be hesitant to share their thoughts and concerns. Sometimes they think if they just sit in their home and do nothing, they’ll do just fine. But the reality is, it is counterintuitive.

As CSAs, knowing many falls are occurring and death and mortality rates are increasing because of them, we must understand that we are giving a gift to older adults by simply starting the conversation. It could be the difference between life and death. Even going back to my dad—knowing what we know now—we could have taken a different approach to manage his risk factors, and while we’ll truly never know, I believe he might still be here with us today if we had started to manage some of his risk factors differently.

I encourage you to start with a simple question and go from there: have you ever had a fall screening? If the answer is no, follow up by expressing how a lot of older adults know someone who has fallen, and share that falls do not have to be a normal part of aging. Recognize that they can be scary, but share how there is a lot that can be done to reduce the risk of potentially falling. Offer to share resources, like the CDC’s Stay Independent brochure or this article, that review some facts about falls and, most importantly, some things to consider.

Remember: ComForCare/At Your Side Home Care views falls as something to be managed daily. Because it takes time for older adults to understand their roles in managing such risk, and patients typically learn better from home, we developed Gaitway. Gaitway is a proactive, patient-centered program focused on education, manageable recovery and reduction of future fall risk. Enrolling clients in ComForCare’s Gaitway program will allow our team to continually monitor fall risk scores and provide immediate interventions as needed. Feel free to call me, and I’d be happy to review more and connect you with a local ComForCare location.  

Meet the Author

Stephanie Wierzbicka, strategic health programs manager, has been employed with ComForCare Franchise Systems, LLC, an in-home care agency with 250 locations in the United States and Canada, for 18 years. She is responsible for developing and managing various programs aimed at improving client care and health-related outcomes. She is also a master certified Matter of Balance trainer, which is a cognitive restructuring class for adults 60 and older to reduce fear and increase activity. Reach her at [email protected] or 248-760-6045.

References

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Bergen, G., Stevens, M. R., Kakara, R., Burns, E. R. (2019). Understanding modifiable and unmodifiable older adult fall risk factors to create effective prevention strategies. American Journal of Lifestyle Medicine, 15(6), 580–589. https://doi.org/10.1177/1559827619880529

Centers for Disease Control and Prevention. (2017). Stay Independent [brochure]. Retrieved May 25, 2022, from www.cdc.gov/steadi/pdf/STEADI-Brochure-StayIndependent-508.pdf

Division of Unintentional Injury Prevention. (2017, September). Take a stand on falls. Centers for Disease Control and Prevention. Retrieved May 25, 2022, from https://www.cdc.gov/features/older-adult-falls/index.html#

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Liem, I. S., Kammerlander, C., Raas, C., Gosch, M., Blauth, M. (2013). Is there a difference in timing and cause of death after fractures in the elderly? Clinical Orthopaedics and Related Research, 471(9), 2846–2851. https://doi.org/10.1007/s11999-013-2881-2

Lips, P., Gielen, E., & van Schoor, N. M. (2014). Vitamin D supplements with or without calcium to prevent fractures. BoneKEy reports, 3, 512. https://doi.org/10.1038/bonekey.2014.7

Ruiz, A. J., Buitrago, G., Rodríguez, N., Gómez, G., Sulo, S., Gómez, C., … & Chaves-Santiago, W. (2019). Clinical and economic outcomes associated with malnutrition in hospitalized patients. Clinical Nutrition, 38(3), 1310-1316. https://doi.org/10.1016/j.clnu.2018.05.016

Sherrington, C., Michaleff, Z.A., Fairhall, N., Paul, S.S., Tiedemann, A., Whitney, J., Cumming, R.G., Herbert, R.D., Close, J.C.T., & Lord, S.R. (2017). Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. British Journal of Sports Medicine, 51(24), 1750-1758. https://doi.org/10.1136/bjsports-2016-096547

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