Fear of Falling

The American Geriatric Society has announced that falls are a leading cause of serious injury and death among the U.S. elderly. HealthDay News reports:

Each year, about one in three Americans aged 65 and older suffers a fall, and 30 percent of those falls cause injuries that require medical treatment. In 2005, almost 16,000 older adults in the United States died from falls, 1.8 million were treated in emergency departments, and 433,000 were hospitalized.

Improving nighttime lighting, reducing clutter, and wearing non-slip footwear can reduce risks in the home, which is where most falls take place. What the article didn’t get into was what doctors can do to reduce their patients’ risk of falls. That’s something that Atul Gawande covered last year in a terrific (and terrifying) New Yorker article on the way we age.



Gawande visits Juergen Bludau, chief geriatrician at the Brigham and Women’s Hospital, and describes the doctor’s 40-minute session with patient Jean Gavrilles; Bludau devoted a lot of time to learning about Gavrilles’s daily routine and examining her feet. He later explained why:

She was doing impressively well, he said. She was mentally sharp and physically strong. The danger for her was losing what she had. The single most serious threat she faced was not the lung nodule or the back pain. It was falling. Each year, about three hundred and fifty thousand Americans fall and break a hip. Of those, forty per cent end up in a nursing home, and twenty per cent are never able to walk again. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without these risk factors have a twelve-per-cent chance of falling in a year. Those with all three risk factors have almost a hundred-per-cent chance. Jean Gavrilles had at least two. Her balance was poor. Though she didn’t need a walker, he had noticed her splay-footed gait as she came in. Her feet were swollen. The toenails were unclipped. There were sores between the toes. And the balls of her feet had thick, rounded calluses.

She was also on five medications. Each was undoubtedly useful, but, together, the usual side effects would include dizziness. In addition, one of the blood-pressure medications was a diuretic, and she seemed to drink few liquids, risking dehydration and a worsening of the dizziness. Her tongue was bone dry when Bludau examined it.

She did not have significant muscle weakness, and that was good. When she got out of her chair, he said, he noted that she had not used her arms to push herself up. She simply stood up—a sign of well-preserved muscle strength. From the details of the day she described, however, she did not seem to be eating nearly enough calories to maintain that strength. Bludau asked her whether her weight had changed recently. She admitted that she had lost about seven pounds in the previous six months.

Bludau’s focus, and what he recommended for Gavrilles, was unlike what patients hear from most doctors. Gawande writes that he expected Bludau to zero in on one the medical issues Gavrilles mentioned at the start of the visit – troublesome back pain, a lung nodule identified in a radiological exam – and that’s probably what most physicians would have done. As a geriatrician, though, Bludau has a different approach:

The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible, and the retention of enough function for active engagement in the world. Most doctors treat disease, and figure that the rest will take care of itself. And if it doesn’t—if a patient is becoming infirm and heading toward a nursing home—well, that isn’t really a medical problem, is it?

To a geriatrician, though, it is a medical problem. People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable, and to avert at least some of the worst effects. So Bludau referred Gavrilles to a podiatrist, whom he wanted her to visit once every four weeks, for better care of her feet. He didn’t see medications that he could eliminate, but he switched her diuretic to a blood-pressure medicine that wouldn’t cause dehydration. He recommended that she eat a snack during the day, get all the low-calorie and low-cholesterol food out of the house, and see whether family or friends could join her for more meals. “Eating alone is not very stimulating,” he said. And he asked her to see him again in three months, so that he could make sure the plan was working.

Nine months later, I checked in with Gavrilles and her daughter. She turned eighty-six this past November. She is eating better, and has even gained a pound or two. She still lives comfortably and independently in her own home. And she has not had a single fall.

Care from geriatricians can boost quality of life for the elderly, but many geriatricians are retiring, and too few doctors are choosing this field. It’s not a specialty that our current system rewards, either for the doctors or for the facilities in which they practice. Gawande writes about a study conducted in St. Paul, Minnesota that randomly assigned at-risk elderly patients to see either their usual physicians or a team of geriatric specialists:

Within eighteen months, ten per cent of the patients in both groups had died. But the patients who had seen a geriatrics team were a third less likely to become disabled and half as likely to develop depression. They were forty per cent less likely to require home health services.

Little of what the geriatricians had done was high-tech medicine: they didn’t do lung biopsies or back surgery or PET scans. Instead, they simplified medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

How do we reward this kind of work? Chad Boult, who was the lead investigator of the St. Paul study and a geriatrician at the University of Minnesota, can tell you. A few months after he published his study, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

“The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he is now a professor at the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a twenty-five-thousand-dollar pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs. Scores of medical centers across the country have shrunk or closed their geriatrics units. Several of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients. “Economically, it has become too difficult,” Boult said.

But the finances are only a symptom of a deeper reality: people have not insisted on a change in priorities. We all like new medical gizmos and demand that policymakers make sure they are paid for. They feed our hope that the troubles of the body can be fixed for good. But geriatricians? Who clamors for geriatricians? What geriatricians do—bolster our resilience in old age, our capacity to weather what comes—is both difficult and unappealingly limited. It requires attention to the body and its alterations. It requires vigilance over nutrition, medications, and living situations. And it requires each of us to contemplate the course of our decline, in order to make the small changes that can reshape it. When the prevailing fantasy is that we can be ageless, the geriatrician’s uncomfortable demand is that we accept we are not.

Read the whole article here.

Depending on the outcome of the upcoming elections, there’s a good chance that the new president and Congress will have healthcare reform as a top priority in 2009. As we’re discussing what we want out of an altered system, we should remember that most of us don’t just want doctor visits and prescriptions – we want to enhance and preserve our quality of life.

The quality-of-life benefits possible through top-quality medical care aren’t always easy to plug into the healthcare equations that underlie our current dysfunctional system, and geriatric care is a perfect example. We need to make sure that our decisions account for the many costs that accrue when elderly patients lose the ability to care for themselves – including the hours of uncompensated care and emotional burdens that fall on caregiving relatives, as well as the costs of home health aids or assisted living facilities – and for the many benefits of having elderly people remain active and engaged in their communities.

When I was a kid, the ecxclamation “I’ve fallen and I can’t get up!” from a medical alert system commercial became a favorite punch line. Now that I know more about what aging entails, it’s not so funny. The fear of falling is widespread and well-founded. Perhaps it can help drive this country toward a better healthcare system.

Comments

  1. #1 Wib smith
    February 17, 2009

    Thanks for the article. I had seen the New Yorker piece you referenced, copied and sent it to my Geriatric Doc. No comment from him.
    I am almost 79, and live on a rural, rocky hilltop. Yard work keeps me going…and have fallen a number of times in the past 3 years, and only a few bruises. It is just harder to react and recover ones balance. I hope for a personal gyroscope, but that would make changing direction difficult.
    I think watching one’s meds is probably the best advice. I got myself off Klonopin because of daytime effects.

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