Daphne Brown, 65, was putting away the dishes in her Washington kitchen when she fell to the floor. Jane Bulla, 82, fell at home in Laurel, Maryland, but managed to call for help with the cellphone in her pocket. Susan Le, 63, who has trouble walking due to arthritis, hurt her leg when she tripped on a pile of leaves in Silver Spring. And late one night when no one was around, Jean Esquivel, 72, slipped on the ice in the parking lot outside her Silver Spring apartment.
Falls are the leading cause of injuries for adults 65 and older, and 2.5 million of them end up in hospital emergency departments for treatment every year, according to the Centers for Disease Control and Prevention. The consequences can range from bruises, fractured hips and head injuries to irreversible calamities that can lead to death. And older adults who fall once are twice as likely as their peers to fall again.
Despite these scary statistics, a dangerous fall does not have to be an inevitable part of aging. Risk-reduction programs are offered around the country.
To reduce the odds of falling again, Brown, Bulla, Le and Esquivel signed up for “UpRight! Balance Training,” a free 12-week exercise class aimed at improving gait, balance and muscle strength held at Holy Cross Hospital’s Senior Source center in Silver Spring. People interested in joining the class must first complete balance tests to determine their risk of falling. Those who are too unsteady may be advised to get physical therapy or discuss other fall-prevention options with their doctors.
Last month, 10 women and one man completed the class, which is offered several times a year.This KHN story also ran in The Washington Post. It can be republished for free (details).
“It definitely made me think first and to make sure I felt comfortable taking my next step,” Brown said after one of the group’s final sessions. Participants took turns, while instructors spotted them, crossing over an imaginary river that instructor Judy Cooper had created with blue yoga mats covered with exercise platforms, small barbells, inflatable cushions and other objects representing rocks and tree branches that they stepped on to get across.
Le nearly tripped on her second turn through the obstacle course. The experience reminded her “to take things slowly, because I walk a lot and I have to watch where I step,” she said.
‘Know What To Avoid’
After decades of walking and rushing, they were learning to be more aware of their surroundings, to watch their posture, maintain their balance and to master a flight of stairs even with less-than-perfect knees. To confront the stairs, they practice going up using their stronger leg first and going down with the weaker leg first. Stepping sideways is another strategy and has the added advantage of allowing the person to hold onto the stair railing with both hands.
Under the careful eye of Cooper and co-instructor Gina Deavers, members of the class practiced stepping off a riser while holding an oversize exercise ball — to simulate a laundry basket — and going down steps facing forward and backward with eyes open and then closed. They also tried walking in a straight line while reading a book. Not everyone was able to do these tasks, and that was part of the lesson.
“If you’re aware of your limitations, you are much less likely to fall because you know what to avoid,” Cooper said.
It’s also important not to be overly cautious, said Thomas Gill, a geriatrician and professor at the Yale School of Medicine and one of the principal investigators for the $30 million federal STRIDE study, the nation’s largest investigation of how to prevent injuries from falling. When older people become afraid of falling, they may cut back on physical activity and eventually grow weaker.
“Paradoxically, that puts them at greater risk of falling,” Gill said. “The fear of falling can be a dysfunctional response, and there is strong evidence that it is a fairly powerful risk factor for serious fall injuries.”
Another free class at Senior Source, “A Matter of Balance,” helps people cope with the fear of falling by discussing how to make their homes safer and how to recognize and modify such risky habits as walking into a dark room or not immediately wiping up a spill on the kitchen floor. Boston University researchers developed the class in 1995, and it is available in 40 states. The average age of class participants is 79, according to Patti League, national program manager at MaineHealth’s Partnership for Healthy Aging, which received a federal grant to train volunteers to teach it.
In a 2015 study, researchers found that people who completed the “Matter of Balance” sessions reduced the number of falls and injuries and saved an average of $938 a year in medical costs.
Despite the need for and success of such programs, some experts are concerned that more people don’t participate. Fewer than half of the usual 16 people signed up for the most recent “Matter of Balance” class, which has been offered since 2007.
“A huge amount of work has gone into fall-prevention research, but many people who could benefit don’t get to [these programs],” said Nancy Latham, director of the STRIDE study, which is recruiting 6,000 patients at 10 clinical sites around the country, including Johns Hopkins Medical Center in Baltimore. The study will test the effectiveness of a “falls care manager” who helps patients enroll in prevention programs like “A Matter of Balance” and addresses problems that can increase the risk of falling, from medications to footwear.
“The fear of falling is real, but people can change it,” said Kristen Wheeden, coordinator for the chronic disease self-management program at Holy Cross, who taught the “Matter of Balance” class last month. “Instead of saying, ‘I can’t do this, no way, I’m going to fall,’ let’s make it so you can, let’s find a buddy system, let’s go out at a certain time of day, and let’s make your world safe.”
What You Can Do
To reduce the risk of a fall, experts recommend that you:
— Stay physically active to improve balance and coordination — even walking helps.
— Fall-proof your home: Install grab bars in the bathroom, increase lighting, remove tripping hazards such as throw rugs and footstools.
— Ask your health care provider to evaluate your risk of falling and to review your medications because some drugs can make you dizzy or sleepy.
— Get vision and hearing checkups at least once a year.
— Join a falls-prevention class. To find one in your area, contact your local senior center or hospital, or find additional resources here.
Imagine that you submitted what you thought was an anonymous bit of needed input at work, only to hear from the very colleague you critiqued that it was useful feedback.
Now imagine that all this takes place when you’re at your most vulnerable, sick and reeling and in need of extensive help — and at a hospital, where privacy is supposed to be paramount.
That’s the cautionary tale of this beautifully written new Cognoscenti post: “Harming Patient Satisfaction In The Process Of Measuring It.” It begins badly:
The first time the social worker asked if she could check in with me was this past summer during chemo. We chatted some, and after a while she got up to leave. Then she parted the privacy curtain, stepped out, poked her head back in and said, “Oh, I forgot to ask. What are you most afraid of?”
Patients are often criticized for what are called “door handle comments” — those comments brought up as the health care provider is walking out of the room and already has one hand on the door. They are often doozies — a patient who has had a very straight-forward appointment might state that they have been having chest pain. Or a myriad of other disclosures that, had they been revealed earlier on, would have directed the appointment very differently.
Health care professionals do it, too.
Then it gets even worse: Author Marjorie S. Rosenthal of the Yale School of Medicine describes filling out a patient satisfaction survey, and then hearing about it from the social worker herself.
The social worker comes over, pulls the curtain and sits down. We talk about my children, work and me. And then she tells me that she appreciates the constructive criticism I gave her in my patient satisfaction survey.
What?! She knows what I wrote and she is acknowledging that to me?
She tells me that she and her supervisor worked on her skills over the past few months and she feels good about her progress.
Really? Because as I sit there in the chemo-pod, under a blanket, IV tubes hanging from my chest, and about to get my chemo-infusion, I feel incredibly vulnerable.
Unbelievable. And makes you miss the old days, when suggestions were written on pieces of paper, and you could be sure they were truly anonymous. Don’t miss the full piece here, and feel free to leave feedback — just don’t expect it to be fully anonymous…
By Judy Foreman
The U.S. Centers for Disease Control and Prevention recently came out with controversial proposed guidelines for opioid prescribing through a process that critics say may harm pain patients and is based on relatively low-grade evidence.
One of those critics is Cindy Steinberg, national director of policy and advocacy for the U.S. Pain Foundation, a patient advocacy group which receives funding from opioid manufacturers. Steinberg said in an interview and in emails that she’s worried the guidelines may negatively impact patients suffering with severe pain. “I am concerned that if these guidelines go forward as they are now written, they will lead to further restrictions on access to opioids for people with unremitting pain who truly need them and take them responsibly,” she said.Recent Coverage Of The Opioid Addiction Crisis In Mass.
- Baker Testifies On His Opioid Bill
- Who Is Overdosing In Boston
- Drug Cocktails Fuel The Crisis
- Plans For Heroin ‘Safe Space’
- Baker Bill Ignites Controversy
Dr. Jane Ballantyne, president of the non-profit Physicians for Responsible Opioid Prescribing (PROP), which is part of a larger group involved in the guidelines process, said in a telephone interview that the worry about limited access to opioids for chronic pain patients is a “very legitimate fear.” But, she added: “We don’t want to reduce access for people already dependent on opioids. The guidelines are designed to not have so many people dependent on opioids in the future…”
Ballantyne said that the new guidelines are similar to previous guidelines with two key exceptions: lower dose limitations and the recommendation that, for acute pain not related to major surgery or trauma, opioids should be prescribed for only three days.
The month-long period for public comment on the proposed guidelines will be over Jan. 13.
A major concern of some critics is the lack of solid evidence backing up the guidelines, which give recommendations on prescribing practices; they include when to start opioids, how to establish treatment goals, how to discuss risks and benefits, recommended limitations on drug doses, duration of treatment and other issues.
For instance, the fifth of the 12 recommendations says that physicians should generally avoid increasing dosage to more than 90 “morphine equivalents” per day. (Opioids differ in potency. One opioid may be three times as potent as another, so doctors use morphine equivalency tables to compare doses.)
But the quality of the evidence backing up this recommendation is rated only “3,” a low rating, acknowledged by the CDC itself. In addition, calibrating morphine equivalents is an inherently tricky process, with multiple, potentially conflicting formulas available. (Moreover, some patients in severe pain may need higher doses.)
The CDC guidelines are aimed at adults with chronic pain “outside of active cancer treatment, palliative care, and end-of-life care.” The guidelines are advisory, not mandatory, but are nonetheless likely to be a powerful influence on physicians, insurers and other government agencies.
The potential problems with the new guidelines are serious enough that on Dec. 18, the U.S. House Committee on Oversight and Government Reform sent a letter to Dr. Thomas Frieden, the CDC director, sharply questioning why the CDC recruited a so-called “core expert group” to write the guidelines instead of complying with standard government (FACA) regulations for establishing advisory groups. (FACA is the Federal Advisory Committee Act.)
On its website, the CDC says it did use a transparent process to create the guidelines.
Among the groups opposing the new guidelines is the American Cancer Society Cancer Action Network, (an advocacy group which lists major drug companies on its corporate member list) which has called for the CDC to withdraw the guidelines, stressing that they were based on “limited” and “low quality” evidence. In a letter to Frieden in October, the cancer group wrote: “We have concerns about the lack of evidence on which the guidelines were based, the methodology used to develop the guidelines and the transparency of the entire process.”
Seven of the 12 recommendations were “very low quality evidence” and five of the 12 were based on “low quality evidence,” according to the cancer group’s letter, which also noted that the CDC’s attempt to solicit public input on the guidelines was “cursory and did not allow adequate opportunity for thoughtful responses.”
I asked the CDC to respond. In an email, a spokesperson said: “Clinical guidelines are always based on best available evidence, including low quality evidence. This does not mean ‘bad’ evidence, it means that not enough randomized control trials were conducted.”
Ballantyne, PROP’s president, acknowledged the lack of good randomized controlled trials on long-term safety and efficacy. But doing such trials is impractical, she said. From clinical experience, she added, “if you use opioids long term, they don’t give you good enough pain relief to warrant the risk.”
(The non-profit PROP “has received financial support from some of its members and from a few individual donors who have been personally impacted by the opioid crisis. We have never accepted corporate support,” according to its executive director, Dr. Andrew Kolodny.
The American Medical Association, on December 17, stated its concern that the guidelines lack “a patient-centered view and any real acknowledgement of the problems chronic pain patients may face.”
In other letters to the CDC (that I obtained) a number of industry-backed organizations expressed concerns, including the American Academy of Pain Management, the Oncology Nursing Society, the Interstitial Cystitis Association and the U.S. Pain Foundation.
The CDC guidelines note that prescription opioid sales have increased by 300 percent since 1999, but also say that “there has not been an overall change in the amount of pain Americans report.” But in 2011, the Institute of Medicine documented the growing chronic pain problem, noting that more than 100 million American adults now live with chronic pain, an increase over previous estimates. The IOM report said the incidence of chronic pain is growing and is likely to continue to do so.
Health columnist Judy Foreman is the author of the 2014 book, “A Nation in Pain: Healing Our Biggest Health Problem.”
Correction: An earlier version of this story incorrectly said that members of the group PROP “were among the group that wrote and reviewed the guidelines…” We regret the error.