RIP Joe Lieberman -- A Reminder that Falls are Dangerous to Seniors
There will be increasing reminders over the next two decades, I'm sure
Death is always with us.
I have no particular thing to say about Joe Lieberman, other than the cause of his death:
CNN: Former Sen. Joe Lieberman dies at 82
Joe Lieberman, the first Jewish vice-presidential nominee of a major party, whose conscience and independent streak later led him on a journey away from his home in the Democratic Party, has died at 82, according to a statement from his family.
The former Connecticut senator passed away Wednesday due to complications from a fall in New York. His wife Hadassah and members of his family were by his side.
Reminder of the frailty of seniors
I have been through some of this before when Ivana Trump died at age 72 due to a fall.
The Death of Ivana Trump: Falls are Dangerous for Seniors
This was the graph I had at the time:
Given we’re talking about seniors, let me focus very specifically on those aged 75 and over, and use more detailed data.
Change in Falls Deaths for Seniors Through the Pandemic
Alas, in trying to extend the death rate data through 2021 and 2022, there is the population estimate problem at older ages.
So I have decided to focus solely on death counts for this post, 2018-2022.
As you can see, deaths due to falls have been steadily increasing through the pandemic, as it was before the pandemic, and most deaths due to falls are in the oldest age groups.
As with my earlier graph, the rate is growing — these death counts are growing faster than the population within these age groups.
JAMA Review Article on Preventing Falls in Seniors
I’m on many mailing lists, and around the various notifications of Joe Lieberman’s deaths, the JAMA research recent publications held the following, published on the same day of his death:
Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults
A Review
Cathleen S. Colón-Emeric, MD, MHS1,2; Cara L. McDermott, PhD, PharmD1; Deborah S. Lee, MD3; et alSarah D. Berry, MD, MPH4,5
Author Affiliations Article Information
JAMA. Published online March 27, 2024. doi:10.1001/jama.2024.1416
Abstract
Importance Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.
Observations Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.
Conclusions and Relevance More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.
Let me do some translation from jargon.
“Community-dwelling older adults” means people aged 65 and older who are not in an institutional setting (that is, a nursing home, hospital, or similar environment).
Basically, a senior adult living in a regular home, whether on their own or with other family members (or roomies or whatever).
To be sure, some seniors die from falls in hospitals and nursing homes, but that is seen as a big failure. As well, the people in these living arrangements are not known for their great mobility. That’s why they are in nursing homes or hospitals in the first place.
What causes falls among people include issues intrinsic to the people themselves (“gait and balance disorders, orthostatic hypotension, sensory impairment”) that may be able to be changed.
There are also external influences: medications and “environmental hazards” (think: stairs, loose rugs, poorly contrasted steps).
From the article, I gleaned that many of the studies were not originally testing reduction of fall risk and were selected due to connection with fall risk factors they knew had increased odds ratios.
But here is something:
Environmental Modification and Assistive Devices
Fall-hazard reduction in the home (eg, installation of lighting, nonslip steps that provide high traction, reducing clutter and trip hazards) is associated with lower fall rates among older adults at high risk (12 studies; 5293 patients; rate reduction, 0.74; 95% CI, 0.61-0.91; absolute rate not reported).66 There is a significant interaction by baseline fall risk, with the rate reduction largest among patients at higher risk (9 studies; 1513 participants; rate reduction, 0.62; 95% CI, 0.56-0.70; absolute rate not reported) compared with patients selected without attention to risk level (6 studies; 3780 patients; rate reduction, 1.05; 95% CI, 0.96-1.16; absolute rate not available).66 A 2021 RCT in New Zealand studied fall injuries after the following home improvements: adding rails by steps, grab bars in the bathroom permanently affixed to the wall, nonslip bathmats, high-visibility slip-resistant step edges spanning the entire stair on outside stairs, fixing elevated edges of carpets/mats, slip-resistant surfacing for outside surfaces such as decks, fixing window catches to prevent falls from windows, and improving lighting from durable solar sources. This study reported a 40% reduction in home fall injuries among individuals in 256 enrolled households (RD, 57 falls per 1000 persons over a mean of 2.3 years of follow-up; 95% CI, 3 per 1000 to 92 per 1000 persons).67 Although no clinical trials of assistive device prescription (eg, canes, walkers) were identified as a standalone intervention for fall prevention, assistive devices are a common component of multifactorial interventions, described in Multifactorial Interventions.
So not canes and walkers per se (except those who need them) — but installing features that reduce fall risk such as reducing slipping floor covers and increasing contrasts for step edges and increasing lighting.
Within the paper as well, fixing cataracts will help (actually, fixing one eye from cataracts is sufficient for fall prevention… but come on, do both eyes.)
The Types of Falls that Kill
I don’t often do this now, but I usually give you aggregated death counts in particular groupings in ICD codes … but there are more detailed breakdowns.
Falls cover W00-W19, and this is how they break out for 2022 (the last full year of data):
Most of the falls that the elderly die in are W18 or W19.
You will see that most of these are falls “on same level” — this is distinct from falls from a great height. Most are just falling from a standing posture.
There are deaths on/from stairs and steps (as with Ivana Trump), but that’s not most of the fall deaths among seniors.
Yes, I know many people do not enjoy the concept that one needs to “senior-proof” their own homes as they age, as one baby-proofed their homes when they had babies, but I think people need to consider this.
Both Stu and I have one of the major risk factors for fall injuries (if we were over 65… but give us time): peripheral neuropathy —
In our cases, other risk issues pertain as well (falls present other dangers to Stu with his cancer treatment). But we did make changes within our living arrangements due to Stu’s particular fall risks once he was diagnosed with metastatic cancer.
Fall risks are real, and they are serious.
They can be mitigated. Other approaches than the ones I mentioned were balance and strength improvements via exercise and physical therapy (as relevant).
Why is the death rate due to falls increasing?
The increasing death count is only partly due to more people living to older ages, and larger populations at older ages.
But as I noted in my Ivana Trump post, the rate has been increasing for a long time — what is up?
I believe a big part of this is more seniors living alone:
The URL may say “social-connections-and-loneliness”, but more to the point, as with Ivana Trump, if you’re living by yourself, if you fall and hurt yourself… well. You’re kind of out of luck.
If you were granny living in a granny attic room and surrounded by family… one of the grandkids would know pretty quick that you were in trouble. Maybe you would get help in time.
I think that makes a big difference.
Of course, if you have no grandkids….
Alas, we will be seeing more awareness to come as the Baby Boomers come into the danger zone (Joe Lieberman was a pre-Boomer, born in 1942).
And many of those Boomers don’t have any grandkids (or any kids). Or a spouse. Or anybody to live with. This does have effects in the death trends.
Yes, I’ve seen various “government loneliness” plans, but I don’t think the government can necessarily fix this bit.
I’m not saying there’s no solution — just that there’s no government solution.
To follow up: this post is one of the most informative and useful things I have ever read w/r/t actionable advice to help one's elderly friends and family. It's really, really useful and a Good Thing.
Don't mean to have my tangent take away from that. Well done.
Dear Mary Pat,
My first question was, "Are increased deaths from falls just a function of a decrease in other causes of mortality?", but you have explored that thoroughly above.
Somewhat related, today, my boss heard that a cousin had suddenly died the day before - somebody only a few years older (~45-50) than him. Relevant because the man's either phone or wearable device (watch) detected his fall (likely fall was caused by fatal event, not vice versa), and auto-alerted his wife and emergency services (although EMS arrived only to pronounce him dead and transport the body.)
Some finance people think that Apple's major market for the Apple Watch is as a medical device, for this reason exactly. The idea is that once it is FDA approved, Medicare/aid will pay for the $700 device and monthly data plan, plus it will also be de facto MANDATORY, resulting in a 20million customer windfall for Apple.
What is your insurance/mortality perspective re: mandatory health monitoring devices? How do you feel about privacy concerns? What is the industry likely to do. How is this vs automobile tracking, like Flight Data Recorder recording, which is going to be forced into every US car?
Detecting falls is something everybody would support. Then blood sugar monitoring ... but where does it end? Tracking alcohol consumption and maybe cutting people off based on drinks/week? Monitoring grocery and restaurant purchases?
BRetty?