In the spring, I’m presenting to our statewide assisted living association on implementing facility-wide fall prevention policies. I’ve spent a lot of time lately reading through research on fall prevention for older adults.
Fall prevention is one of the most common problems faced by institutions that care for older adults. According to the CDC, fall death rates in the US increased by 30% from 2007 to 2016. If this rate continues, it’s anticipated there will be seven fall deaths every hour by 2030. It's obvious the problem is getting worse, despite efforts to prevent avoidable falls.
In my research, I’ve found a few problems. Namely, the discrepancy between what research has found actually works and how falls prevention programs are structured in real life. Not to mention the “fluffy” information available to the general public online.
Not only do most fall prevention programs not work, but we implement policies that have actually been shown to increase fall rates. The current approach to reducing fall rates involves trying to keep older adults in their beds or chairs. The thought process is that less movement means lower risk. But the opposite is true. The less we move, the more likely we are to fall.
Another example is the use of bed and chair alarms. Ironically, bed alarms have been shown to increase rates of falls in most cases.
“Falls don’t “just happen” and people don’t fall because they get older.” -NIH Senior Website
And this points to a major issue in healthcare that goes beyond fall prevention. We provide advice contrary to evidence because it’s what’s familiar. We are afraid of new approaches and aren’t sure how to implement them. And this isn’t the only aspect of medicine where we encounter this phenomenon. There are countless examples of clinical practice not matching up with evidence-based approaches.
So why does this happen? Mainly out of fear and the huge undertaking of changing systems. We tend to do things the same way because “this is how we’ve always done it” despite evidence showing our approaches don’t work.
If you Google information on fall prevention, you’ll find a lot of guidelines with fluff. Tips that equate to bubble-wrapping the environment to make it safe for older adults to live in. But this presents a glaring problem. We can’t cushion every environment we encounter. And it’s the lack of challenge that increases our risk of falls.
This points toward a bigger problem: we live in a society that fears risk. Even if accepting a little risk brings about a greater benefit. Which is how most “fall prevention programs” fail.
The real way to prevent falls is to accept reasonable risk. We can’t live life risk-free. The truth is we all fall at some point. We can’t stop it from happening. We should certainly minimize unnecessary falls, but we also need to prepare ourselves for the falls that will happen. Counterintuitive to the current approach, the two things that work are to make sure older adults are physically challenged daily and that they actually practice falling and getting on and off the floor.
“We are mostly under-moved and not at all too old.” -Katy Bowman, Dynamic Aging: Simple Exercises for Whole-Body Mobility
Adopting evidence-based fall prevention programs also requires accepting a certain level of discomfort. Not only by those who are at risk of falling, but also by family members, friends, and caregivers they are surrounded with. In therapy, we talk about this phenomenon of learned dependence. When someone loses the ability to do something they are physically capable of because others step in to do it for them. No one likes to watch their loved ones struggle. And we think we mean well by stepping in when in reality we could be causing harm.
As providers, we are afraid to tell our patients and their families that life comes with risk. We are shooting for this lofty goal of encouraging those we treat that they can live a life of comfort without adverse events. But we can’t have it both ways.
There are examples sprinkled all throughout healthcare where we implement solutions that aren’t effective. Areas such as addiction medicine, lifestyle management of type 2 diabetes, and treatment of heart conditions are all areas that have similar patterns.
Chronic pain is yet another example. Chronic pain is the number one cause of long-term disability in the US, costing $560-$635 billion dollars in medical expenses annually with an additional $299-$325 billion in lost productivity annually. The traditional approach to treating chronic pain involves imaging to search for tissue damage, followed by some sort of repair. Until everyone realized this wasn’t actually reducing reported pain levels or improving the quality of life for those who live with chronic pain.
Where do you turn when treatment isn’t working? It turns out stress, your income level, and your lifestyle choices are more likely to dictate whether or not you develop chronic pain than whether or not you have a bulging disc or two in your spine. So the interventions that are more likely to work, like promoting good quality sleep, increasing physical activity, counseling sessions, and improving diet quality are seen as difficult and expensive to implement. Most physicians don’t even offer these interventions to their patients, either due to lack of time or a belief that their patients won’t be interested.
“In a fragmented system, it’s easier to close a program providing essential patient services than to recognize its uncounted gains and fight to restructure the system so they count.” -Louise Aronson, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life
Louise Aronson highlights one clear-cut example of where we are focused on the wrong interventions in her book Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life. She reports that in 2016, Mark Zuckerberg and Priscilla Chan announced a three-billion-dollar investment to “cure, prevent or manage all disease in our children’s lifetime.” As she notes, this is great for science and medicine but not so great for American healthcare.
She states, “Well-studied, proven-effective, and cost-effective strategies already exist and could be preventing illness and injuries right now if only we sincerely supported and actively disseminated them… Curing disease is an important and inspiring goal, but we could make huge strides toward better health and health care for people on this planet right now by focusing less on the pursuit of what isn’t known and significantly more on making better use of what is.”
A major underlying issue in all of this is that our healthcare system incentivizes fancy, expensive treatments above preventative measures. But they look at the wrong measurements in terms of a program’s success. Programs are measured in profits rather than healthcare dollars saved or quality of life improved. We need to start viewing preventative programs in terms of investment rather than cost.
It’s easier to get funding for studies looking at medications, surgical procedures, and other treatments than for preventative measures like social services, exercise, and healthy eating. The latter are not seen as profitable, but they work.
We can’t structure programs that work to prevent these major health conditions until we change the system.
In our example of fall prevention programs, the thought of undertaking an evidence-based approach to the issue is daunting for most facilities because of the up-front cost. Mobilizing older adults requires training staff early and often on fall risk factors, medication issues, and how to help people enjoy movement more. Most of these facilities are already understaffed, and most view setting up such a program as not feasible even though it would save expenses and improve the quality of life for their residents in the long run.
And the sad reality is that as a therapist, I would make more money treating a hip fracture than I would by preventing that hip fracture in the first place.
The lesson we can take from this is that we can’t expect healthcare alone to swoop in and change these issues without change at the systemic level. And systemic change takes time, so we can't sit around and wait.
In the meantime, there are ways you can make sure you don’t get trapped in medical treatments that just aren’t working or initiate a vicious cycle of needing more expensive and invasive treatments.
We need to recognize what issues belong to the doctor's office and which ones don’t. It’s important to discuss any health issues you are facing with your doctor, but don’t expect them to have an easy fix for everything. Ask your doctor if there are any additional resources they can direct you to for an active approach to what you are facing. Seek out multiple opinions and providers who offer a variety of options. If you know you want to reduce stress, get more restful sleep, improve your eating habits, or find joy in your physical mobility there are simple measures you can turn to and try on your own. Implementing daily habits like meditating, gratitude practice, and walking can go a long way.
And we can all hope that one day, incentives will change to focus our attention on healthcare on solutions that actually work.