[Senate Hearing 107-505]
[From the U.S. Government Publishing Office]
S. Hrg. 107-505
PREVENTING ELDER FALLS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON AGING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
ON
EXAMINING THE IMPACT OF MENTALLY ILL OFFENDERS ON OUR JUSTICE SYSTEM,
FOCUSING ON THE COUNCIL OF STATE GOVERNMENTS' ``CRIMINAL JUSTICE/MENTAL
HEALTH CONSENSUS PROJECT'' REPORT, WHICH PROVIDES A GUIDEBOOK AND
RECOMMENDATIONS FOR THE CRIMINAL JUSTICE SYSTEM TO IMPROVE THEIR
RESPONSE TO PEOPLE WITH MENTAL ILLNESS
__________
JUNE 11, 2002
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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WASHINGTON : 2003
____________________________________________________________________________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut JUDD GREGG, New Hampshire
TOM HARKIN, Iowa BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington PAT ROBERTS, Kansas
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York MIKE DeWINE, Ohio
J. Michael Myers, Staff Director and Chief Counsel
Townsend Lange McNitt, Minority Staff Director
______
Subcommittee on Aging
BARBARA A. MIKULSKI, Maryland, Chairman
CHRISTOPHER J. DODD, Connecticut TIM HUTCHINSON, Arkansas
PATTY MURRAY, Washington JUDD GREGG, New Hampshire
JOHN EDWARDS, North Carolina JOHN W. WARNER, Virginia
HILLARY RODHAM CLINTON, New York PAT ROBERTS, Kansas
Rhonda Richards, Staff Director
C. Kate Lambrew Hull, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
Tuesday, June 11, 2002
Page
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Maryland....................................................... 1
Hutchinson, Hon. Tim, a U.S. Senator from the State of Arkansas.. 3
Struchen, Lilie Maria, Washington, DC; Bobby Jackson, Vice
President For National Programs, National Safety Council,
Washington, DC; Mary E. Watson, Falls Clinical Nurse
Specialist, Central Arkansas Veterans Health Care System,
Little Rock, AR; and Peter Merles, Director, South East Senior
Housing Initiative, Baltimore, MD.............................. 6
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Lilie Maria Struchen......................................... 20
Bobby Jackson................................................ 20
David W. Fleming, M.D........................................ 23
Mary E. Watson............................................... 26
Peter Merles................................................. 28
(iii)
PREVENTING ELDER FALLS
----------
TUESDAY, JUNE 11, 2002
U.S. Senate,
Subcommittee on Aging,
of the Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The meeting of the subcommittee convened at 2 p.m., in room
SD-430, Dirksen Senate Office Building, Senator Mikulski
(chairman of the subcommittee) presiding.
Present: Senators Mikulski and Hutchinson.
Opening Statement of Senator Mikulski
Senator Mikulski. The subcommittee on Aging of the Health,
Education, Labor, and Pensions Committee will now come to
order.
Today the subcommittee is examining the issue of the number
of falls facing the elderly within the United States of
America. This is an enormously serious issue, and we want to
thank the National Safety Council for bringing it to the
attention of my colleague Senator Tim Hutchinson and myself,
and I want to acknowledge that Senator Hutchinson has taken the
leadership role in directing the legislation in response to
this issue.
We intend to work on a bipartisan basis to deal with this,
and we are deeply troubled to find that falls are the leading
cause of injury deaths among persons aged 65 and older; that
over 340,000 adults suffer fall-related hip fractures each
year, many of them women, many of the hip fractures related to
both the fall situation and osteoporosis, causing terrible pain
to the individual, great stress on the family, at a cost of
$18,000 to $20,000 to the health care system.
Falls do not discriminate. One of our most prominent
Washington women, Kay Graham, the chief executive of The
Washington Post, a Pulitzer Prize winner, a grand dame of
American politics and an important figure in our social
history, died because of a fall.
Many of you today probably have friends or families who
have had the same experience.
Falls can be prevented by taking important steps which we
look forward to hearing about today. We want to be able to
address the solution in terms of a legislative public awareness
campaign, and again, we look forward to hearing your ideas and
your recommendations.
One out of every three adults over the age of 65 falls
every year. Falls are the leading cause of doctor visits,
hospital admissions, and emergency room visits. Older adults
are most likely to have this happen to them and most likely to
have it happen in their homes.
I am going to ask unanimous consent that my full statement
go into the record, because I know that Senator Hutchinson and
I believe that the best ideas and the best information comes
from the people.
Without objection, my full statement will go into the
record.
[The prepared statement of Senator Mikulski follows:]
Prepared Statement of Senator Mikulski
Today the Subcommittee on Aging is examining the troubling
problem of elderly falls in this country. The facts are
staggering. Falls are the leading cause of injury deaths among
persons aged 65 and older. About 340,000 adults suffer fall-
related hip fractures each year. Women sustain 75-80% of all
hip fractures. 90% of hip fractures are associated with
osteoporosis. The cost of a single hip fracture is estimated at
$16,300 to $18,700 during the first year after the injury.
Falls don't discriminate. Kay Graham, a nationally known,
affluent person was the victim of a fall. Many of you here
today probably have friends or family members who have fallen.
Yet falls can be prevented by taking steps like, home
modification, exercise reviewing medications to reduce side
effects that lead to falls.
Today the Subcommittee will examine the impact of falls and
what needs to be done to prevent them.
To help seniors live longer, healthier lives and to reduce
health care costs.
What is the problem?
One out of every three adults over 65 falls every year.
Falls are a leading cause of doctor visits, hospital
admissions, and ER visits. Older adults are most likely to fall
right in their own homes. When falls are not fatal, they can
have a devastating impact on a person's physical, emotional,
and mental health.
For example, an older woman loses her footing on her front
porch steps, falls, and suffer a hip fracture. She would likely
spend about two weeks in the hospital and may discover that she
has osteoporosis. There is a 50% chance that she could not
return home or live independently after her injuries. She would
face large medical bills.
What is the solution?
More work is needed to prevent falls in both residential
and institutional settings. Falls can be prevented. Many people
are not aware of steps they can take to prevent elder falls.
That's why I joined Senator Hutchinson to introduce the Elder
Fall Prevention Act. This important legislation provides a
framework to reduce and prevent elder falls through public
education campaigns and for seniors, their families, and health
care providers. Research to develop better ways to prevent
falls, improve the treatment and rehabilitation of elder falls
victims, evaluate the effectiveness of community programs, to
prevent elder falls in assisted living facilities and nursing
homes. Demonstration programs on ways to prevent elder falls
from home modification to targeting those at high risk for
second falls.
The bill also requires an evaluation of the effect of falls
on Medicare and Medicaid. This study would look at potentially
reducing costs by expanding coverage to include fall-related
services.
Closing. Welcome all of our witnesses here today and
acknowledge the National Safety Council who brought the serious
issue of elder falls to our attention.
I want to especially welcome Peter Merles from the South
East Senior Housing Initiative in Baltimore (part of SECO). The
Centers for Disease Control and Prevention (CDC) has also
provided written testimony for the record about what steps CDC
is taking to prevent elder falls.
I look forward to the testimony of all our witnesses on
this very important issue.
Senator Mikulski. I am going to turn to my colleague, who
has really been a leader on this issue and a strong advocate of
having a public response to this crisis.
Opening Statement of Senator Hutchinson
Senator Hutchinson. Thank you, Senator Mikulski.
Thank you for holding the hearing today, and thank you for
your leadership on an issue that both of us care very deeply
about.
In my home State of Arkansas, falls are the second leading
cause of unintentional injury deaths among seniors. Nearly 100
older Arkansans die each year from fall-related injuries.
Tragically, these are deaths that could be prevented by the
kinds of things that we want to do and the kinds of things that
the Government can do through education and prevention efforts.
I am sure that everyone in this room has a parent or a
grandparent--looking at the age of those in our audience today,
mostly grandparents--but someone who has suffered from a fall-
related injury. Nationwide, falls are the top cause of
unintentional injury deaths among older Americans, well above
the number of deaths caused by motor vehicle accidents, which
receive a great deal of attention.
One of every three older Americans falls every year, and 60
percent of those falls occur at home. Ninety-five percent of
hip fractures occur as the result of a fall, and the incidence
of fall-related hip fractures is on the rise. In 1999, 330,000
seniors were admitted to the hospital due to a hip fracture,
compared to 230,000 in 1988--an increase of 100,000. Even more
startling is that 25 percent of elderly fall victims who
sustain a hip fracture die within 1 year.
Only half of seniors are able to live independently after
sustaining injuries from a fall. So it is abundantly clear that
falls have a serious impact on the quality of life for seniors.
Additionally, falls take a tremendous toll on our Medicare
system. Medicare costs attributable to fall-related injuries
were $2.9 billion in 1991. These costs are increasing and are
expected to continue to increase exponentially over the next
several decades.
Education and prevention are steps we must take to address
this epidemic. We are going to hear today from the National
Safety Council and Mr. Jackson, who has taken a lead in elder
falls research and prevention through community-based programs.
We are also fortunate to have the benefit of written testimony
from the Centers for Disease Control, which has established a
widely disseminated Fall Prevention Tool Kit. There are many
other efforts underway at the local level which we are going to
hear about.
Additionally, I am pleased to have introduced legislation
along with Senator Mikulski which aims to improve Federal and
community-based efforts to prevent elder falls through public
education, research and demonstration programs.
So I look forward to hearing from our witnesses, and I do,
Madam Chairman, want to extend a special welcome to Mary
Watson, who flew here from Arkansas to be with us today, and
that is a lengthy flight--no easy way, no direct flight. So we
are very glad to have Mary here today as well, and I look
forward to the opportunity to introduce Ms. Watson at the
appropriate time.
Senator Mikulski. Senator, first of all, thank you for your
excellent statement, and of course, we welcome Ms. Watson.
What I would like to do is go through the introductions and
have you tell us more about Ms. Watson, and then we will go to
the testimony.
The subcommittee wishes to welcome Ms. Lilie Maria
Struchen, who is originally from Iowa. She has been a resident
of Washington, DC for over 7 years, and over the past few
years, she has actually fallen three times. She is here to tell
us what that meant and how it could have been prevented. We
expect that she is going to be an outstanding witness because
she was a teacher in Iowa for 23 years, and we are looking for
her to educate the committee. She is a graduate of Iowa State
Teachers' College, as well as Buena Vista University in Storm
Lake, IA. We welcome her.
We also have with us Mr. Bobby Jackson, who is vice
president of national programs for the National Safety Council,
which really brought this to our attention. It is a nonprofit
public service organization working with business, government
at all levels, and community organizations to reduce
unintentional injuries in the workplace, highways, and in our
homes and communities.
Mr. Jackson was previously with the National Mining
Association; he was an infantry officer in the army and was in
Vietnam. He is a graduate of Montana State University.
Senator Hutchinson, do you want to tell us about Ms.
Watson.
Senator Hutchinson. I would love to, Madam Chairman.
I am pleased to introduce Mary Watson, who serves as an
advanced practice nurse for the Central Arkansas Veterans
Health Care System Veterans Hospital in Little Rock, and is the
coordinator of the Fall Prevention Program for the VA in Little
Rock and North Little Rock.
She is from Bald Knob, Arkansas, and she received her
bachelor's and master's degrees from the University of Central
Arkansas in Conway, AR. She has worked as a health care
provider for both veterans in substance abuse programs as well
as those living in nursing homes.
Ms. Watson currently serves as chair of both the VA Nurses
and Advanced Practice Committee and the VA Nursing Research
Council. She is a member of the American Nurses Association and
the National Organization of VA Nurses.
Ms. Watson has distinguished herself in Arkansas and the VA
Health Care System as an expert in fall prevention and
research. To most people in Arkansas, she is simply known as
``the falls nurse.''
Mary, we welcome you this afternoon and look forward to
your testimony. You have traveled a great distance, and we
appreciate you being here.
Senator Mikulski. And Ms. Watson, a special welcome,
because I chair the subcommittee that funds veterans' health
care, so I am going to listen with even extra attention to see
if there are not lessons learned, Senator Hutchinson, that we
might even be able to find appropriations for this year, just
to move this along, again because of the admissions issues and
the need for very expensive orthopedic intervention as well as
rehabilitation.
Senator Hutchinson. Hear, hear.
Senator Mikulski. I would like to share with the committee
and welcome Mr. Peter Merles, who is the director of the South
East Senior Housing Initiative, which is part of a group called
the South East Community Organization, in my own home town and
in my own neighborhood. I actually helped start the umbrella
organization which the Housing Initiative is part of. But in
addition to advocacy for neighborhoods, it also went into
programs that would really help to empower people--home
ownership, among others. We have one of those naturally-
occurring communities where a lot of people are aging in place
in those wonderful rowhouses in Baltimore. When they sold for
$45,000 they were ``rowhouses''; now that they are selling for
$90,000, they are ``townhouses.'' I am sure you would
appreciate that.
Senator Hutchinson. I will say that we do not have a lot of
them in Arkansas.
Senator Mikulski. Yes; you have catfish, and we have
rockfish.
Mr. Merles is a social worker with a degree in group work
and community organization from Columbia. He has also had great
experience working as director of administration at the Jewish
Community Centers. He is a veteran of the United States Army
and has been an officer of the Maryland Senior Centers and is
currently president of the Senior Center Directors' Council,
which means they all get together and share information and see
how they can help people.
So we welcome you, Mr. Merles.
What I would like to do is start with Ms. Struchen, because
the people who are the most affected should be the ones who
kick this off. Then, if we could go to the broad policy issues
and Mr. Jackson, and then, Ms. Watson and Mr. Merles for your
very sound, grassroots, hands-on experience to give us a lot of
the practicality and hopefully some of the really concrete
solutions that are specific and affordable.
So, Ms. Struchen, would you please lead off, and the
committee looks forward to hearing your testimony.
STATEMENTS OF LILIE MARIA STRUCHEN, WASHINGTON, DC; BOBBY
JACKSON, VICE PRESIDENT FOR NATIONAL PROGRAMS, NATIONAL SAFETY
COUNCIL, WASHINGTON, DC; MARY E. WATSON, FALLS CLINICAL NURSE
SPECIALIST, CENTRAL ARKANSAS VETERANS HEALTH CARE SYSTEM,
LITTLE ROCK, AR; AND PETER MERLES, DIRECTOR, SOUTH EAST SENIOR
HOUSING INITIATIVE, BALTIMORE, MD
Ms. Struchen. Thank you very much. I thank both of you. My
voice does not carry. Can you hear me now?
Senator Mikulski. Yes, ma'am.
Ms. Struchen. Well, in the first place, I am happy to be
here, and I think it is wonderful that you are having this
meeting and discussing something that is very important to us
as we get older--and everyone will get older, you know.
As the paper says, I am 91 years old, and I live at
Friendship Terrace, a retirement community here in Washington,
DC. I just moved there recently, about 3 years ago, and I am
very happy to be there, because they have conveniences for us
and help us in a lot of ways. They have a library and 24-hour
desk security, a shuttle bus for us if we want to go shopping
or get groceries and things like that. So I am happy to be
there.
I was on one of these shopping tours when I fell. I
happened to be on Wisconsin Avenue and, leaving the CVS
drugstore, I crossed to get to the Giant store. And of course,
I do not cross streets until I see the second green light,
because you cannot start in the middle of the green light and
get across. It is hard enough after the second green light. And
I stumbled on the curb and fell flat on my face right by the
light pole. And of course, you know, you have to lie there for
a while to get your bearings, and I did not really get hurt
very much, but I did knock my teeth in, and I lost the lens out
of my glasses.
Finally--people passed me, and I think they thought they
had better not pick me up--but a lady stopped her car, got out
and picked me up and took me home, and then she went and got
some bandages for the few little hurts that I did have. So I
was very fortunate.
But you know, it was about 2 or 3 weeks later that I did
the very same thing. There just was not time to get across that
street and not hurry; you had to hurry to get there. Even now
sometimes, I have to hurry to get across with my walker. I
think I did that when I did not have a walker yet; now I have
one, and it helps. But even then, sometimes someone has helped
me get across in time.
So that was my first experience. Then, I fell in the
bathroom. That is such a very small, narrow space, and it
happened so fast. It was a tile floor, and there were a few
drops of water on it. I was wearing my leather-soled shoes, and
I just went like that--so fast. I knocked this side, and I
knocked that side, finally knocking my head before I went down
completely on the floor. That disturbed me, of course, because
no one would have heard me call to anyone, because the doors
were closed except for the bathroom door; I could not have
fallen down if it had been closed.
The panic button was on the other wall, and I could not
reach that. So I wondered what I should do, and finally, I
thought, well, the only way I can get up is I have to turn on
my knees to get on my knees and pull myself up. Well, you know,
I do not get on my knees--older people do not--but that is what
happened. I turned on my knees and pulled myself up. I had a
cut on my arm and a big bruise, but that was all that I had. I
was so glad I had not broken any bones; a lot of people do, you
know. I have had friends who did break bones and had to go to
the hospital, and some had to go to nursing homes and never
returned to our building.
I was just very lucky, I think, because I always dreaded
having a hip broken or something like that, or even to have
knee surgery, because some of them are not very successful, I
hear. So I was just lucky.
Thank you.
Senator Mikulski. Well, thank you very much, and it says
several things--one, how frightening the experience is, and
although the injuries were not ones that required surgical
intervention or a cast, it was pretty traumatic, the glasses
breaking and so on. It could have caused all kinds of very
serious damage, but also left you with a feeling of insecurity,
I know. And wasn't it wonderful the good Samaritan who came to
your rescue. Well, you are a brave lady, Ms. Struchen, and we
thank you for your testimony.
[The prepared statement of Ms. Struchen may be found in
additional material.]
Senator Mikulski. Mr. Jackson, do you want to tell us about
what the National Safety Council thinks about this, and why
they are willing to come all the way to the Congress of the
United States with this issue?
Mr. Jackson. Yes, ma'am, if I could address a few of the
broader issues.
To be a bit redundant, my name is Bobby Jackson, and I am
vice president of national programs for the National Safety
Council.
Madam Chairman, the Council is certainly appreciative of
the opportunity to testify here and for you holding this
hearing on S. 1922, the Elder Fall Prevention Act.
With your permission, Madam Chairman, I will submit my
written statement for the record and summarize briefly.
Senator Mikulski. Great.
Mr. Jackson. And again to be redundant, the National Safety
Council is a congressionally-chartered nonprofit,
nongovernmental public service organization. We were founded in
1913, and the Council is the Nation's leading safety and health
advocate, and we are dedicated to protecting life and promoting
health.
Falls among our Nation's seniors is a serious problem. In
fact, 2 years ago, the National Safety Council published its
``Safety Agenda for the Nation'' which identified falls among
the elderly as a leading concern.
Almost everyone to whom we have spoken has a story to tell
about a friend or a neighbor or a relative who has had
experience with a fall and how it has dramatically impacted
their lives. I am sure that everyone in this room, as Senator
Hutchinson mentioned earlier, has a personal experience that
they could describe not unlike Ms. Struchen's moving statement
of a few moments ago.
In 1999, the CDC reported that over 10,000 senior citizens
died from fall-related injuries. One in four seniors who fall
and sustain a fractured hip die within 1 year of sustaining
that injury. More alarmingly, hip fractures are expected to
exceed 500,000 by the year 2040.
S. 1922 has four major provisions to address the prevention
of falls to the elderly. Those are: a comprehensive national
education campaign; demonstration projects; research programs;
and an HHS review of Medicare and Medicaid reimbursement
policies.
Through our charter at the National Safety Council, we have
been charged by the United States Congress to ``arouse the
Nation in injury and accident prevention.'' The Council has led
many successful national campaigns such as the seatbelt and
airbag campaigns. The Council has numerous outreach vehicles
including our network of about 49 State and local chapters, an
extensive volunteer network, and the National Safety Council
founded the National Alliance to Prevent Falls as We Age. This
Alliance is a coalition of over 20 organizations that are
dedicated to reducing elder falls.
We intend to apply our outreach expertise to communicate
with senior citizens, with their families, with institutional
caregivers and others on fall prevention intervention.
Today, many Americans do not even know that they can make
simple changes in their environment such as in lighting or home
design, or they do not know that pre- and postfall counseling
and vision correction have actually demonstrated a reduction in
falls.
While we have a well-established base of information for an
initial education campaign, we certainly need to learn more. To
that end, the National Safety Council will oversee some of the
demonstration and research projects that are fostered in this
legislation.
S. 1922 will provide resources to the community-based
organizations like the South East Senior Housing Initiative,
which we will hear from in a few moments, to implement local
programs. In addition, S. 1922 has a CDC research component to
improve identification of high-risk elders and data collection.
Understand that S. 1922 is not just altruistic legislation
for a human problem, but it addresses major economic
implications. CDC estimates that the direct costs to Medicare
and Medicaid for fall-related care will exceed $32 billion in
the year 2020.
When he signed on as a cosponsor to this legislation,
Senator Max Baucus issued a statement that said, and I quote:
``As chairman of the Senate Finance Committee, senior health
issues are one of my top priorities. I am committed to
protecting and improving programs to better serve seniors with
crippling illnesses like cancer and heart disease.'' But the
Senator went on to say: ``But I believe Congress must also
address other health hazards that can be just as devastating.
One of these hazards is falls to seniors.''
S. 1922 will charge HHS to review the reimbursement
policies of Medicare and Medicaid relating to positive fall
prevention interventions. Clearly, a small resource investment
now will foster huge savings in the future.
As I said earlier and others on the panel will testify to,
and certainly Ms. Struchen's statement, falls to seniors are a
serious problem. Our friends, our neighbors, our relatives, and
quite possibly each one of us will be benefited by this
legislation.
The National Safety Council certainly wants to commend both
you, Madam Chairman, and Senator Hutchinson for your leadership
in this positive and worthwhile initiative. We certainly urge
other Members of Congress to embrace these worthwhile efforts.
We look forward to working with the Congress as we continue
to address the important matter of falls among the elderly.
Thank you, Senator.
Senator Mikulski. That was excellent.
[The prepared statement of Mr. Jackson may be found in
additional material.]
Senator Mikulski. Ms. Watson, I am going to turn to you,
but before I do, we have the testimony of Dr. David Fleming,
who is acting director of CDC, and at this point in the record,
I am going to ask unanimous consent that his testimony be
included in the record as part of the framework from both the
national advocacy group and the national Federal agency
involved with this issue.
[The prepared statement of Dr. David Fleming may be found
in additional material.]
Senator Mikulski. Ms. Watson, welcome.
Ms. Watson. Madam Chairwoman and Senator Hutchinson, I am
really honored to be here today.
We have just heard the statistics on the incidence of falls
and fall-related injuries and the cost to care. But the amount
of pain and suffering from these injuries, like Ms. Struchen's,
cannot be estimated.
I have given you my written testimony for the record, but I
would like to summarize the rest of my remarks.
As you mentioned about Katherine Graham's death, America
also knows that President Reagan's physical activities declined
after his fall and hip fracture. And something of interest to
me personally, which I discovered when doing family genealogy,
was that my great-grandfather, a Civil War veteran from
Pennsylvania, at the age of 75 fell on the ice and fractured
his hip. His death certificate said that he died as the result
of a fall.
Now, that was in 1918, and here we are in the year 2002,
and we still have significant numbers of older Americans dying
within the first 6 to 12 months of falls with fractures.
Over time, as the chairwoman mentioned, falls will affect
every American family. A lot of good people are working on this
issue, and this is what I know is being done. The VA has made
patient safety and fall prevention a top priority. My role is
unique in the VA system. As an advanced practice nurse, I
coordinate our fall prevention program and see inpatients on
consult and to assist staff with interventions.
Last fiscal year, we reduced our inpatient major injuries
by 50 percent. Our Little Rock VA and I have been supported in
our efforts by staff at other VAs. Audrey Nelson and Pat
Quigley's work at the VA Patient Safety Center of Inquiry at
Tampa is extensive in this area. They have set up fall
prevention programs and clinics; they are addressing the issue
of fear of falling and have hosted three excellent evidence-
based fall conferences.
I have 5 minutes in which to talk to you about falls. This
conference lasts 3 days, with outstanding researchers like Rein
Tideiksaar and Janice Morse.
Our VA has also benefited from the work of the VA Patient
Safety Center of Inquiry at White River Junction, VT. We were
involved with a Falls Collaborative Project chaired by Peter
Mills that included 37 VAs and other institutions. Real people
struggled for 7 months to develop and implement a safer
environment for patients while reducing restraint usage. The
results were a tremendous 79 percent reduction in major
injuries.
The VHA National Center for Patient Safety, under the
direction of Jim Bagian, has published a guide entitled ``Fall
Prevention and Management.'' It is a quick and excellent
resource for clinical staff in an inpatient setting.
Realizing that elder Arkansans are also at high risk for
falls, our University of Arkansas for Medical Sciences, Donald
W. Reynolds Center on Aging, with a grant from the Hartford
Foundation, has implemented a fall prevention study in an
outpatient setting. I am very pleased to be an expert
consultant for the Hartford Center for Geriatric Nursing
Excellence at Arkansas.
We based our program on recently published fall prevention
guidelines in the American Geriatric Society Journal. The co-
chair was the distinguished Dr. Laurence C. Rubenstein from
UCLA and the VA GRECC. Supported by The Hartford, geriatric
nurses in Arkansas have been instrumental in implementing these
guidelines to test their effectiveness and to translate them
into clinical and public health practice.
This is the tool kit that we have developed to engage
patients and clinical staff to change customs and practices. It
is the same principle as washing your hands. We all know that
washing hands has been shown to prevent disease, and we know
that not everyone does it all the time. So with fall prevention
and management, we must encourage everyone to incorporate these
principles all the time.
Another intervention, hip protectors to reduce injuries
from falls, has been implemented at the Little Rock VA and
other VA sites and private institutions. They have been shown
to reduce fractures by 50 to 75 percent for the small price of
$30 to $60 per pair.
So my message to you today is that we know a lot about the
causes of falls and their management, and we have heard of some
examples here today. The next step is to use our knowledge and
expand on it and then translate it into practice. To do so will
improve the quality of life for the ever growing population of
older Arkansans, veterans, and Americans.
Them, once this is done, we will need to implement
permanent funding sources to maintain these effective
prevention programs.
Thank you. That concludes my statements.
Senator Mikulski. Excellent. Thank you very much.
[The prepared statement of Ms. Watson may be found in
additional material.]
Senator Mikulski. Mr. Merles, welcome.
Mr. Merles. Good afternoon, Madam Chairman and Senator
Hutchinson. Thank you very much for this opportunity to be here
and to share with you our concern for fall prevention among the
elderly, and it is very reassuring to know that it is a high
priority for you.
The South East Senior Housing Initiative is dedicated to
helping seniors remain in their own homes and in their own
communities. As we became aware of the issue of falls and the
need to help seniors prevent falls, we joined together with a
number of agencies in the community to look at the problem and
to come up with an action plan.
We sat down with a number of partner agencies--the
Baltimore Medical Systems, a series of community-based health
clinics; with Banner Neighborhoods, a community development
corporation; with Neighborhood Housing Services of Baltimore,
and with the Baltimore City Commission on Aging, which is our
Area Agency on Aging. We also brought in the Hopkins School of
Public Health.
We devised an action plan, our Safe at Home Program, to
demonstrate that falls can be prevented by providing home
modifications, safety repairs, assistive devices, training by
an occupational therapist, social work interventions, nutrition
services, health education, and ongoing communications with
physician, family, and client.
The Robert Wood Johnson Foundation agreed that this was a
promising proposal and went a little bit out of their normal
funding path to support this effort with a 4-year grant. We
received matching funds from four local foundations.
We hope in the near future to have some of these efforts
supported by the Maryland Medicaid Waiver Program, where we
have run into quite a few stumbling blocks in that attempt.
Our work with the Hopkins School of Public Health is based
on a contract with them to do an in-depth analysis of our data
and to help measure whether and to what degree these
interventions really are effective. One of the first steps in
the process was the development of an intake and screening tool
which, very much in line with a recent paper put out by the
American Association for Retired People, helps to focus the
effort on people who are most at risk for falls so the dollar
benefit of the intervention is maximized.
Our data as it is collected over the next 3 years will be
analyzed against baseline data previously researched by Dr.
Linda Fried at the Johns Hopkins School of Public Health. It is
a little premature to reach conclusions--we have been in
operation for only about 18 months--but the trends are very
positive. They seem to be moving in the directions we expected.
The Robert Wood Johnson Foundation challenged us as part of
this effort to keep physicians involved in the process, to see
if we could keep the doctors aware of the effect of the home
environment on the potential for falls and the risks that they
present to seniors.
Our target over the 4-year period of this project is to
serve 550 low-income seniors, people over the age of 55, who
seem to be at risk for falls. To date, 18 months into the
program, we have about 260 clients, so we feel that the people
who need the service certainly are out there.
We are frustrated daily by the numerous calls we get from
people outside our geographic catchment area. Our program is
limited by our funding to Southeast Baltimore, and we get calls
from every quarter of the city and from the surrounding suburbs
looking for the help that we provide.
There really is not anybody else in the city doing quite
what we are doing, and the need is clearly out there.
Baltimore's typical rowhouse, as Senator Mikulski indicated,
can present specific challenges for senior adults. Typically,
the bathroom is on the second or third floor; frequently, the
kitchen in the basement. The steps are very steep, narrow, and
sometimes twisting.
Most of our clients are widows or widowers living alone.
They have very limited income. They have lived in the same
house all of their married lives, some of them all of their
lives, and many of them are second or third generations. So
that efforts to make changes in the home environment meet very
strong resistance. Even moving a piece of furniture that might
be in the path of their walking traffic can sometimes be very
difficult, or moving a throw rug.
Mortgages have long ago been paid off, so that very few of
these clients carry homeowner's insurance. This leads to not
making appropriate repairs, for example, to roof damage, which
then leads to ceilings falling and to floors warping, creating
a tripping obstacle.
Some of the interventions that we provide, the typical home
modification interventions, include: Installing railings on
interior and exterior stairs; grab-bars, handheld showers,
improved lighting, taping down throw rugs; providing cordless
phones so you do not have to run to answer the telephone;
replacing broken steps; removing extension cords and adding
outlets that are 18 inches above the floor; moving laundry
facilities up from the basement; providing assistive devices,
transfer devices; providing safe stepping stools and reaching
devices; building wheelchair ramps; installing stairglides;
repairing broken and warped flooring, and removing carpeting
that may be too shaggy or too worn; and rearranging furniture.
Another vital piece of our program is the ongoing contact
with the client. We re-contact every client approximately every
90 days to maintain a relationship. Often, suggestions that we
have had for them at the beginning are not accepted, and 90
days later, as we develop the relationship, they are willing to
attempt some of the things we want to do.
We are very grateful for your attention to this concern,
and we hope that the Senate and Congress will follow this
initiative and help provide the means for bringing this to
national attention and dealing with the problem.
Thank you very much.
[The prepared statement of Mr. Merles may be found in
additional material.]
Senator Mikulski. Thank you, Mr. Merles.
All of the testimony was just excellent and very much
appreciated.
Ms. Watson, I want to ask you two questions. One, in your
opening remarks, you talked about how you had a 50 percent
reduction--did you say in admissions?
Ms. Watson. In major injuries.
Senator Mikulski. Do you want to talk about what you did
and how you did that? That is a stunning statistics, and the
consequences on the VA medical budget are quite significantly.
Ms. Watson. Certainly. Along with reduction in pain and
suffering, we instituted a more formal assessment, as these two
gentlemen have spoken about. On admission, our patients are
assessed, and we determine whether or not they are at risk.
Although I have some ideas that people should all be considered
at risk--universal fall precautions are implemented at our
hospital for all veterans--then, we have a moderate risk and a
higher risk. We have improved and enhanced our method of
communication about that risk to all shifts, and when a patient
is transferred from unit to unit, they are reevaluated; if they
are there for a period of time, they are periodically
reevaluated. So the assessment was quite crucial, and we
implemented the Janice Morse Falls Scale to do this.
Along with assessing patients, of course, we have ongoing
education to staff regarding the kinds of strategies that
should be implemented once someone is at risk. Based on whether
or not someone is alert and oriented, you might simply make
sure they have a bedside commode, make sure they have good
slippers, that a light is on in the bathroom, make sure that
that call light is always within easy reach--those kinds of
things.
Then, for those who are more confused and disoriented, you
might move them closer to the nurses' station. Using bed and
chair alarms is another intervention that we have really pushed
at our VA as well as in our long-term care area, implementing
hip pads, using low beds to the floor with floor mats.
Senator Mikulski. That is really very interesting.
Also, on page 4 of your testimony, you use the term ``hip
protectors.'' I find that a fascinating term. Some of us think
we have a little too much hip protection. [Laughter.] Could you
tell me what a hip protector is?
Ms. Watson. Well, I believe you might have an attachment to
my testimony with a picture of this. Basically, it is an
undergarment that has extra padding over the hips. This can be
either a soft material type or a harder type of shell, based on
which company produces it. They have been available for the
last 15 years, but it has only been in the last 5 years that we
have had a lot of research in this area, particularly in
England and Sweden. A study came out in the New England Journal
of Medicine in December of 2000 that indicated that this
product was quite effective for those who would wear them.
They have a slim fit that can fit under your regular
clothing. If you are a nursing home patient, they have larger
sizes that have more room; and if you were incontinent, you
would wear them over your incontinent brief.
Senator Mikulski. So it is a low-tech, high-impact
technique for minimizing----
Ms. Watson. That is right. If they are worn 100 percent of
the time, day and night, they are very, very effective.
Senator Mikulski. That is very interesting.
I just want to say to the committee that I am going to have
to go to another committee hearing, and with Senator
Hutchinson's indulgence, I would like to ask Mr. Merles two
questions and then turn it over to you for such time as you
deem necessary.
First of all, thank you very much, Ms. Watson, and again,
we have other questions, but in the interest of time, I will
turn to Mr. Merles.
Mr. Merles, are you bankrolled only by the Robert Wood
Johnson Foundation?
Mr. Merles. At this point, the Robert Wood Johnson
Foundation, the Franz-Merrick Foundation, the Knott Foundation,
and the Ericsson Foundation, four local Baltimore foundations,
match the funding from Robert Wood Johnson.
Senator Mikulski. I appreciate that.
Let us go to page 2, where you talk about how to improve
those Baltimore rowhouses. That is exactly the neighborhood
where I grew up, but it is where my mother and father aged in
place. My father had Alzheimer's, and eventually, we had to
turn to long-term solutions, and mother developed diabetic
neuropathy, so we needed the stairlift and so on. We did those
things, and they were expensive.
My question to you, because I think it is great--you list
installing railings, chairlifts, a lot of practical things--are
you actually--``you'' meaning the program--actually paying for
these things?
Mr. Merles. Yes, we are--not the chairlifts. We have
installed a few chairlifts because they have been donated to
us. We frequently get recycled equipment as part of our
community loan closet, and then, if we find a home where it
fits, we can install it.
Senator Mikulski. Because those cost several thousand
dollars.
Mr. Merles. Yes. Our average expenditure per client, total
average expenditure, is about $1,200.
Senator Mikulski. And that is usually for these
modifications, lighting, and so on.
Mr. Merles. Right--and shoes. We really put a big stress on
safe, comfortable shoes.
Senator Mikulski. So again, though, $1,200, when you think
about the admission--and do you work with private contractors?
Mr. Merles. Yes, we do, although we do get some of our work
done through labor which comes to us at no cost through the
Living Classrooms Foundation which is part of a program for
training young people in construction industry skills and
actually does a lot of our installation work. That helps to cut
down on the costs.
Senator Mikulski. If in fact--and I know about Living
Classroom--Senator Hutchinson, you would like it. It is where,
in the old days, they would have called them ``dead-end kids,''
and this is usually a second chance, but instead of just
lecturing them to be good, they are given role models and
mentors and practical skills, particularly in area like
carpentry and other work force shortage areas in the building
trades. Then, they can move into apprenticeships, and their
lives are changed.
I have talked to these kids, and when they are doing some
of your kind of work, for the first time, Senator, they feel
pride. They are actually, instead of destroying the community
or breaking their grandmother's heart, repairing homes. So it
is a double win.
Mr. Merles. Senator, if I may relate one vignette, we had a
wonderful experience working with the young people from Living
Classrooms in a joint program with the Veterans Authority where
we had a senior adult, a veteran who was a double amputee now
confined to the basement level of his home. We were able, with
the labor provided by Living Classrooms and funding for
materials from the VA, to put in an adapted bathroom, where
there had been no bathroom on that level, with a roll-in shower
so he could move in easily, and wit all the proper grab-bars
for transferring to the toilet, and it was an extremely
successful project--and it was not just the work itself. As you
were alluding to, it was the excitement of these young people
about working with a person who needed their help and seeing
what a great job they were accomplishing. It was really a nice
win-win situation.
Senator Mikulski. What would be the appropriate agency to
go city-wide? If we looked at demonstration programs, should
this be run through municipalities, nonprofit organizations,
all of the above?
Mr. Merles. I think some combination of nonprofits with the
Baltimore City Commission on Aging would probably be a very
viable approach. There are organizations in other parts of the
city--I am thinking of Light Street Housing and High
Neighborhoods in Northwest Baltimore and maybe HarBel in
Northeast Baltimore who could all probably do something like
this.
Senator Mikulski. So when the committee looks at this, your
suggestion would be--because again, our dear colleague is
interested in the rural issues--to work through the Area
Agencies on Aging and let them see if they could either
administer it or delegate it through a contract with a
nonprofit.
Mr. Merles. Contract to a nonprofit, yes.
Senator Mikulski. When they talk about the Commission on
Aging, that is the Baltimore City Area Agency on Aging. Would
you recommend that?
Mr. Merles. Yes, I think that would be a very viable
approach.
Senator Mikulski. Thank you. And again, I want to thank you
for your very good work, both of you; Mr. Jackson for bringing
this to our attention; and Ms. Struchen, who is quite a brave
lady.
Ms. Watson, you can be assured that as somebody who
bankrolls the VA, we are going to see how we can provide a
little more behind the National Center for Patient Safety, and
I will work with my colleague on that.
Thank you very much, Senator Hutchinson. I look forward to
working with you on this.
Senator Hutchinson [presiding]. Thank you, Senator
Mikulski. And I am on the authorizing committee, and we will
look forward to working with you on the VA.
Senator Mikulski. Thank you. Let us see if we can do that
this year, like soon.
Senator Hutchinson. Excellent. Very good. Already something
great has come out of this hearing.
I want to thank all of our witnesses. Ms. Struchen, we are
glad that you are with us. I think you are very fortunate,
having had those three falls that you narrated to us, to be
looking good and in good health and good condition. So we are
glad for that.
According to the CDC, an individual who falls once is two
to three times more likely to fall again, and that is the
category you are in. So I want to make sure to get all those
suggestions that have been made, those practical things that
can be done to ensure that we have you for a long time and that
we do not have any more serious falls.
Ms. Struchen. Thank you very much.
Senator Hutchinson. I want to ask Mr. Jackson kind of a
philosophical question. What I find is that when I am
sponsoring legislation dealing with elder falls as a
conservative Republican, there is a little rolling of the eyes
or a little snicker, implying what is Government doing in the
area of elder falls.
I get posed that question, and I have an answer for it, but
I want to hear what the National Safety Council has to say
first. What do I tell my colleagues on the Republican side of
the aisle why they should be supporting a very modest
investment, really, in a program to reduce alder falls?
Mr. Jackson. Senator, without identifying my political
leanings, I have a pretty good answer for that. First of all,
the business community looks for a return on investment.
Clearly, there is a return on investment here to Medicare,
Medicaid, and the VA by investing a relatively small amount of
money now to save this large amount of money that is going to
be outputted in the future if we do not reverse this trend in
falls.
So it is a simple ROI.
Senator Hutchinson. Yes, it is. A long time ago, our
Government and our people, the citizens of the United States,
made a commitment that we were going to care about our senior
citizens in the establishment of the Medicare program and a
health insurance program for our seniors. We said as a people,
as a society, and as a compassionate culture that we cannot
ignore those who are most vulnerable and particularly those who
have reached their golden years and may not have health
insurance.
So when you take that into consideration, what we have
proposed on elder falls really makes all the sense in the
world, because Medicare will face and continues to face an
ongoing financial crisis, and this is clearly not only
compassionate, to help people and save lives, but it is also a
very, very good investment of taxpayers' dollars if we can
reduce death and injury from elder falls.
So that is my message to my colleagues, and I think we are
going to find a lot of bipartisan support for what we are
proposing,and I want to commend the National Safety Council,
because what we must do here in Congress as well as across this
Nation is to focus attention, heighten people's sensitivity to
this issue and their awareness that this is a major problem in
our country. You are doing a good job at that, as the National
Safety Council has done on issues for many, many years.
As we think about raising awareness of falls and how
devastating the resulting injuries can be, Ms. Watson--I might
say that your testimony was outstanding. Chairman Mikulski
leaned over to me and said, ``Excellent witness,'' and I was
very proud that you are from Arkansas--but you mentioned that
seniors need to be encouraged to come forward regarding their
fall history. Is it your experience that a typical senior is
embarrassed to admit that he or she has fallen, and have you
encountered cases where seniors who have fallen are even
reluctant to tell their own families?
Ms. Watson. Oh, yes, definitely. Of course, no one wants to
admit--or, they might discount it because they thought they
were just clumsy. Some people may use the excuse that, ``I am
just getting older. Of course I would fall.'' Others might be
afraid that their family members would curtail their
activities.
One such case was my grandfather, who was my grandmother's
caregiver. When he fell and broke some ribs and then developed
pneumonia, it complicated his case, and my mother insisted that
they be institutionalized, and they were admitted to the home
in York, PA.
So there are many reasons why someone might not want to
tell others they have fallen. If you fall even in the hospital,
``The doctor might delay my discharge.'' So coming forward
might be difficult.
However, as you mentioned, developing a relationship with
your provider or someone such as your group is what the
American Geriatric Society is recommending, that elders be
asked on a periodic visit to their provider, ``Have you had a
fall in the last couple of months?'' or in the last year, and
perhaps get a dialogue going, and then perhaps do a simple
noninvasive test in which they get up, walk across the room,
turn around, and come back, and the provider can watch and see
how they are doing.
Over a period of time, the person might trust their
provider, that the provider is there to help them maintain
their mobility, maintain their independence, if we just know
what is really, truly going on.
Senator Hutchinson. Senator Mikulski asked you something
about the hip protectors, and it kind of got my attention, too.
Clearly, in your program in the VA, these are being used with
great effect. You said they have been around for 15 years.
Ms. Watson. Yes.
Senator Hutchinson. Is there any effort to have the use of
hip protectors expanded, and is there any utilization that you
are aware of on a formal basis outside of what you are doing in
the VA?
Ms. Watson. Certainly, the National Center for Patient
Safety through the VA is doing everything they can to promote
the use of hip protectors.
Senator Hutchinson. That is within the VA.
Ms. Watson. Within the VA, yes. They are implementing a
small study at our VA relatively soon in which we are going to
ferret out the problems with hip protectors. Not everyone will
wear them. There might be problems with laundry, comfort. There
are various products out there that need to be tested and tried
so that we can come up with an algorithm or a protocol that
will be helpful to whatever institution wants to use the
product.
Senator Hutchinson. And you said the investment is only $30
to $60 dollars?
Ms. Watson. Yes, $30 to $60 per pair. Someone would need
approximately two pair, one to wash and one to wear, as they
say. They go through approximately 125 to 150 washings. And
based on whatever model you choose, you can go out in public,
perhaps; if you have a fear of falling, this might give someone
a little bit more comfort and security that if anything
happens, they will not break their hip.
Senator Hutchinson. Thank you.
In your testimony, you mentioned that approximately 14
percent of falls are accidental and attributable to
environmental factors, while the majority of falls are due to
physiological factors. And physiological factors would mean
poor eyesight or imbalance, something of that nature.
Ms. Watson. Yes, that is correct. If you have a sudden,
acute illness, perhaps--an infection might make you weak, and
you would fall; a chronic illness like diabetes with peripheral
neuropathy, in which your feet are kind of numb, so your gait
and balance may be affected; other chronic diseases like
Parkinson's disease that cause gait and balance disorders. A
simple lack of exercise and deconditioning over time can also
predispose someone physiologically to a fall--as you mentioned,
vision, hearing, poor nutrition can physiologically predispose
you to weakness.
Senator Hutchinson. When you said that 14 percent of falls
are attributable to environmental factors, what struck me
immediately was that it does not seem like that many falls are
attributable to environmental factors, 14 percent--but there is
a lot of interrelationship between the physiological and the
environmental factors, so that even if there is a physiological
predisposition to being vulnerable to a fall, if you take the
proper precautions and preventive measures in your environment,
you can minimize or lessen the risk.
Ms. Watson. That is correct. If you have a gait and balance
problem, simply walking from one end of the house to the other
might be more difficult for someone because of something in the
environment. So that it can certainly be a simple accident,
such as tripping on something that is wet, or it could be a
combination of the fact that you have a gait and balance
problem and you trip over a tiny bump in the rug.
Senator Hutchinson. And I cannot remember the percentage,
but you mentioned what percentage occur in the home as opposed
to outside the home. Do you recall?
Ms. Watson. Sixty percent.
Senator Hutchinson. Sixty percent occur in the home?
Ms. Watson. Yes, in the home.
Senator Hutchinson. Maybe I mentioned that.
Ms. Watson. I think you did.
Senator Hutchinson. And with the 60 percent that occur in
the home, are there statistics on where in the home the highest
risk is, like in the bathroom?
Ms. Watson. I think the bathroom and the bedroom areas are
high-risk. Certainly, an environmental assessment, as you were
mentioning, in great detail by a physical therapist or an
occupational therapist who can certainly see the person as they
move through their day-to-day activities, where they are having
the most problems, then they could individualize the
interventions there in the home.
Senator Hutchinson. Bobby, is there anything you want to
say on that? You looked like you were ready to comment.
Mr. Jackson. No. I was just affirming what she was saying
about locations. Our data indicate that the bathroom and the
bedroom are two vulnerable locations in the house.
Senator Hutchinson. Mr. Merles, you mentioned the great
demand for the services you provide, but I take it you are
really the only service provider doing what you are doing in
the Baltimore area. Why do you suppose others have not gotten
involved in this area?
Mr. Merles. Because there is very little funding for it.
The other community agencies that we have talked to have said
they would love to be able to do it if they had funding to do
it.
Senator Hutchinson. And that is what we are looking at.
Hopefully, we can be of help on that.
I think I am about to exhaust the questions that I wanted
to ask, but I want to give any of our witnesses today the
opportunity to have a closing word or to make any particular
statement for the record and for the committee.
Mr. Jackson. If I may, Senator, just a couple of comments.
There may be a question from time to time about competition, if
you will, between a national campaign of education and so on
and local experience. Clearly, we think that these two issues
are compatible, working in a national education campaign, to
give broad behavior modification, not unlike what we have gone
through over the years with most recently child safety seats,
for example. Fifteen years ago, we did not use them; now the
use if very good. That is a behavior modification activity.
The local experience, though, is a practical experience
where the rubber meets the road, where it can really get done.
I think these two issues certainly have synergy.
HHS is to study, by the way, as part of this statute the
impact of tax credit. We are talking about seniors not being
able to afford this. Well, if there is a possibility for
impacts of a tax credit for prevention interventions, that is
what HHS is supposed to look into.
My final comment is that many cynics that I have talked to
say that old folks are going to die anyway. Well, here is the
case where they do not have to die--they do not have to die
from accidental falls. Worse than that is surviving a fall and
changing their lifestyle and the reduction in quality of life.
That is the worst of the incidents that can happen, and we can
stop that through this activity.
Senator Hutchinson. Well said.
Anybody else?
[No response.]
Senator Hutchinson. Then, let me thank our panel for your
excellent testimony and presentations today and for laying the
groundwork for what I hope will be a very productive action on
the part of the U.S. Senate.
So thank you for your participation, and the hearing is
adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Lilie Maria Struchen
I am a 91-year old woman, and I live at Friendship Terrace, a
retirement community here in Washington, DC. I am happy there and am
pleased that I am still very independent. I cook, clean my own
apartment, and have a full calendar of activities. I have been going to
a lunch program at a nearby church two days a week, but I am giving
that up for awhile so I can devote more time to painting, and to join a
book discussion group. Our retirement home has a wonderful library. I
also appreciate the 24-hour security desk, the shuttle bus that takes
us shopping and to medical appointments, the nurse who is here two days
a week, and the services of the IONA Senior Services.
During the past few years, I have fallen both while out shopping
and in my bathroom. I fell twice on the same street corner while
crossing from the drugstore to the food store. I fell flat on my face,
breaking my glasses and hurting my nose. Although it took me a little
time to get my bearings, fortunately, I was not badly hurt. The falls
may have been due to carelessness, but I was hurrying because there is
not enough time between the green and red lights for me to get across
the street. Now, even if the light is green, I wait and don't start
crossing until the next time it turns green. Also, I no longer take the
public bus, but rather wait for our shuttle bus.
When I fell in the bathroom, I think it was because of a little
water on the tile floor that made it slippery. My body twisted and my
left side hit the tub and then my right side hit the sink and counter.
My right arm had a very bad bruise and deep cut. My left arm hit the
toilet very hard, and, luckily for me, the seat was up and my fist went
down to the bottom of the bowl. If the toilet seat had been down, I
think I would have broken my wrist or arm on it. I fell to the floor
and couldn't reach the ``panic button.'' No one would hear me call with
the door closed, so I had to struggle to get to my knees--which I
hadn't done in a long time--and then finally stand up. I was badly
shaken up by this fall, but I wasn't too badly hurt physically. The
nurse where I live was able to take care of the cut on my arm. I'm
thankful I didn't have to call 911, because another time when an
ambulance took me to the hospital, it was very expensive.
I have discussed getting the type of emergency response system you
wear around your neck, but I am not sure if I am ready to do that yet.
One reason is cost. I understand it costs about $40 to set up a system
and about $35 a month after that. This is money I could use to buy
groceries--things I want that are not served at the evening meal which
is included in my rent. Also, emergency response systems do not help
when you are out in the community, only in your own home. I have
thought it might be helpful for older people to always have cell phones
with them. However, this would be an expense, and if you fall you might
not be able to make a call.
Besides waiting for green lights and making sure bathroom floors
are dry, my other suggestions for preventing falls are grab bars in
bathrooms, railings in hallways, and making sure there is a little
light in your room at nighttime in case you want to get up when it is
dark. It is also important to have someone check on you. At Friendship
Terrace, you need to let them know if you will not be at dinner.
Otherwise, if you do not appear, it is reported to the office and
someone calls to see if you are okay.
Even though I have had several falls, I have not been badly hurt.
However, I have friends and acquaintances who have fallen and suffered
injuries that required hospitalizations. Unfortunately, in many cases,
people do not recover or must leave their homes and enter a nursing
home.
Senators, I appreciate your work to help prevent falls among
elderly people, and I thank you for inviting me to participate in
today's hearing.
Prepared Statement of Bobby Jackson
The National Safety Council (NSC) appreciates the opportunity to
provide congressional testimony related to the Elder Fall Prevention
Act of 2002 (S.1922). The National Safety Council is the nation's
leading non-profit, non-governmental safety and health organization,
comprised of 37,500 organizational members and millions of Americans
that are employed by its members. Founded in 1913, and chartered by the
U.S. Congress in 1953, the Council is the nation's leading safety and
health advocate and has been instrumental in saving the lives of
Americans in the workplace, on the highways and in their homes and
communities.
Falls among our nation's valued elderly is a serious public safety
and health problem. Two years ago, the National Safety Council issued
its Safety Agenda for the Nation, which identified the seven most
critical safety and health issues in America. Falls to the elderly was
preeminent among those issues--along with drunk driving, teen driving,
seat belt use, large truck safety, workplace safety leadership and
pedestrian safety.
In 1999, the latest year that data is available from the CDC, over
10,000 seniors age of 65 or older died from fall-related injuries.
Falls are the leading cause of injury death among older adults and the
most common cause of non-fatal injuries and hospital admissions for
trauma. Alarmingly, more than one-third of adults 65 years or older
fall each year.
The most common of fall-related injuries are hip fractures, which
are expected to exceed 500,000 by 2040. Of all fall-related fractures,
hip fractures cause the greatest number of deaths and lead to the most
severe health problems and reduced quality of life.
In fact, one in four seniors who sustains a hip fracture die within
one year and three out of four seniors who survive will never regain
their pre-fall quality of life.
The Elder Fall Prevention Act is not just altruistic legislation
that has identified human benefits. It also has major economic
implications. For example, CDC estimates that direct costs alone to
Medicare and Medicaid will exceed $32 billion in 2020.
Senator Max Baucus, a co-sponsor of S.1922 recognizes these type of
health care costs, as a serious problem. Senator Baucus strongly
supports the fall prevention legislation from a health care cost
savings perspective. Senator Baucus issued the following statement:
``As Chairman of the Senate Finance Committee, which has jurisdiction
over Medicare and Medicaid, senior health issues are one of my top
priorities. I am committed to protecting and improving these programs
to better serve seniors with crippling illnesses like cancer and heart
disease. But I believe Congress must also address other health hazards
that can be just as devastating as these horrible diseases. One of
these hazards is falls by seniors.''
Additionally, The Elder Fall Prevention Act will charge the
Secretary of Health and Human Services to undertake a review of the
effects of falls on the costs of the Medicare and Medicaid programs and
the potential for reducing costs by expanding the services by these two
programs. The review will include a review of the reimbursement
policies of Medicare and Medicaid to determine if additional fall-
related services should be covered or reimbursement guidelines should
be modified.
As is the case with most public safety and health problems, funds
spent on prevention are multiplied in savings in private and public
sector health care costs. A small investment now will foster huge
savings for our health care system later.
Falls to the elderly is a public safety and health problem that
demands significantly increased focus on prevention. Therefore, NSC
strongly supports S. 1922 and firmly believes that it will provide the
necessary resources and direction to implement a national, coordinated
strategy to address this serious problem through national education
campaigns, demonstration projects and research.
Through our Charter, The National Safety Council is charged by you,
the U.S. Congress, to ``arouse the nation in injury and accident
prevention''. The Council is prepared to fulfill its Charter for older
Americans in part through its involvement in this legislation. Through
funding provided by this bill, the National Safety Council will
implement a three-year nationwide public education campaign along with
demonstration and research project to prevent fall-related injuries and
death.
Over its 90-year history, the National Safety Council has led or
played key roles in national education campaigns on a number public
safety and health issues, including workplace safety, seat belts, air
bags, and lead poisoning.
Through national education campaigns, including those led by the
National Safety Council, Americans today are much more knowledgeable
about the benefits for example of seat belts. Thousands of lives have
been saved on our highways because of this knowledge and because of the
simple change in behavior of wearing seat belts.
We are committed to raising the national consciousness and
knowledge about fall prevention. We might compare where we are today in
knowledge about fall prevention with where the nation was a generation
ago regarding the use of seat belts. The Council firmly believes that
falls can be prevented though educational awareness and behavioral
changes.
Similarly, today many Americans do not know how simple changes- in
lighting, floor coverings, handrail installation, vision correction,
exercise and various aspects of home design can reduce falls. Many
older Americans do not know how simple changes in how they walk up and
down stairs and sidewalks can reduce the likelihood of falls.
Additionally, pre-and-post fall counseling of seniors and their
families are proven, effective measures that have demonstrated a
reduction in elder falls. This is just a small sampling of the
knowledge that the NSC hopes to share with our nation through an
educational campaign.
While these factors may seem like relatively simple matters in
which public education is needed, there are many complex factors
affecting Americans' fall risk. Providing public education about these
risk factors and causes will require a comprehensive plan that
recognizes that falls occur due to a variety of risk factors and causes
with varying prevalence of each among different groups of people.
Falls may be an indicator of a serious health problem, may indicate
progression of a chronic disease, or simply may be a marker for the
onset of normal age-related changes in vision, gait and strength.
Among the most prevalent risk factors cited in existing research
are environmental hazards, gait and balance impairment, sensory
deficits such as vision impairment, medical illness, age-related
frailty, vertigo, impaired ADL, muscle weakness, depression, effects of
over medication and history of falls.
NSC has the capability of using its national network of state and
local chapters, media sources, its extensive volunteer network, and
website as effective outreach tools. Additionally, the NSC founded the
National Alliance to Prevent Falls As We Age. We will apply our
expertise on fall prevention to communicate with senior citizens,
families, community groups, senior citizen groups, employers, health
care providers and the business community about effective pre-fall and
post-fall prevention methods and strategies.
A key component of the NSC outreach network will include the
aforementioned National Alliance to Prevent Falls As We Age. The
Alliance's mission is to prevent falls and fall related injuries to
older adults through outreach and innovative interventions, including
educating the public and key stakeholders on the impact and
preventability of elderly falls and related injuries of those age 50
and older.
The Alliance will work to reduce falls and fall-related injuries in
adults age 50, and over through collaborative activities of federal
agencies and other health and professional organizations. Strategies
will include innovative outreach and educational activities, including:
providing information, resources, and training to individuals,
families, medical practitioners, community organizations, the media and
policy-makers on the economic impact and prevention of falls by adults
age 50 and over. Information will include both intrinsic and extrinsic
factors including, but not limited to: home environment modification,
medication review, vision, physical activity and enhancement of balance
and strength, risk assessment, behavior change, fall-prevention
counseling and other emerging protective and risk factors and
preventive measures that contribute to or mitigate the risks of falls
as we age.
The objectives for the Alliance are as follows:
1. Identify and increase collaboration among organizations with an
interest, knowledge, resources and expertise to potentially impact
prevention of falls and fall injuries, including federal, non-profit,
professional, and other organizations. Develop a mechanism to network
and share information among Alliance members.
2. Establish criteria for selection and identification of science-
based resources, strategies, materials and evaluated programs related
to fall prevention. Make information available through a variety of
print, internet, and media modalities.
3. Convene a symposium to develop a National Action Plan to prevent
older adult falls (e.g., research, surveillance, communication,
training, resources, etc.)
4. Conduct falls prevention strategies targeting older adult
populations and their families and caregivers to promote fall
prevention.
5. Identify and implement appropriate strategies from the National
Action Plan.
6. Prevent almost 50,000 fall-related fatalities by the year 2008
and 75,000 by 2012.
7. Achieve a 10% reduction in fall-related hospital admissions by
2008 and a further 10% reduction by 2012 and preventing 13.2 million
fall-related injuries over the next 12-years.
8. Increase research related to this critical issue.
Additionally, S. 1922 will provide much-needed funding in the form
of grants to qualified organizations, such as the Southeast Senior
Housing Initiative in Baltimore, Maryland.
These grants will enable organizing of state-level coalitions,
comprised of state and local agencies, safety, health, senior citizen
and other local, community-based organizations, to design and carry out
local education campaigns, that focus on ways of reducing the risk of
elder falls and preventing repeat falls.
These public education campaigns will be overseen and supported by
the NSC through the management and oversight of the Department of
Health and Human Services Administration on Aging. Partnering with a
federal agency to conduct public education campaigns is something the
Council has done many times--including its partnership with the
National Highway Traffic Safety Administration (NHTSA) on the seat belt
campaign, which was referred to earlier in this testimony.
The second aspect of the National Safety Council's involvement in
the Elder Fall Prevention Act after the public education campaign, is
to oversee and support the demonstration and research projects that
provide grants to qualified applicants to design and carry out both
pre-fall and post-fall demonstration programs in both residential and
institutional settings.
These programs are critical to expand the base of knowledge related
to a number of issues. The knowledge to be obtained through
demonstration and research includes: Determining the effectiveness of
various prevention approaches with certain target groups; Evaluating
fall risk screening and referral programs; Targeting, screening and
counseling methods for high-risk potential fall victims; Effectively
educating health care and social service providers; Measuring the
effectiveness of different post-fall treatment and rehabilitation
strategies; and Determining the effectiveness of fall prevention
programs in residential, multifamily and institutional settings.
The last major component of the Bill charges HHS to conduct and
support research including: Improve the identification of elders with a
high risk of falls; improve data collection and analysis to identify
fall risk and protective factors; Improve strategies that are proven to
be effective in reducing subsequent falls; Expand proven interventions
to prevent elder falls; Improve the diagnosis, treatment and
rehabilitation of elderly fall victims; Assess the risk of falls
occurring in various settings; and Evaluate the effectiveness of
community programs to prevent assisted living and nursing home falls by
elders.
The National Safety Council believes that a structured approach and
program of demonstration and research projects is the right approach to
obtaining this knowledge. In this initiative, the Council will work
under the leadership of the Centers for Disease Control and Prevention.
The Council and CDC already have a working relationship through their
shared chairmanship of the National Alliance To Prevent Falls As We
Age.
As noted previously, falls to the elderly is one of the seven most
critical safety and health issues in America. The National Safety
Council is committed to preventing the life changing impact of fall
injuries and death. The NSC believes that a large percentage of falls
can be prevented through effective measures.
The National Safety Council is committed to producing short-term
results and long-term successes in preventing fall-related injuries and
death, controlling health-care costs and producing significant results
in reducing the impact of this significant public safety and health
problem.
The National Safety Council thanks Senator Mikulski for her
demonstrated leadership in this initiative and for including the NSC in
this very important hearing addressing elder falls. Likewise, the NSC
recognizes Senator Tim Hutchinson for his dedicated commitment to
preventing falls to the elderly through his sponsorship of the Elder
Fall Prevention Act of 2002.
NSC looks forward to working with Congress as we begin to further
address these issues.
Prepared Statement of David W. Fleming, M.D.
INTRODUCTION
Madame Chairwoman and Members of the Subcommittee, the Centers for
Disease Control and Prevention welcomes this opportunity to provide
this statement for the record on the issue of falls among older
Americans. CDC is working with our Federal and non-federal partners in
addressing the serious consequences older Americans face as a result of
falls; identifying opportunities to improve the health and safety of
older Americans: and reducing the negative economic impact that falls
produce in our rapidly aging nation.
THE NATURE OF THE PROBLEM
Falls represent a serious public health problem in the United
States. One of every three older Americans-about 12 million seniors-
fall each year.
Data show that falls are the leading cause of injury death among
people 65 years and older. In 1999. more than 10,000 older adults died
from fall-related injuries. This number will increase as the number of
people over age 65 continues to grow.
Nonfatal falls are also significant. Falls are the most common
cause of hospital admissions for traumatic injuries. In 2000 alone, 1.6
million seniors were seen in emergency departments for fall injuries.
Every year, falls among older people cost the nation more than $20.2
billion in direct medical costs. By 2020, the total annual cost of
these injuries is expected to reach $32.4 billion. Annual Medicare
costs for hip fractures is almost $3 billion. These economic costs are
significant.
Of all fall-related injuries. hip fractures not only cause the
greatest number of injury deaths. but then also lead to the most severe
health problems and reduced quality of life. Women sustain 75-80% of
all hip fractures and the rate increases sharply from age 65 to 85. One
out of three women will have a hip fracture by age 90. In 1999, there
were over 300,000 hospital admissions for hip fractures, 77% were
women.
The impact of hip fractures is significant, both in terms of
quality of life and economically. Only half of community-dwelling older
adults who sustain a hip fracture can live independently one year
later. This contributes to the fear of falling and loss of independence
which are a great concern of older adults. In a recently published
study, 80% of the older adults in the study said they would rather be
dead than experience the loss of independence and quality of life from
a bad hip fracture and admission to a nursing home.
WHAT WE KNOW ABOUT FALLS
Risk factors for falls include muscle weakness, balance and walking
problems. taking four or more medications (and taking certain types of
medications), vision problems, certain chronic diseases (such as
Parkinson's Disease, arthritis, stroke), previous falls, and having
multiple risk factors. In one study, the risk of falling increased from
10% to as high as 69% as the number of risk factors increased from one
to four or more. This kind of information is the foundation for
developing effective prevention strategies.
Research has demonstrated a number of ways to prevent falls and the
negative consequences of the resulting injuries:
Multi-component programs: Several studies have shown that programs
that involve multiple components--usually exercise, medication review.
vision correction and environmental changes in the home--are effective
in reducing falls and fall injuries in people living in the community.
Review and reduction or modification of medications and vision
correction: Multiple medications and certain types of drugs (such as
anti-depressants) are a significant risk factor. However, additional
research is needed to more fully understand the role of all medication
and falls, and to develop clinical guidelines related to fall
prevention for those at high risk for falls.
The form of exercise called Tai Chi: In some populations, when used
as a sole intervention (as opposed to being part of a multifaceted
intervention program). Tai Chi appears to reduce fall risk. In addition
to improving balance, strength, and coordination, it also improves the
sense of well-being and reduces the fear of falling.
Home modification: Sixty percent of older adults fall in their own
home. So it makes sense to make the home safer, in particular an older
adults ability to enter and exit the home, and to move around safely
within the home. Installing stair railings, ramps, and grab bars (such
as in the bathroom) are simple but effective modifications. These are
most successful when combined with other interventions (such as
exercise and medication review).
CDC ACTIVITIES TO PREVENT FALLS
CDC is committed to preventing older adult falls and ensuring
healthy aging. and is already investing in a comprehensive approach to
tackling this public-health issue. This approach includes:
UNDERSTANDING THE PROBLEM OF FALLS AMONG OLDER ADULTS THROUGH DATA
COLLECTION AND ANALYSES
CDC collects data on the number of people who die, are hospitalized
or visit emergency departments from falls. National and state-level
data about deaths and emergency department visits are available to
researchers and the public through CDC's interactive, web-based system
called WISQARS (Web-based Injury Statistics Query and Reporting System)
at www.cdc.gov/ncipc wisqars. People can use WISQARS to create reports
and maps that help them understand the problem in their communities.
DEVELOPING AND TESTING INTERVENTIONS TO REDUCE FALLS AND THEIR
CONSEQUENCES
CDC has funded studies to evaluate risk factors for falls and
research to explore interventions to prevent falls.
Nationwide, half of all nursing home residents--roughly 750,000--
fall at least once a year. The high rate of falls in nursing homes is
generally attributed to the frailness of their residents. Research
funded by CDC at Vanderbilt University is testing a fall prevention
program in nursing homes. The Tennessee Fall Prevention Program teaches
staff how to reduce obstacles and other hazards in residents' daily
environment and monitor medication use. Originally piloted in seven
pairs of nursing homes. the researchers found that residents were 20%
less likely to fall after the program was implemented.
CDC is funding the California State Health Department to implement
and evaluate a multi-faceted older adult community fall prevention
program. Seniors are counseled about their risk for falls and steps to
take to prevent falls, including enrollment in an exercise program,
getting their medications reviewed, home modifications, and screening
and referral for treatment of osteoporosis.
CDC research contributed to the development of hip pads, which
reduce the force on the hip when an older person falls. Hip pads
developed from this and other research have been shown in studies to
reduce hip fractures.
CDC is the major funder of a large multi-site study of the costs
and benefits of trauma systems. The purpose of this study is to
evaluate the additional benefits of trauma systems over routine
emergency department care. It includes a focus on older adults,
particularly the costs of treatment of those who fall.
New research funds are available in FY02 for a 3-year study on fall
prevention for community-dwelling older adults. The study will not only
evaluate the effectiveness of the intervention strategies, but also
identify how to facilitate effective collaborations among the community
services, delivery systems, public health and health care providers.
SHARING INFORMATION ON PROVEN STRATEGIES
Information on falls and other injuries is available from the CDC-
funded National Resource Center on Aging and Injury. based in San Diego
and established by the San Diego State University Center on Aging, in
conjunction with the American Society on Aging. The resource center has
an interactive Website (www.olderadultinjury.org) that includes links
to newspaper and journal articles, and other websites. The center also
hosts online seminars on falls prevention. safety for older drivers,
and related issues. Since it began in 1999. the resource center has
reached more than 2 million older adults. caregivers, health care
practitioners, and policymakers.
In an effort to spread the word about the risk of falls and to
promote physical activity among older adults, CDC has internet
resources available for the public and practitioners. For example, CDC
developed the National Blueprint on Physical Activity Among Adults Age
50 and Older to promote physical activity among older adults.
CDC also compiled the Tool Kit to Prevent Senior Falls, a
collection of research findings and educational and assessment
materials for use by professional service providers. The tool kit,
available in English and Spanish, has been distributed to more than
6,000 organizations, such as local health departments, Area Agencies on
Aging, non-profit organizations, health care agencies, etc.
CDC is also funding the National Safety Council to conduct focus
groups to assess the effectiveness with older adults of educations
tools and strategies related to safety and health.
WHAT IS NEEDED NOW?
Use proven interventions--We have interventions that work. but need
to learn how best to provide them to older adults who are at risk for
falls. The multi-faceted programs that combine exercise. medication
review. vision correction and environmental changes in the home are
shown to have an impact in trials, but we need to learn how best to
provide these on a broad scale. We need to work with health care
providers to ensure that people at highest risk are identified and
receive interventions. and also evaluate how best to deliver falls
prevention services to older adults.
Evaluate promising interventions--Further work is needed to
evaluate different exercise programs and to learn how to increase the
use of hip pads among frail older adults. Health status varies greatly
among older adults, as does the risk of falling. Research is needed to
identify which interventions work best in different subgroups of older
adults. Research on the cost-effectiveness of different strategies for
caring for an older person with a fracture, including whether or not
the availability of care at a designated trauma center improves
outcomes, could be helpful to decisionmakers.
Develop and test new interventions--New interventions are needed to
decrease the risk of falling and decrease the risk of injury when older
people fall. These interventions could include those that require
behavior change, but also those that result from changes in the
environment. Better understanding of the biomechanics--that is, what
happens to the human body during a fall--may lead to new environmental
interventions to decrease fall and injury risk, such as improved
flooring. Better understanding of how older people interact with their
environment may also provide new avenues for prevention.
CONCLUSION
Because of major strides in medicine and public health, we
Americans are continuing to live longer-and healthier lives. As a
result, injuries among older Americans now ranks with heart disease and
stroke as a major contributor to death and disability among this
population.
Fortunately, we have made great strides in learning how to reduce
the chances of falling and to mitigate the impact of a fall that
occurs. We know, for example, there are many steps people can take
themselves to prevent falls. Older adults can reduce their risk by
doing certain kinds of exercise. They can make their living spaces
safer by removing tripping hazards, using nonslip mats in the tub and
shower, improving lighting in the house and installing grab bars and
stair rails. They can have their doctor review their medications for
side effects and interactions and have their eyes examined each year.
Still, there is a compelling need to identify and eliminate
barriers to implementing proven interventions and new interventions
need to be developed which are appropriate to the many different
subgroups of older adults. Those that work with older Americans in the
community, in nursing homes, and where elders receive counseling
services need to have knowledge of, and access to, the best information
on programs and interventions. As our society ages, the burden of falls
in older adults will increase. We as a nation must act now to prevent
falls and fall injuries among older adults.
Prepared Statement of Mary E. Watson
Mr. Chairman and members of the Committee, my name is Mary Watson
and I am a Falls Clinical Specialist for the Central Arkansas Veterans
Healthcare System. I am also a consultant for the John A. Hartford
Center for Geriatric Nursing Excellence at Arkansas. My thirty-four
years of nursing and 14 years with VA has primarily focused on the
geriatric population.
I am honored to be here today at the request of Senator Tim
Hutchinson to speak about the issue of elder falls and how this issue
affects Arkansans, veterans, and our aging population in general.
Arkansas ranks 9th in the percentage of elders in America with 14
percent of the population or 378,598 over the age of 65 (U.S. Census
Bureau, 2000). We know that each year one out of 3 of our elders over
65 years of age fall at home. The average number of falls in hospital
is 1.5 falls per patient per year with the number of falls increase in
nursing homes to 2 falls per patient per year. The number one and most
serious consequence of a fall is a hip fracture. It is expected that 3-
6 percent of all falls results in a hip fracture. For Arkansans that
would mean a minimum of 126,000 falls a year with a possible 378 to 756
hip fractures. Twenty-five percent of those elders with hip fractures
die within 6-12 months. That would mean 94-189 Arkansans would die.
Another 25 percent go on to be institutionalized or experience a
decrease in functional abilities. The direct cost of fall-related
medical expenses in 1994 per the CDC (Fact sheet) is $20 billion
nationally a year and climbing. The amount of pain and suffering from
these injuries cannot be estimated.
We at VA. are acutely aware of this very serious patient safety
Issue and have made the reduction of elder falls, death from falls and
injuries a top priority. I have personally been involved in the
development and management of a comprehensive prevention program at our
Litile Rock facility. My role, as a Falls Clinical Specialist, is
unique in the VA system. As an Advanced Practice Nurse, I see
inpatients on consult who are identified to be at high risk, those with
repeat falls and major injuries and I can thereby, assist staff with
implementation of patient specific interventions. In one fiscal year,
we reduced our inpatient major injuries by 50 percent. The Central
Arkansas Veterans Healthcare System and I have been supported in our
efforts to reduce the pain and suffering experienced when an elder
veteran falls through the work of VHA's National Center for Patient
Safety (NCPS) led by Dr. James Bagian, and VHA's Veteran's Integrated
Service Network (VISN) 1 and 8's Patient Safety Centers of Inquiry,
which report to Dr. Bagian. NCPS coordinates the work of the four VA
Patient Safety Centers of Inquiry to mobilize experts and to apply
knowledge in an effective way. Audrey Nelson and Pat Quigley's work at
the VISN 8 Patient Safety Center of Inquiry in the area of fall
prevention through clinical investigation with 11 other VAs extends
knowledge and disseminates findings throughout VA and the private
sector. They, and the University of South Florida, have hosted three
excellent Evidence-based Falls Conferences. Outstanding researchers in
fall prevention like Rein Tideiksaar, PhD., from the United States and
Janice Morse, PH.D, RN, from Canada have presented at this annual
conference held in Clearwater Beach, FL. The next conference will be in
April 30-May 2, 2003.
Falls Collaborative Project. Peter Mills, Pat Quigley, and I
participated with nine additional expert faculty members to assist
thirty-two other VAMCs, four State Veterans Homes and one private
facility to improve upon their Fall Prevention Programs. Using the
Plan, Do, Study, Act or PDSA theory, small cycles of change are used to
implement complex programs. The results were a 79 percent reduction in
major injuries over a seven-month period. It is obvious that the
effects of this program were enormous.
The VHA National Center for Patient Safety (NCPS) is deeply
involved in the reduction of falls and prevention of injuries. Our
Falls Collaborative Project found that NCPS' recent publication
entitled ``Fall Prevention and Management'' is an excellent aid to
guide the practice of clinical staff, in an inpatient setting. This
handy laminated pocket ``FLIP BOOK'' was distributed to all 163 VAMCs
by NCPS and developed by the Patient Personal Freedoms and Security
Taskgroup, chaired by Dr. James Bagian; Director of NCPS.
Approximately 14 percent of falls are accidental and due to
(extrinsic) environmental factors, the majority of falls are due to
(intrinsic) internal physiological factors (Morse, 1997). A panel of
experts from the American Geriatric Society, the British Geriatric
Society and the American Academy of Orthopedic Surgeons reviewed an
exhausting number of research articles and then published evidence-
based fall prevention guidelines (JAGS, May 2001). The co-chair was Dr.
Laurence Z. Rubenstein, of the Sepulveda, Cal., VA Geriatric Research,
Education, Clinical Center (GRECC). The guideline recommends that all
Americans over the age of 65 be asked about falls during a periodic
primary care visit. If there is a history of falls in the past year, a
simple non-invasive screening test is done and, if positive, a more in-
depth evaluation is done. We know that a fall is a sign or symptom of
an underlying problem (Brummell-Smith, 1989). Research findings, like
that of Dr. Mary Tinnetti from Duke and Dr. Kevin Means of our Central
Arkansas Veterans Healthcare System (CAVHS) and the University of
Arkansas for Medical Sciences (UAMS), have found that the causes of
falls as well as the interventions can be singular or multi-factorial.
The physical causes may consist of one or more of the following: an
acute illness, an exacerbation of chronic illness, lack of exercise,
gait and balance disorders, medications, diet, and sensory deficits.
Combining physical health problems with environmental hazards will most
assuredly cause a fall. Assessment and development of an individualized
treatment plan is necessary and may require only a singular or a
multifaceted approach.
Realizing that elder Arkansans are at high risk for falls. our
University of Arkansas for Medical Sciences, Donald W. Reynolds Center
on Aging, with a grant from the John A. Hartford Foundation. have
implemented these guidelines in an outpatient setting. The Donald W.
Reynolds Center on Aging in Little Rock is one of five Hartford Centers
for Geriatric Nursing Excellence In the nation. Geriatric nurses in
Arkansas have been instrumental in implementing these guidelines to
test their effectiveness. Not my will all elder Arkansans be screened
during periodic visits but also staff will he supposed in their efforts
to implement this screening. Marisue Cody Ph.D. Principal Investigator
for this Hartford Grant and a VA/UAMS Nurse Researcher has said that we
already know a lot about the causes of falls and prevention from our
research findings but translating these findings into clinical and
public health practice is another matter. That is what the Donald W.
Reynolds Center on Aging and the John A. Hartford Foundation is
attempting to do in Arkansas. Not only must patients be encouraged to
come forward regarding their falls history, they must become engaged in
implementing fall prevention strategies by making changes in their life
styles, and so must Clinical staff. Clinical staff must integrate these
new screening principals into their usual routine/practice. This
integration is being accomplished through staff education, streamlining
the screening process, use of computer templates to make the
``paperwork easier'', and feedback regarding patient response to
interventions initiated. Monitoring patient outcomes will help to
determine the effectiveness of this program. I believe you already have
examples of useful educational documents found in this tool kit.
Another project for late fall 2002 will be developing a multifaceted
educational program on reducing falls and injuries for Nursing
Assistants working in Arkansas Community Nursing Homes.
Since not all falls can be prevented, another innovation to reduce
injuries from falls has been implemented at CAVHS and at other VA
medical centers. Hip protectors have been shown to reduce fractures
with an estimated 50 percent to 75 percent reduction in hip fractures
for the small price of $30-60 dollars per pair. For our veterans
nation-wide, it is estimated that of our 44,000 nursing home patients,
approximately 20,000 will experience a fall every year; of these
anywhere from 466 to 1337 will have a fracture incurring expenses of
$8.9 to $40 million. The NCPS is currently initiating an effort that
will support expanded hip pad use within the VA. This effort will
involve gathering, synthesizing, and then disseminating practical tips
on effectively implementing a falls program that incorporates hip pads.
Hip protectors have been available on an inpatient basis at CAVHS
since October of 2001. We are now preparing a letter or intent seeking
funding through a joint VA and Agency for Healthcare Research and
Quality project to translate research into practice by initiating hip
protectors in CAVHS outpatient settings. While hip protectors have been
found to be effective, patient acceptance and compliance, as well as
other issues involving comfort and fit, need to be further addressed.
As you can tell by the testimony today, the basic guidelines for
screening, management and treatment to reduce elder falls and injuries
are known but there is still work to do. Taking this knowledge,
expanding upon it and translating it into practice is the next step to
improve the quality of life for the ever growing population of elderly
Arkansans, veterans and Americans. Once this is done we will need to
implement and maintain these effective fall and fall-related injury
prevention programs.
This concludes my statement. I will be happy to respond to the
Committee's questions.
Prepared Statement of Peter Merles
In light of the significant cost of providing health care to the
elderly in the United States, it is easy and appropriate to apply the
old adage, ``An ounce of prevention is worth a pound of cure.'' Studies
by numerous researchers have documented the costs to our society for
providing medical care to our seniors who have been injured in falls.
Because the South East Senior Housing Initiative is dedicated to
helping older Americans remain in their own homes and in their
communities, we looked at the data and concluded that by preventing
accidental falls we could improve quality of life of these citizens,
keep the as vital, stabilizing members of our community and reduce the
expense to our health care system associated with falls.
We brought together many of the other parties in our community who
were concerned and developed a program to demonstrate that falls can be
prevented. Our partners include Baltimore Medical System, a network of
community based medical clinics serving the low income elderly in
Southeast and East Baltimore, Banner Neighborhood Community Development
Corporation, Neighborhood Housing Services of Baltimore, the Baltimore
City Commission on Aging and Retirement Education (our Area Agency on
Aging) and the Johns Hopkins School of Public Health.
Our SAFE AT HOME program has set out to demonstrate that falls can
be prevented by providing home modification, safety repairs, assistive
devices, training by an occupational therapist, social work
intervention, nutrition services, health education and ongoing
communication with the physician and family. The Robert Wood Johnson
Foundation agreed that this was a promising proposal, and funded a
four-year demonstration program, along four local foundations. We just
received a commitment from the Weinberg foundation to fund two
additional years if we can locate the rest of the funding needed. The
Maryland Medicaid Waiver can pay for some of the services we provide
for qualified clients.
We have contracted with the Johns Hopkins School of Public Health
to provide an indepth analysis of the effectiveness of our program, to
measure objectively whether we have indeed reduced the incidence of
falls. emergency room visits, hospital stays and nursing home
admissions. Our data will be compared to base-line research by Dr.
Linda Freed and others. Although we are just a year and one half into
this four-year project, and it is premature to reach conclusions, the
trends in our data appear to be heading in the direction we expect. We
are very happy that this effort has met with a great response from the
community. The Robert Wood Johnson Foundation challenged us to get
primary care providers involved. We are even meeting with some success
there. Our target is to have served 750 clients over the age of 55
residing in Southeast Baltimore who were at risk for falls. Eighteen
months into the program we have had over 250 referrals. We are
frustrated daily, however, as we receive calls from all quarters of
Baltimore City and from areas outside the city from seniors, doctors,
family caregivers, physical therapists, social workers and clergy who
are seeking the services we provide. Our current funding limits us to
only one quarter of the City. There isn't anyone else doing what we are
doing in Baltimore, or anywhere else. We know about the need out there
by the number of calls we receive every day, from within our geographic
area out of our boundaries.
Baltimore's typical row house is very senior unfriendly. There is
one bathroom, upstairs, and often the kitchen is in the basement.
Stairwells are steep, narrow and sometimes winding. Most of our clients
are elderly widows or widowers living alone. Typically they live on
just Social Security income or a small pension. They have lived in the
same house all of their married lives, some for their entire life,
being second or even third veneration in the home. Mortgages have long
ago been paid off, so homeowners insurance is not maintained. This can
prevent seniors from doing costly repairs such as to roof damage,
leading to deterioration of interior ceilings and floors.
Some of the ways we help prevent falls:
Installing railings on interior and exterior stairs.
Installing grab-bars, raised toilet seats, shower benches, anti-
skid decals and hand held showers in bathrooms.
Improving lighting on stairs and in task areas. Taping down throw
rugs.
Providing cordless telephones and walkers1bags with pockets to
accommodate the cordless phone.
Replacing broken steps.
Removing extension cords by adding or repairing electric outlets,
installing new outlets 18'' above floor level.
Moving laundry facilities from basement to kitchen
Providing podiatry service in-home and custom-made safe shoes.
Instruction and technical devices to improve medication compliance.
Providing safe stepping stools and reaching devices.
Teaching proper transferring from wheel chairs; providing transfer
devices. Build wheel chair ramps.
Installing stair-glides and wheelchair lifts when available.
Repairing broken or warped flooring.
Removing worn and torn carpeting.
Rearranging furniture for clear lines of movement.
An important element in our program is our ongoing relationship
with each client. Within a week of receiving a referral, the Baltimore
City Commission on Aging and Retirement Education does an in-depth
intake assessment of each client and connects them to many services
that are appropriate to their needs (nutrition, pharmacy assistance,
transportation, socialization, etc.) Then our case manager and
occupational therapist visit the client at home and do an in-depth
environmental assessment. A service plan is devised and shared with the
clients, their caregivers, and their physician. Upon the clients
approval some or all of the interventions and modifications are
provided. Our occupational therapist instructs in proper use of
assistive devices, transfer methods and safety techniques.
We re-contact our clients, and revisit if needed, after 90 days to
assess their use of the devises, and to learn whether their condition
or needs have changed. Often a client will accept a suggestion that was
originally rejected, as they build trust in our services, or recognize
how helpful these modifications and devices can be. Physicians are
alerted to any significant change we observe in a client, and are kept
informed of the support and services we have provided. The doctors are
supplied with a few questions that we request they ask each client at
their next appointment. This procedure is repeated about every 90 days.
We believe this model of in-home services, physical modification,
safety repairs and ongoing contact will demonstrate a significant
effectiveness in reducing falls and the costs to our society associated
with them
The Research: Value of Fall For Seniors Living in the Community
Falls are common among the elderly and contribute to excess
mortality, ex. hip fractures are a determinate of institutionalization
and death. A study in London targeted patients who sought care at
emergency departments following a fall. The intervention group received
a detailed medical and occupational therapy assessment with referral to
relevant services; those assigned to the control group received usual
care. One year following the intervention, falls had been substantially
reduced in the intervention group and rates of fracture were decreased
by 50%.--Close J et al. Prevention of Falls in the Elderly Trial
(PROFET). Lancet 353: 93-7, 1999.
The average direct cost per patient during the first year following
hip fracture is $40,000. A 1997 Swedish study concluded that the yearly
potential cost savings per patient from preventing hip fractures is
$22,000.--Zethraeus N et al. The Cost of a Hip Fracture: Estimates for
1,709 Patients in Sweden. Acta Othopedica Scandanavia 68 (January): 13-
7, 1997.
In 1997 researchers reported that hip fractures are a burden to the
individual and the community since only 50% of patients regain the
mobility and independence they enjoyed 12 months before the fracture
occurred. The cost per hip fracture avoided is $48,000 if a 62 year-old
woman with osteoporosis receives preventive treatment. The number of
hip fractures worldwide is projected to increase from 1.7 million in
1990 to 6.3 million in 2050 because of the aging of the population. The
total cost of hip fractures in 2050 will be $131.5 billion.--Jonnell O.
The Socioeconomic Burden of Fractures: Today and in the 21st Century.
American Journal of Medicine 103 (August): 20S-25S. 1997.
A 1998 study in New Haven, Conn. found that the homes of older
people with physical deficits, i.e. difficulty sitting on and raising
from a toilet seat or trouble walking, were rife with environmental
hazards. In comparison to older people without disabilities, hazards
that contribute to trips and falls were more common in the homes of
older people with disabilities. The researchers conclude,
``interventions designed to enhance the everyday function of frail
older people need to focus on the environment as well as the
individual.''--Gill TM et al. Mismatches Between the Home Environment
and Physical Capabilities Among Community-Living Older Persons. Journal
of the American Geriatric Society 47 (January): 88-92, 1999.
A study in the May-June 1999 issue of the Archives of Family
Medicine found that frail seniors who received intensive service and
home adaptations were more independent and experienced less pain than
frail seniors who received typical services, i.e. home nursing, Meals
on Wheels, or help with personal care. More money was initially spent
to modify the home environment and to introduce assistive devices.
However, after 18 months, seniors receiving intensive at-home services
demonstrated dramatic medical savings--mean costs for seniors receiving
intensive services were $5,630 in contrast to a mean cost of $21,847
for seniors receiving traditional services. Those provided with
assistance accounted for only $98 for inhome nursing and care manager
visits, compared to $855 for the control group.--Mann WC et al.
Effectiveness of Assistive Technology and Environmental Interventions
in Maintaining Independence and Reducing Home Care Costs for Frail
Elderly. Archives of Family Medicine 8 (May-June): 210-7, 1999.
In San Francisco, CA, a study of 233 seniors found that providing
minor home modifications reduced the rates of falls, scalds and burns
by 60% in the intervention group. Interventions required 10 person
hours of unskilled labor and on average $93 worth of materials and
included safety assessments and modifications such as removing clutter,
installing handrails, grab bars or nonskid strips, securing rugs and
electrical cords.--Plautx B et al. Modifying the Environment: A
Community-based Injury Reduction Program for Elderly Residents.
American Journal of Preventive Medicine 12: 33-8, 1996.
A program of in-home comprehensive geriatric assessments delays the
development of disability and reduces permanent nursing home stays
among elderly people living at home. A 1995 study demonstrated that
annual in-home assessments provided with support services delayed
seniors need for assistance in activities of daily living by 55%.--
Stuck AE et al. A Trial of Annual In-home Comprehensive Geriatric
Assessments for Elderly People Living in the Community. New England
Journal of Medicine 333 (November): 1184-9, 1995
A targeted program providing a combination of medication
adjustment, behavioral recommendations. and exercises decreased an
individual's total mean health-care costs by $2,000. The series of home
assessment by a social worker cost an average of $925 and included
environmental modifications, Falls were reduced by 35%.--Rizzo JA et
al. The Cost-Effectiveness of a Multi-factorial Targeted Prevention
Program for Falls Among Community Elderly Persons. Medical Care 34
(September): 954-69, 1996.
[Whereupon, at 3:05 p.m., the subcommittee was adjourned.]