[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


80-286              U.S. GOVERNMENT PRINTING OFFICE
                            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.]

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