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Falls are the leading cause of death by injury for the elderly, and the number of deaths per year due to falls is growing.1The mortality rate due to falls by the aged has increased 39 percent between 1999 and 2005, and during this time 1.8 million elderly people who fell were treated in emergency rooms, with 433,000 hospitalized due to these falls.1
One in three adults age 65 and older fall each year,2,3 with 20 to 30 percent suffering severe enough injuries to hinder their ability to live independently, and as a result of these falls have an increased risk of early death;4 estimated to be approximately 16,000 deaths per year.1
According to the Centers for Disease Control (CDC), every 18 seconds an older adult is treated in an emergency department for a fall, and every 35 minutes someone in this population dies as a result of injuries.5The aged are hospitalized for fall-related injuries five times more often than they are for injuries from other causes.4The scope of the problem that falls by the aged poses has been described above. The action taken to implement a solution to the problem came in 2007 in legislation to redirect the efforts of the Public Health Service.
The goals of this article are to state the nature of the problem, namely that falls by the aged are creating a health care crisis; describe recent legislation that has been enacted, in part due to the efforts of the American Physical Therapy Association (APTA); direct the public health system toward addressing the problem of falls, and demonstrate why physical therapy is the most appropriate health care source to directly intervene in the lives of the aged to help prevent falls.
Supporting a Solution
Falls cost the elderly their health, their functional independence and potentially their lives. Falls by the aged cost society millions of dollars per year, and a problem this costly and widespread requires a solution of some magnitude.
A solution such as this can be addressed through public policy, legislation and public health systems. Implementing this solution requires action on the part of both individuals and organized groups. Specifically, addressing falls requires health care workers to intervene directly in the lives of the aged, and groups such as the APTA to push for legislative change to create public awareness of the problem.
The APTA took part in lobbying efforts "to amend the Public Health Services Act to direct the Secretary of Health and Human Services to intensify programs with respect to research and related activities concerning falls among older adults."6
Lobbying for a proposed amendment was also supported by the National Safety Council, the National Counsel on Aging, the Home Safety Council, AARP and the American Occupational Therapy Association.1The proposed amendment was introduced in both the United States House of Representatives and United States Senate. It was introduced in the House as H.R. 3701 by Rep. Frank Pallone (D-NJ) on Sept. 27, 2007. This amendment was also introduced by Sen. Michael Enzi (R-WY) as S.845 in the Senate.
The bill was passed by the Senate on Aug. 1, 2007, and was passed by the House on April 8, 2008. The bill was then signed into law as Public Law 110-202, the Safety of Seniors Act, by President Bush on April 23, 2008.
The details of this act include authorizing the Secretary of Health and Human Resources to facilitate a national education campaign regarding falls by the aged; awarding grants and agreements to carry out local education campaigns; conducting and supporting research that identifies individuals at risk for falls, identifies fall risk and prevention factors, and evaluates fall prevention plans; creating fall prevention and intervention programs; improving treatment and rehabilitation of those at risk for falls; identifying fall risk factors in various environments; evaluating the effectiveness of community programs; providing professional education for health care professionals, and reporting to Congress on the costs and effects of falls by the aged.7
This act also contains authorization of financial appropriation of $58.4 million for 2008 and equivalent amounts for 2009 and 2010 with an overall estimated cost by the Congressional Budget Office (CBO) of $178 million.8
The Cost Concerns
In 2000, the cost of all fall injuries for people 65 and older surpassed $19 billion9 and by 2020 is expected to reach $43 billion (or $54.9 billion in 2007 dollars).10 Fractures due to falls are the most common and costly type of nonfatal injuries, accounting for 61 percent of health care costs, amounting to more than $12 billion in the year 2000, with costs rising yearly.9 Hip fracture is the most frequent type of fall-related fracture, and the average cost of hospitalization for hip fracture is about $18,000.11
Of the aged who survive for a year after sustaining a hip fracture, half require help walking, a quarter require long-term nursing care, and all continue to be at high risk of sustaining another fracture.12 In 2000, traumatic brain injuries (TBI) and injuries to the hips, legs and feet were the most common and costly fatal fall injuries, and accounted for 78 percent of fall fatalities and 79 percent of fall costs.9Statistics like these clearly indicate the severity of the problem that falls pose to the aged, the impact this problem has on society as a whole and the need for public policy to address this problem. Some would even call this a health crisis.
What Can PT Do?
An examination of the activities listed above clearly demonstrates the number of ways physical therapy can play a pivotal role in implementing the new Safety of Seniors Act. Specifically, physical therapists and physical therapy educational programs can conduct research pertaining to falls, including identifying fallers, causes for falls, ramifications of falls, testing and treatment methods and so on.
Physical therapists can design and implement fall prevention, intervention and rehabilitation programs. Physical therapists can take part in community programs and provide education to not only potential fallers and caretakers, but also to health care professionals. Each of these activities is an integral part of what we do on a regular basis with patients in our practices, and as a part of our educational process.
There are many specific things that the physical therapy profession can do to address the problem of falls. Physical therapists can perform gait assessments and examinations of people at risk for falls, be this in a clinical setting, community centers or even in general public in settings such as healthfairs, using tests such as the Dynamic Gait Index (DGI), Tinetti Test, Berg Balance Test or the Timed Get-Up-And-Go Test.
Physical therapy professionals can educate the community at large, potential fallers and health care providers. They can develop and implement exercise programs to address risk factors such as osteoporosis and balance impairment through activities such as weight-bearing exercise programs and Tai Chi.
Therapists can screen medications and screen for visual deficits in potential fallers. They can also perform home hazard assessments and modifications, including recommending adaptive equipment such as shower stools, toilet seat risers and stair lifts. They can also train caregivers in transfer techniques and safe mobility of potential fallers.
It has been recognized that falls by the aged is a growing health crisis in the United States. The number of people falling each year is growing and the high cost of these falls financially-and functionally-is growing at an even greater pace. To address this issue, legislation has been passed, in part due to the efforts of the APTA.
Implementation of solutions to this problem can be undertaken in large part through the field of physical therapy. Physical therapists are skilled practitioners who provide fall-related services on a continuing basis already, and now simply need to be redirected to provide these services though the Public Health System.
References
1. Roscow, D. (2008). National Safety Council Applauds House Passage of Safety of Seniors Act. Reuters. Retrieved from www.reuters.com/article/pressRelease/idUS230178+08-Apr-2008+PRN20080408
2. Hausdorff, J., Rios, D., & Edelber, H. (2001). Gait variability and fall risk in community-living older adults: A 1-year prospective study. Archives of Physical Medicine and Rehabilitation, 82(8), 1050-1056.
3. Hornbrook, M., Stevens, V., Wingfield, D., Hollis, J., Greenlick, M., & Ory, M. (1994). Preventing falls among community-dwelling older persons: Results from a randomized trial. The Gerontologist, 34(1), 16-23.
4. Alexander, B., Rivara, F., & Wolf, M. (1992). The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health, 82(7), 1020-1023.
5. CDC.gov National Center for Injury Prevention and Control. (2008). Costs of Falls Among Older Adults. Retrieved from www.cdc.gov/ncipc/factsheets/fallcost.htm
6. GovTrack.us. S. 845--110th Congress (2007): Safety of Seniors Act of 2007. GovTrack.us (database of federal legislation). Retrieved from www.govtrack.us/congress/bill.xpd?bill=s110-845
7. Opencongress.org. (2007). Senate Bill Safety of Seniors Act 2007. OpenCongress. Retrieved from www.opencongress.org/bill/110-s845/show
8. APTA.org Public Health Initiatives Resource Center. (2008). Falls Prevention. Retrieved from www.apta.org/AM/Template.cfm?Section=Public_Health_Initiatives1&Template=TaggedPage/TaggedPageDisplay.cfm&TPLID=286&ContentID=32179
9. Stevens, J., Corso, P., Finkelstein, E., & Miller, T. (2006). The costs of fatal and nonfatal falls among older adults. Injury Prevention, 12, 290-295.
10. Englander, F., Hodson, T., & Terregrossa, R. (1996). Economic dimensions of slip and fall injuries. Journal of Forensic Science, 41(5), 733-746.
11. Barrett-Connor, E. (1995). The economic and human costs of osteoporotic fracture. American Journal of Medicine, 98(suppl 2A), 2A-3S to 2A-8S.
12. Edwards, B. & Perry, H. (1994). Age-related osteoporosis. Clinics in Geriatric Medicine, 10, 575-587.
Jeff Heskin received his BA in psychology from the University of Minnesota-Duluth in 1989, a BA in health and natural sciences from the College of St. Scholastica in 1997, and an MA in physical therapy from the College of St. Scholastica in 1999. He is currently working toward his tDPT degree also from the College of St. Scholastica. He works for St. Mary's/Duluth Clinic, in Superior, WI, treating general orthopedic and neurological conditions. His experience also includes working in long-term, acute and subacute care, and he has been adjunct faculty in the PTA program at Lake Superior College in Duluth, and the PT program at the College of St. Scholastica in Duluth.
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