Preserving independence while guarding against injury: an evolving balancing act
In 1790, Americans 65 and older represented less than 2% of the U.S. population. We now live in a society where 15% of the population is 65 or older. In Italy, Germany, and Japan the figure is 20%. In China there are 100 million people 65 and older1. In much of the world the life expectancy is 80+ years and as we age our physical condition becomes gradually more compromised despite modern medicine and best intentions.
The ability to walk is the single most important factor that allows the aged to be independent and to remain in their home. Activities of daily living, including bathing, meal preparation, dressing, and using the bathroom, are not easily done by those confined to a wheelchair. Each year nearly 350,000 Americans fall and break their hip (or break their hip and fall). Of those, 40% end up in a nursing home and 20% can never walk again. Falls account for 20% of hospital visits by seniors and 40% of nursing home admissions, according to The Centers For Disease Control and Prevention, and are the leading cause for injury in people 65 or older and also the leading cause of brain injury. The three primary risk factors for falling are poor balance, muscle weakness, and taking four or more prescription drugs. In a single year, elderly people without risk factors have a 12% chance for falling and with all three risk factors a 100% chance of falling.
In the February 26, 2015 Minneapolis Star Tribune, Jeremy Olson reported:
“Preventable falls resulted in six deaths and 73 disabling injuries to patients last year and has resulted in 67 deaths since Minnesota’s Adverse Health Event reporting began in 2005.” Hospitals have spent considerable time and resources addressing this problem—increasing the use of alarms and motion sensors to alert staff when a patient moves—and purchasing adjustable beds and other protective gear. The lack of progress suggests the need for fresh ideas, Rachel Jokela (director of the State Health Department) said, redesigning hospitals so that the most common occasion for patients falling, going to the bathroom, becomes safer. ‘We can’t just keep doing the same things we’ve been doing because the numbers keep staying the same’”.
Actually, the numbers are probably getting worse. In 1970, when I began my orthopedic practice in northeastern Minnesota, people were admitted to the hospital to be safe from falling. The admitting physician assessed the patient as to the degree of activity considered safe. Accordingly, bed and/or wheelchair restraints were ordered if the patient was at risk of falling and stand-by assistance with walking. In the 1980’s the Patient Rights movement made it a serious offense to use physical restraints for this purpose so chemical restraints through sedation were necessary and patients have been falling like leaves from a tree ever since.
About this time seat belt use became mandatory in most states and child safety seats in automobiles at all times enforced by severe penalties to reduce the severity of passenger injury because of collision. Why is using restraints to protect a patient in the hospital from injury a violation of his civil rights while that same patient must be restrained when brought home from the hospital in the family’s automobile? How can this be? Because of the legal climate and to avoid negligence claims, hospitals and nursing homes must err on the side of safety and patients are unnecessarily prohibited from walking and the independence that this allows. Physical therapy can restore strength and balance but risks of injury from falls remains so long as patients desire to be independent. The cost for nursing home care for a patient at risk of falling is more than 5 times that of living independently at home. Retirement communities often cost upwards from $30,000 a year with $60-120 thousand up front. The prospect of spending the golden years in a nursing home is more like living in a prison than a home because the staff determines what you eat, what you wear, what you watch, when you bathe, when you get up and when you go to bed–and is nightmarish to consider.
I return to the automobile seat belt and air bag system. Neither system lowers the accident rate but they do reduce the severity of injury when an accident occurs. This is exactly what is needed in patient care; a wearable device that reduces the severity of injury allowing patients at risk of falling to remain independent and in control of their own lives.
-Jay A. Davenport, M.D.