OHSU geriatrician on treating and preventing injuries from falls, as incidents increase

At Oregon Health & Science University, the number of patients treated for falling injuries has increased by 90% compared with 2016. These are falls that occur on ground level, not from heights. Nationwide, about three-quarters of those patients are over the age of 65. That’s why Katie Drago, an OHSU geriatrician and associate professor of medicine, says the problem is becoming “a growing public health emergency.” We talk with Drago about the study the hospital has begun to help people prevent these injuries, and the need for more attention on the subject.

The following transcript was created by a computer and edited by a volunteer:

Dave Miller: From the Gert Boyle studio at OPB, this is Think Out Loud. I’m Dave Miller. The number of patients treated for ground-level falling injuries at Oregon Health and Science University nearly doubled between 2016 and 2022, and Oregon is not alone. According to a recent study, the rate of fall-related deaths among older Americans is increasing significantly nationwide.

That’s why Katie Drago, an OHSU geriatrician and associate professor of medicine, says falls are truly becoming a public health emergency. It’s also why OHSU is currently enrolling participants in a six-month study designed to reduce the risks of falls among people 65 and older. Katie Drago joins us now to talk about why people fall and what can be done to prevent it. Welcome to the show.

Katie Drago: Hi, Dave. Thanks for having me.

Miller: You’ve called this program, or this problem, as I just mentioned, a public health emergency. It’s a strong statement. What do you mean?

Drago: It is a strong statement and one that I think is really valid. We know from vital statistics data over many, many years that fall-related injury is actually the number one cause of accidental death in this country among those 65 and older.

Miller: What are the potential… I mean, death is, as I mentioned earlier, there’s been a doubling ‒ from I think about 1999 to 2020, nationwide ‒ in terms of deaths from these falls. What are the other potential repercussions?

Drago: We worry about loss of independence, loss of ability to engage in beloved hobbies and activities, to stay engaged, all the way up to major injuries. We think about things like fractures of arms, legs, hips, spine and then traumatic brain injuries, all of which can be life altering, if not life ending.

Miller: And just to be clear, we’re not talking here about falls from heights from a ladder. We’re talking, say, about somebody going into the bathroom and slipping there.

Drago: Exactly right. These really are two different beasts. Falling from a ladder, falling off a roof, is a very different mechanism from our perspective, than someone tripping over a curb or even tripping over their feet in their house, struggling in the bathroom, struggling in the kitchen. Totally different.

Miller: There has been, as I noted, a nearly doubling of these serious falls at OHSU that you’ve categorized over the last six or seven years that can’t be explained by baby boomers, like this big cohort of older Americans getting older. So what’s behind the increase?

Drago: That’s a great question. There are a few theories out there. I have my own theories. You know, we are living longer as a society and that’s a wonderful, wonderful benefit of great medicine and great health care and advances in medicine over many decades. What that does mean is that many of us are living longer with chronic conditions. We’re living longer with multiple medications. And we’re living into our later years with more cognitive impairments and functional impairments that elevate our everyday risk of having a fall event.

Miller: Can you give us some of the most common circumstances for these falls? I mean, what in general leads to these falls, physically?

Drago: Oh my gosh, that is an excellent question. I see a lot of folks that wind up in our hospital with traumatic injuries after a fall, and far and away, these falls never happen for just one reason. We are always looking at scenarios where there are multiple factors that come colliding together in a particular situation to cause the fall and then the injury. I think about…

And what I hear a lot, is about people living with balance troubles.

Maybe they use a walker or a cane. Maybe the walker was across the room when they fell. Maybe they got up in a hurry to use the bathroom or answer the phone or the doorbell and left the walker behind. Maybe there was a new medication that was started that actually is contributing to some dizziness or some fatigue, that in that setting with balance impairments, with other medications, with a household maybe that’s a bit cluttered, or there’s furniture in the wrong spot ‒ all of those factors conspire together in order to cause someone to fall.

Miller: What is it about aging in particular that makes falls more likely?

Drago: That, too, is a great question. Falls are not inevitable. I do want to start there – that it’s not a normal part of aging, to fall. We do see falls becoming more common as people get older, in part, because they’re living with more medical issues. Older adults take a lot more medication in an average year than their younger adult counterparts. And there are lots of us in our later years living in the community with things like various dementias after strokes, after heart attacks, that can actually dramatically change our lives both physically and mentally.

Miller: So let’s turn to some of the advice that you give to your patients starting with exercise. What can people do physically to make falls less likely?

Drago: I’m fond of saying that bodies in motion stay in motion. Thank you, Newton. And it really is true that the more you move around ‒ the more you use your body, your muscles, your balance controls ‒ there are going to be those muscles and strength are going to be there to support you when you have the accidental trip over your toes or trip over a curb. We generally recommend more than just walking. Walking is really good cardiovascular exercise, but we really recommend that people focus on muscle training. So strength training and then flexibility and balance training.

There is great evidence in the medical literature for tai chi, in particular, that regular practice of tai chi ‒ we usually recommend around 2 to 3 hours a week, either, mostly 2 to 3 days a week, about an hour at a time ‒ can reduce the risk of falling by about 50% and even reduce the risk of having an injury.

Miller: What’s special about the movements or the practice of tai chi?

Drago: tai chi really focuses on balance. So, it really focuses on what we call dynamic balance, which is maintaining your balance and your position as you move between different positions. That is often one of the strengths that our bTodies call upon when we’re moving around, when we’re most likely to fall. So if you’re practicing your dynamic balance through tai chi, those skills are going to be at the ready to save you, should the unthinkable happen.

Miller: What about something like reaction time? I mean, just your ability to recognize that something has happened, and then to move your foot or your arms to catch yourself is… can that be practiced?

Drago: Reaction time does generally slow as we get older. And it’s believed that that is a normal part of aging. Practices like tai chi can actually improve or give you more confidence as you’re moving around. So that way, even though you’re fighting some of the physiology, you actually are priming your body to protect you in those situations.

Miller: You’ve also said that minding medication is one of your broad recommendations. When you say that, are you talking to older people themselves ‒ to patients ‒ or are you talking to primary care doctors?

Drago: Really to all of the above. You know, we are learning lots and lots every day about polypharmacy ‒ which is the condition of taking multiple medications per day ‒ that affects older adults. We’re learning lots about de-prescribing – the process of gradually reducing medications that may be unnecessary or maybe proving to be risky, where maybe they weren’t years ago. So the science in that area is rapidly evolving, but I do really want to empower patients and their families.

A lot of older adults are aging with their medications, meaning they take them for years and years and years, sometimes decades. And that’s not a bad thing, inherently. But an 85-year-old body is not the same as a 40-year-old body. So what was appropriate or what was necessary at 40 or 45 may no longer be appropriate or necessary at 85 or 90.

What I usually recommend is for patients and their family members ‒ if you’re accompanying a loved one or a friend or a family member to a visit with their doctor ‒ I make it a point every year to have my dad ask: “Can we go over my medications? Can we get rid of anything I don’t need anymore?” That actually can be a really powerful step that patients and family members can take to make sure that we all are working together to curate medication lists to match the needs of the person at that individual time.

Miller: The last thing you recommend is clearing a path. This has to do with people’s homes, their hallways. If you are walking through some space, what are you on the lookout for?

Drago: That’s an excellent question. Our environment can really do a lot to support us in maintaining independence. What I think about, and what I encourage patients and family to think about, is making sure that there are wide enough hallways and trafficked corridors through rooms, especially if you use a cane or a walker.

Making sure that you have a wide enough space that you can easily maneuver around, so that way your assistive device doesn’t become more of a hindrance or become something that you leave behind. Watching out for maybe legs of furniture that stick out a bit farther, other tripping hazards. Assistance needs for getting in and out of bed, if the bed is too tall. Are there steps, step stools, maybe that could be used to help getting in and out of bed. Is it time, maybe, for a different bed – maybe that’s lower or higher, depending on what you need.

And then thinking about adaptive equipment like bars for the bathroom, bars and rails that can help you stand up or get down, sitting down on a toilet, benches that can help get in and out of a tub, other bars in common areas where we are moving around in ways that may pose more of a risk.

Miller: Twenty years ago the surgeon and writer Atul Gawande wrote a fascinating essay that ended up in his book,Being Mortal. He followed a geriatrician around, a seemingly wonderful doctor, and Atul Gawande was really surprised by how much time this doctor spent just looking at his patient’s feet. And Gawande said, basically: ‘I’m a surgeon. I’m used to fancy expensive interventions. And why are you spending so much time looking at people’s feet?’ And what he said is, ‘If I don’t, there’s a much better chance that they will fall and hurt themselves,’ and do all the things that you were talking about at the beginning.’

But the sense I got from that was that geriatricians ‒ this was 20 years ago ‒ that they were lonely voices in the medical establishment, paying attention to crucial details that are often ignored by other doctors. I’m wondering if you think that is still the case.

Drago: Geriatricians and geriatric medicine training really gives us a unique perspective in medicine and on patient care. We focus on the intersections between the physiologic, the psychologic and the social environment. That’s really one of the main underpinnings of the field of geriatrics. And so as a natural extension of that approach, we think about people in their “natural habitats.” So in their social circles, in their living space, in the spaces they like to be, the hobbies they like to engage in.

And we really think about how does necessary medical care – medications, procedures ‒ how does not fit into the overall narrative of this person’s life, what they want from their life,

what barriers they are currently seeing to their life. And oftentimes there are really elegant and simple solutions that are out there and available that we can use in order to keep people living the lives they want to live. I think about things like feet and foot care. Happy feet are really the key to a happy life. So doing simple things like trimming toenails, trimming calluses that may be painful and may make it hard to walk, thinking about what footwear you are wearing, and is it doing you a good service? Those are really easy things for us to think about.

Miller: But most older people don’t see geriatricians, right? They see primary-care doctors who don’t have the specialty that you’re talking about, and don’t necessarily come from the same philosophic point of view. I’m wondering what it would take to change the culture of American medicine or American society to make everything you’re talking about more commonly talked about and practiced.

Drago: That is one of our big, big agendas in the field of geriatric medicine is to “geriatri-size” healthcare, because there will likely not be enough geriatricians and geriatric-trained providers to meet the demands from the aging population. This desire is where national initiatives like the Age-Friendly Health Systems initiative come from.

This is a nationwide quality improvement initiative run by the Institute for Healthcare Improvement and the John A. Hartford Foundation that is designed to embed the core principles of really high-value geriatric care into primary care, specialty care, inpatient care, long term care and rehab across the country. The framework that they use is called the “4Ms.” These are expert recommended, distilled down, geriatric best practice, and it comes down to:

- What matters, which really speaks to goal-concordant care ‒ making sure that patients get exactly the care they want, no more, no less.

- Medications, which really speaks to minimizing high-risk medications, and making sure that people are only taking the medications they absolutely need.

- Mobility at all stages of care, which means helping people move to the best of their ability and making sure that we’re focusing on helping them do the things they want to do.

- And then mentation, which really speaks to addressing and managing delirium, depression and dementia across the spectrum of care.

Miller: Katie Drago. Thanks very much.

Drago: Thank you very much, Dave.

Miller: Katie Drago is an associate professor of medicine at Oregon Health and Science University, where she is a geriatrician.

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