Once Just an Aging Sign, Falls Merit Complex Care

By JOHN LELAND

MEDFORD, N.J., 10 nov 2008 — Katherine Aliminosa, 93, shattered her lower leg while getting snacks for her nieces.

Susan Arnold, 87, broke her hip hanging a photograph.

In mid-July, in a nursing unit of a retirement community here, the two women were at the start of a recovery process that both hoped would return them to their previous lives.

Their progress over the next few months, and their divergent outcomes, illustrate the unpredictable impact that common falls can have on the bodies of older people.

By early autumn, Ms. Aliminosa had graduated to an independent living apartment and was able to get around with a walker. She looked like a different person: more robust, content.

Though six years younger, Ms. Arnold never recovered her strength after hip surgery. Her muscles atrophied from inactivity, and she developed pneumonia. She died on Sept. 6.

Once considered an inevitable part of aging, falls are now recognized as complex, often preventable events with multiple causes and consequences, calling for a wide range of interventions, both psychological and physiological, that many patients never receive.

Even falls that cause only minor injury “need to be taken as seriously as diabetes,” said Dr. R. Sean Morrison, a professor of geriatrics and adult development at Mount Sinai School of Medicine in New York, because “they can be a real warning sign that something serious is wrong.”

Dr. Mary E. Tinetti, a falls expert at Yale University medical school, compared falls to strokes in their harmfulness, adding that people do not always report them or seek help, for fear their families will try to put them in nursing homes. For some people, Dr. Tinetti said, admitting that they fall is tantamount to admitting that they are no longer competent to take care of themselves.

Each year, 1.8 million Americans over age 65 are injured in falls, according to the Centers for Disease Control and Prevention. Some rebound as if the injury never happened. But for some, the fall sets off a downward spiral of physical and emotional problems — including pneumonia, depression, social isolation, infection and muscle loss — that become too much for their bodies to withstand.

In 2005, the last year for which statistics are available, 433,000 people over 65 were admitted to hospitals after falling, and 15,800 died as a direct result of the fall. Less visible are the many who survive the fall but not the indirect consequences.

When first interviewed in mid-July, Ms. Aliminosa and Ms. Arnold felt vulnerable and constrained, their world diminished. Both had led accomplished professional lives — Ms. Arnold as a school psychologist, Ms. Aliminosa as a medical researcher — and had been active in the community’s independent living apartments. But neither could be confident about what the future held.

Ms. Aliminosa said she was depressed, and able to walk only in very small stretches. A small woman with a soft voice and grainy New York accent, she barely filled her chair. She seemed defeated. “Emotionally I have not been well,” she said. “It’s made me very aware of my age, and that’s hard to accept.”

Ms. Arnold, by contrast, was full of emotional energy, so angry about her broken hip that she kicked out for emphasis as she talked, turning conversation into a full-contact sport. Before her fall, she had been preparing for a vacation with her daughter at a family beach house on Long Island — the same house where she had spread her husband’s ashes. Now that plan was gone.

“It kills me, it just kills me,” she said. “This was going to be the frosting on the cake, and somebody ate it.”

Of the two women, Ms. Arnold was up against the longer odds. One in five hip-fracture patients over age 65 die within a year after surgery, according to the C.D.C.; one in four have to spend a year or more in a nursing home. When younger people fall, they tend to break their wrists catching themselves, but in older people, who have slower reactions and less upper-body strength, the weight more often falls on their hips or heads. Any underlying conditions, like heart disease or respiratory problems, increase the chances of a downward health spiral.

Ms. Arnold had a history of pulmonary disease, and had been a heavy smoker, starting after high school. “She had a boyfriend in college,” her daughter, Margery Creek, said, “and it was the lesser of evils — sex, drinking or smoking.”

But her lung problems did not keep her down. In 2006, she took a 10-day trip to Sweden. Even after she fell and fractured a hip that autumn, she lived independently and was able to drive, returning to the beach house. That day in mid-July, even as she talked about depression, she took jubilant delight in photographs of her grandchildren and great-grandchildren. “Now if that isn’t the picture of a baby,” she said. “Isn’t she a sweetie?”

If Ms. Arnold were a machine, it would be simple to draw a straight line between her lung disease, her hip surgery and her chances of recovery. Older bodies typically have several weakened systems that are dependent on one another, and rely on drugs that may or may not work well together. “If you take 70-year-olds, on average they’re taking five medications,” Dr. Tinetti said. “When you get to 10 medications” — as a patient might after a fall — “the likelihood of adverse effects is close to 100 percent.”

But psychological factors can be as devastating as the physical trauma, Dr. Tinetti said. “It’s the fear of falling, the lost confidence. Good walkers stop walking, stop going to church. They become socially isolated and depressed.”

After Ms. Arnold’s first broken hip, she had reduced feeling in one foot, which added to the likelihood that she would fall again.

On July 6 this year, it happened: Ms. Arnold turned her body without moving her foot, pulling the closet door down with her when she fell and fracturing her hip bone.

“I’m outraged,” she said a week after the fall, raising her voice and then becoming fatigued. Her breathing was interrupted by coughing spasms. She said she was determined not to end up using an electric cart. “Disappointment,” she said, accenting each syllable. “I had a very good life.”

“But your life isn’t over,” said Deanna Gray-Miceli, an adjunct assistant professor of nursing at the University of Pennsylvania and an expert in geriatric falls who was looking in on Ms. Arnold in the nursing unit.

“Well, it bloody well is,” Ms. Arnold said. “I have no strength. Let’s talk about depression.”

The period of immobility after a fall is particularly dangerous, said Dr. Gray-Miceli, whose research includes studying a group of patients after falls. “Being immobile, you’re not taking deep breaths, you’re more prone to orthostatic pneumonia, or older people can develop urinary incontinence. And that can have a whole cascade of emotional consequences as well as the physical consequences, such as skin breakdown, pressure sores, bladder infection, lung infection.

“We also see temporary confusion from infection,” she added, “And that can lead to someone’s demise.”

Dr. Gray-Miceli’s work focuses on identifying the causes of falls, which might include treatable factors like changes in gait, low blood pressure, declining vision or heart arrhythmias, as well as conditions in the home. In a study by Dr. Tinetti, simple preventive suggestions from doctors, like physical therapy and changes in medication, reduced falls by 11 percent. (The C.D.C. offers tips to reduce falls at home, like removing loose rugs and making sure stairway handrails go all the way to the bottom, at cdc.gov/ncipc/duip/preventadultfalls.htm.)

For Ms. Arnold, it was too late. Shortly after surgery she grew depressed and fatalistic, her daughter said. “One morning when my brother was here, she woke up and said, ‘I’m weary, I’m just absolutely weary,’ ” Mrs. Creek said. “And she had no muscle that came back. Her arms had really gotten down to skin and bones. You hear that term — it certainly seemed that way, no muscle.”

In August, Ms. Arnold developed pneumonia and spent three nights in the hospital. Though she responded well to the medications, Mrs. Creek said: “It was just one more nail. She said she was ready to be with Dad.”

The last time Mrs. Creek called her, in early September, Ms. Arnold could recognize her voice but not respond, Mrs. Creek said. “I think she just said, ‘I’ve had it, I’m checking out.’ ”

Down the hall, Ms. Aliminosa’s response after her leg fracture was just as unpredictable.

On April 4, she was enjoying a visit from two favorite nieces — Ms. Aliminosa never married — when she found herself on the floor of her apartment, she said. She had no memory of how she fell.

Ms. Aliminosa has osteoporosis and a history of falling, so she told her relatives not to touch her until the nurses came. She needed a metal rod in her leg and began a slow process of physical rehabilitation. She said the falls were the first thing that made her feel old. “I’d love to be able to have dinner and take a short walk, and I can’t do that,” she said.

Because she was in a full-spectrum medical facility, her care was well coordinated, said Dr. Albert Siu, a professor and chairman of geriatrics and adult development at Mount Sinai.

“For example, osteoporosis is often at root of this,” Dr. Siu said. “But in a three-day hospital stay, addressing osteoporosis is not at the top of everyone’s mind. There it’s dealing with the pain, the complications and the repair of the fractured hip.” Medications for blood pressure or pain might increase dizziness or chance of falls. In mid-July, while Ms. Arnold was angry but relatively mobile, Ms. Aliminosa seemed resigned to a loss of mobility and independence. The prospect weighed heavily on her. When asked if she had considered counseling for depression, she said she did not think she could bear talking about it. “I think as we get older it’s hard to control our emotions,” she said.

Patients’ pessimism can be self-fulfilling, because they may not walk to the extent they can. “Their stride becomes shorter,” Dr. Morrison said. “They don’t use their lungs.”

Dr. Gray-Miceli said it was important for doctors and nurses to keep the patient focused on tangible signs of progress, “so she can say: ‘Today I got up by the side of the chair and took five steps. Yesterday I only took four steps.’ ”

Ms. Aliminosa began a physical therapy regimen to build strength in her legs and upper body and improve her gait. With improvement she gained a sense of optimism and control over her body.

She said the depression returned from time to time, as did the fear of falling again. But she said: “The thought that I’m getting better has helped a great deal. I try to think so each day, really.”

She smiled; she joked. On a recent morning, she groused amiably about her fitness program, but finished, with no sign of pain or exhaustion. “I’m walking,” she said, “I wouldn’t say to my satisfaction, because I used to be a hiker. I can’t expect that yet, but I’m hoping for it.”