Wednesday, September 08, 1999
After a fall, doctors work on getting elderly patients back on their feet
BY SUE MacDONALD
The Cincinnati Enquirer
Falling is seldom an expected event, and 88-year-old Elizabeth remembers very little of her two falls except being upright one minute and flat on the ground the next.
The first time, about nine years ago, she stumbled on a traffic cone that was perched near an under-construction sidewalk, and she fell onto a cement driveway. The second time, last October, she tripped on the carpet leading into the bathroom of her new apartment at a Monroe retirement community.
Each time, she fractured a hip — first the left, then the right.
“I'm hoping by the end of the year, I'll be back to normal,” says the woman who has lived all over North America as an Army wife, once caught a halibut in Alaska and is now 10 months into her recovery from a second hip-replacement surgery. She asked that her last name not be used because of concerns about safety.
The seemingly simple act of falling, it turns out, can be a particularly life-changing, dangerous and potentially fatal event among older people. It also makes some older people feel vulnerable in ways they never imagined.
For some, falling produces an instantaneous hip or bone fracture, and hip fractures are a leading cause of disability among older people, affecting 300,000 people a year in the United States (most of them women). In Hamilton County in 1997, falls were the leading cause of injury-related death among people over 65.
A fall can be the first symptom of mental impairment, underlying bone/spinal fracture or other health problems, ranging from blood pressure problems to infections to small, undetected strokes.
Researchers who study falls and hip fractures recommend exercise and household safety for preventing falls, and a Rhode Island company now sells an undergarment called SafeHip with a sewn-in, hard-but-flexible hip-pad protectors to absorb the shock of a fall and reduce the risk of fractures by 50 percent.
Losing confidence
But what concerns many health experts is the emotional and lifestyle impact from even a single fall. It can be so profound that everyday activities — exercising, walking, leaving home, having confidence in simply moving about — are never the same.
“There's nothing like the fear that sets in once you've fallen,” says Dr. Eugenia Mills, chair of nursing at Miami University. “It's so severe sometimes that people are afraid to leave home. It's a little like falling off a horse and getting back on — you have to face some frightening situations to do that.”
Luckily, Elizabeth has every intent on getting back on her feet — literally. Both times after her hip-replacement surgery, she engaged in intensive physical therapy several times a week.
Even now, 10 months after the second surgery, she walks every morning and rides a stationary bicycle at least 15 minutes a day. She quit wearing shoes with heels, installed night lights in her apartment and uses a cane when she feels unsteady on her feet. Her bathroom has two safety bars — one in the shower, one next to the toilet.
“The more therapy you can have after something like that, the better off you are,” she says. “Your recovery's much better. I try to get out there, moving and walking as much as I can. If I'm going to get back to normal, I need to do that, don't I?”
Certainly that is the goal, yet many older people never fully recover from a hip fracture, says Dr. Michael Swank, surgeon with Freiberg Orthopaedic Group.
“We know among hip-fracture patients, even if they're ambulatory when they come in to see us, 30 to 50 percent of them never walk again, even though their fractures heal,” he says. “Part of it appears to be because they're declining in function. Some develop an unnatural fear of falling.”
Indeed, some become so fearful of another fall that they become homebound, sit more and walk less. Less activity, unfortunately, leads to weaker muscles, instability and an increased chance that they will be unable to physically withstand (or prevent) another fall.
“The most important thing to remember about the causes of falls in older people is that it's seldom just one thing,” says Dr. Gregg Warshaw, director of geriatric medicine at the University of Cincinnati Medical Center. “Usually, several factors come into play — it may be vision, it may be deconditioning from not walking or exercising enough, it may be dizziness from problems in the inner ear or a small stroke, it can be a medication that they've started on that's lowered their blood pressure and made them less alert.”
In nursing homes, he points out, a common cause of falls is urinary tract infections, which can cause pain, discomfort and fever.
“Most of the falls are unexpected,” he says. “And a lot of time, most people haven't had much of a chance to adapt. Some people who know they're prone to falling will do things to protect themselves — use a cane, walk with a rail near them, use a walker, walk with friends for steadiness.”
New product
SafeHip is a relatively new product that can reduce fall-related fractures, but only if people agree to wear it regularly, says George M. Ferencik, president of Sahvatex, Inc., the Rhode Island company that markets the device.
It looks like a pair of white bike shorts with hard sewn-in shells that fit over the femur, the bone that sticks out at the side of the hip. If someone falls, the shell absorbs and distributes the impact of the fall, reducing the likelihood that the femur will shatter or break (it's $89.95 plus $5 shipping from (877) 728-3447).
Hip fractures, Mr. Ferencik points out, are a major reason people move into nursing homes, and people who have experienced one hip fracture are more at risk of another.
“For our users, mostly elderly folks, it's very much a quality of life issue,” he says. “It's very, very rare that anyone would die of a hip fracture, but 20 percent will die in the first year from complications, like bedsores or pneumonia.” About half of all people with hip fractures require some kind of help for the rest of their lives, he adds.
Because it's a snug garment that must fit correctly, SafeHip was designed to be worn by someone with arthritis, he says. It can be pulled on by lifting upwards on the shell with the fingers and removed by pushing down on the shell with the hands or palms.
Yet Dr. Swank points out that in some people, the fracture actually occurs before the fall, sometimes because the simple forces of twisting, turning or lifting improperly are enough to fracture an already-fragile bone or vertebra.
In people with brittle bones or hairline fractures, those seemingly simple activities can cause the fracture first, with the fall happening seconds later.
Whatever the cause, getting people moving and walking quickly seems to be important in how well they recover from a fracture or fall, he says. Sometimes, doctors even encourage patients to begin walking or putting weight on joints sooner than they otherwise would because the long-term payoff is increased confidence.
“The more aggressively we get people out and moving, right away, the less the patients are afraid of falling or limited in their ability to walk at all,” he says.
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