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Statement by
David W. Fleming, M.D.
Acting Director,Centers for Disease Control and Prevention, U.S. Department of Health and Human Services
on
Falls Among Older Americans: CDC Prevention Efforts
before the
Senate Subcommittee on Aging Committee on Health, Education, Labor and Pensions

June 11, 2002

Introduction

Madame Chairwoman and Members of the Subcommittee, the Centers for Disease Control and Prevention welcomes this opportunity to provide this statement for the record on the issue of falls among older Americans. CDC is working with our Federal and non-federal partners in addressing the serious consequences older Americans face as a result of falls; identifying opportunities to improve the health and safety of older Americans; and reducing the negative economic impact that falls produce in our rapidly aging nation.

The Nature of the Problem

Falls represent a serious public health problem in the United States. One of every three older Americans�about 12 million seniors�fall each year.

Data show that falls are the leading cause of injury death among people 65 years and older. In 1999, more than 10,000 older adults died from fall-related injuries. This number will increase as the number of people over age 65 continues to grow.

Nonfatal falls are also significant. Falls are the most common cause of hospital admissions for traumatic injuries. In 2000 alone, 1.6 million seniors were seen in emergency departments for fall injuries. Every year, falls among older people cost the nation more than $20.2 billion in direct medical costs. By 2020, the total annual cost of these injuries is expected to reach $32.4 billion. Annual Medicare costs for hip fractures is almost $3 billion. These economic costs are significant.

Of all fall-related injuries, hip fractures not only cause the greatest number of injury deaths, but they also lead to the most severe health problems and reduced quality of life. Women sustain 75-80% of all hip fractures and the rate increases sharply from age 65 to 85. One out of three women will have a hip fracture by age 90. In 1999, there were over 300,000 hospital admissions for hip fractures, 77% were women.

The impact of hip fractures is significant, both in terms of quality of life and economically. Only half of community-dwelling older adults who sustain a hip fracture can live independently one year later. This contributes to the fear of falling and loss of independence which are a great concern of older adults. In a recently published study, 80% of the older adults in the study said they would rather be dead than experience the loss of independence and quality of life from a bad hip fracture and admission to a nursing home.

What we know about falls

Risk factors for falls include muscle weakness, balance and walking problems, taking four or more medications (and taking certain types of medications), vision problems, certain chronic diseases (such as Parkinson's Disease, arthritis, stroke), previous falls, and having multiple risk factors. In one study, the risk of falling increased from 10% to as high as 69% as the number of risk factors increased from one to four or more. This kind of information is the foundation for developing effective prevention strategies.

Research has demonstrated a number of ways to prevent falls and the negative consequences of the resulting injuries: � Multi-component programs: Several studies have shown that programs that involve multiple components � usually exercise, medication review, vision correction and environmental changes in the home � are effective in reducing falls and fall injuries in people living in the community.

• Review and reduction or modification of medications and vision correction: Multiple medications and certain types of drugs (such as anti-depressants) are a significant risk factor. However, additional research is needed to more fully understand the role of all medication and falls, and to develop clinical guidelines related to fall prevention for those at high risk for falls.
• The form of exercise called Tai Chi: In some populations, when used as a sole intervention (as opposed to being part of a multifaceted intervention program), Tai Chi appears to reduce fall risk. In addition to improving balance, strength, and coordination, it also improves the sense of well-being and reduces the fear of falling.
• Home modification: Sixty percent of older adults fall in their own home. So it makes sense to make the home safer, in particular an older adults ability to enter and exit the home, and to move around safely within the home. Installing stair railings, ramps, and grab bars (such as in the bathroom) are simple but effective modifications. These are most successful when combined with other interventions (such as exercise and medication review).

CDC activities to prevent falls

CDC is committed to preventing older adult falls and ensuring healthy aging, and is already investing in a comprehensive approach to tackling this public-health issue. This approach includes:

Understanding the problem of falls among older adults through data collection and analyses

CDC collects data on the number of people who die, are hospitalized or visit emergency departments from falls. National and state-level data about deaths and emergency department visits are available to researchers and the public through CDC's interactive, web-based system called WISQARS (Web-based Injury Statistics Query and Reporting System) at www.cdc.gov/ncipc/wisqars. People can use WISQARS to create reports and maps that help them understand the problem in their communities.

Developing and testing interventions to reduce falls and their consequences

CDC has funded studies to evaluate risk factors for falls and research to explore interventions to prevent falls.

• Nationwide, half of all nursing home residents�roughly 750,000�fall at least once a year. The high rate of falls in nursing homes is generally attributed to the frailness of their residents. Research funded by CDC at Vanderbilt University is testing a fall prevention program in nursing homes. The Tennessee Fall Prevention Program teaches staff how to reduce obstacles and other hazards in residents' daily environment and monitor medication use. Originally piloted in seven pairs of nursing homes, the researchers found that residents were 20% less likely to fall after the program was implemented.
• CDC is funding the California State Health Department to implement and evaluate a multi-faceted older adult community fall prevention program. Seniors are counseled about their risk for falls and steps to take to prevent falls, including enrollment in an exercise program, getting their medications reviewed, home modifications, and screening and referral for treatment of osteoporosis.
• CDC research contributed to the development of hip pads, which reduce the force on the hip when an older person falls. Hip pads developed from this and other research have been shown in studies to reduce hip fractures.
• CDC is the major funder of a large multi-site study of the costs and benefits of trauma systems. The purpose of this study is to evaluate the additional benefits of trauma systems over routine emergency department care. It includes a focus on older adults, particularly the costs of treatment of those who fall.
• New research funds are available in FY02 for a 3-year study on fall prevention for community-dwelling older adults. The study will not only evaluate the effectiveness of the intervention strategies, but also identify how to facilitate effective collaborations among the community services, delivery systems, public health and health care providers.

Sharing information on proven strategies

• Information on falls and other injuries is available from the CDC-funded National Resource Center on Aging and Injury, based in San Diego and established by the San Diego State University Center on Aging, in conjunction with the American Society on Aging. The website (www.cdc.gov/aging/orglinks_cdc.htm) includes email forums, publications, and links to other organizations that have programs supporting healthy aging.
• In an effort to spread the word about the risk of falls and to promote physical activity among older adults, CDC has internet resources available for the public and practitioners. For example, CDC developed the National Blueprint on Physical Activity Among Adults Age 50 and Older to promote physical activity among older adults.
• CDC also compiled the Tool Kit to Prevent Senior Falls, a collection of research findings and educational and assessment materials for use by professional service providers. The tool kit, available in English and Spanish, has been distributed to more than 6,000 organizations, such as local health departments, Area Agencies on Aging, non-profit organizations, health care agencies, etc.
• CDC is also funding the National Safety Council to conduct focus groups to assess the effectiveness with older adults of educations tools and strategies related to safety and health.

What is needed now?

Use proven interventions � We have interventions that work, but need to learn how best to provide them to older adults who are at risk for falls. The multi-faceted programs that combine exercise, medication review, vision correction and environmental changes in the home are shown to have an impact in trials, but we need to learn how best to provide these on a broad scale. We need to work with health care providers to ensure that people at highest risk are identified and receive interventions, and also evaluate how best to deliver falls prevention services to older adults.

Evaluate promising interventions � Further work is needed to evaluate different exercise programs and to learn how to increase the use of hip pads among frail older adults. Health status varies greatly among older adults, as does the risk of falling. Research is needed to identify which interventions work best in different subgroups of older adults. Research on the cost-effectiveness of different strategies for caring for an older person with a fracture, including whether or not the availability of care at a designated trauma center improves outcomes, could be helpful to decisionmakers.

Develop and test new interventions � New interventions are needed to decrease the risk of falling and decrease the risk of injury when older people fall. These interventions could include those that require behavior change, but also those that result from changes in the environment. Better understanding of the biomechanics � that is, what happens to the human body during a fall � may lead to new environmental interventions to decrease fall and injury risk, such as improved flooring. Better understanding of how older people interact with their environment may also provide new avenues for prevention.

Conclusion

Because of major strides in medicine and public health, we Americans are continuing to live longer�and healthier�lives. As a result, injuries among older Americans now ranks with heart disease and stroke as a major contributor to death and disability among this population.

Fortunately, we have made great strides in learning how to reduce the chances of falling and to mitigate the impact of a fall that occurs. We know, for example, there are many steps people can take themselves to prevent falls. Older adults can reduce their risk by doing certain kinds of exercise. They can make their living spaces safer by removing tripping hazards, using nonslip mats in the tub and shower, improving lighting in the house and installing grab bars and stair rails. They can have their doctor review their medications for side effects and interactions and have their eyes examined each year.

Still, there is a compelling need to identify and eliminate barriers to implementing proven interventions and new interventions need to be developed which are appropriate to the many different subgroups of older adults. Those that work with older Americans in the community, in nursing homes, and where elders receive counseling services need to have knowledge of, and access to, the best information on programs and interventions. As our society ages, the burden of falls in older adults will increase. We as a nation must act now to prevent falls and fall injuries among older adults.