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Sound Body

Before the fall

A record number of Massachusetts seniors died in 2006 after a tumble. But there are many ways to reduce the risk.

Tai chi Elliot Edwards, center, instructs a class at the Medway Senior Center in Norfolk. Tai chi Elliot Edwards, center, instructs a class at the Medway Senior Center in Norfolk. (Globe Staff File Photo / Bill Polo)
Email|Print|Single Page| Text size + By Stephen Smith
May 5, 2008

At the time, sprawled on an East Boston sidewalk, felled by a tree root, Rose Maffei was not feeling especially lucky, what with her shoulder wrenched and an eye bloodied.

But the truth is, the 88-year-old said last week, "I'm one of the lucky ones. I certainly am. I survived the fall."

In 2005, when Maffei took her tumble, 207 elderly men and women died from falls in Massachusetts. A year later, the number of fatalities attributed to falls rose sharply - to 341. When the latest figures were released last month, troubled public health investigators launched an urgent review into the increase.

This much is for sure: Many of the falls that injure or even kill should never happen in the first place.

They are the legacy of tattered carpets and tired bodies, good intentions and bad choices. They reflect what happens when multiple doctors put one patient on multiple medications, fueling a fog of confusion. They suggest that physicians, nurses, and institutions caring for the aged need to devote more attention to signs that a patient is primed for a fall.

"There's so much in medicine we don't have evidence for, but falls are frustrating because we do know what works and we know how to attack it," said Diane Mahoney, geriatric nurse-practitioner at the MGH Institute of Health Professions.

Falls happen with stunning regularity. The US Centers for Disease Control and Prevention reports that nearly one of every three people 65 and older suffers a fall each year, and when they happen, they are far more damaging. In Massachusetts, fall-related deaths killed four times as many seniors than all other adults in 2006.

And, too often, seniors are hesitant to tell relatives or doctors when they tumble the first time, a reticence that can prove lethal.

"Many older people feel that it's a sign that they're on the downward slope, and if they admit to falling, that's just one step away from a nursing home," said Judy Stevens, a CDC specialist in fall prevention.

But by acknowledging that they have fallen, seniors can actually begin to place themselves on a safer path.

Maybe, for instance, they fell because their leg muscles had turned flaccid through years of inactivity. The solution: take a class that builds strength and flexibility. Similarly, there can be problems with balance. Activities such as tai chi, an ancient Chinese exercise regimen emphasizing steadiness and concentration, can make seniors more sure on their feet.

Still, for many people in their 70s, 80s, and beyond, exercise hasn't been a regular part of their lives.

"This isn't the Nike 'Just Do It' generation," said Alice Bonner, cochairwoman of the Massachusetts Falls Prevention Coalition. "There are some people who never exercised."

But nudging reluctant seniors to take physical fitness classes represents just one strategy to reduce the risk of falling. It's also vital to evaluate their vision and the medications they're taking. Aged pupils, for example, don't dilate as well in darkness or constrict as well in brightness.

One study showed that falls decreased 34 percent among seniors who had the milky opaqueness of a cataract removed from their eyes. Some specialists also point to bifocals and trifocals, which can blur vision, as potentially contributing to falls.

It's also common for lighting to be so inadequate that navigation of hallways and rooms can be treacherous, said Dr. Gary Chu, vice president for community collaborations at the New England Eye Institute.

Chu visits the apartments of seniors living in Boston Housing Authority buildings and evaluates their lighting and other factors that might spur falls. Often he finds that lights aren't positioned where they're most needed: A bathroom will have a light over the sink but not over the shower, already made dark by a curtain.

"And then there are issues around contrast," Chu said. A younger eye can spot the lip of a carpet-covered stairstep when an older eye can't. So a sliver of tape with a contrasting color can be applied to yield a visual cue.

Still, Chu said, "when you have a single intervention, that doesn't seem to be the key. Falls are a really complex issue, and when you put interventions together, it makes a bigger impact."

So specialists in fall prevention also make it a point to review the medications seniors receive. Certain drugs, separately or taken together, can cause dizziness, drowsiness, and dangerous drops in blood pressure.

Frequently, patients with a constellation of health woes will visit different specialists who aren't aware of what other doctors have prescribed, potentially creating a fall-inducing mix. Research by Dr. Mary Tinetti of the Yale School of Medicine found that physicians understood the risk, but did not respond the same way.

"We had physicians who would say, 'Yes, the most important thing is to keep people safe and if the medication is doing harm, we should reduce it,' " Tinetti said. "There were other physicians who would say, 'They need it for their heart disease or diabetes or high blood pressure and they're just going to have to put up with it.' "

That reflects a common dilemma for doctors and for seniors: assessing risks and benefits, and making choices. "It's really about thinking about ways of minimizing risk," said Carlene Pavlos, director of the Division of Violence and Injury Prevention at the state Department of Public Health, "and not trying to take away people's independence."

On the day Rose Maffei took a tumble along Saratoga Street, grocery bags dangled from her hands. She never saw the root protruding from the sidewalk. After making her way home, "I went to an orthopedic man right away," she said. Therapy helped repair her dislocated shoulder, and, since then, she has faithfully attended classes where she stretches and moves her legs and focuses on balance. She line dances, too.

"I feel great," Maffei said, "but I'm frightened. That's why I joined the balance club, because I noticed I'm getting a little older, and my balance isn't as good as it used to be. But you have to be active, you have to move.

"If you just sit," she said, "that's the end."

Stephen Smith can be reached at stsmith@globe.com.

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