COVID-19 may have been the leading concern for older adults’ health in 2020, but a longtime silent killer lurked in its shadow: falls.
According to provisional data released by the Centers for Disease Control and Prevention in June, the rate of fall-related deaths among Pennsylvanians over age 65 reached near-highs in 2020: an estimated 76.3 fatalities per 100,000 people between July and September, a 9% jump from the previous year.
Although the full effect of COVID-19 won’t be clear until more data are tallied, geriatric experts are concerned. Inactivity and isolation during the pandemic may have eroded seniors’ strength and overall physical and mental health, all factors associated with falls.
“We’ll still have some time before we see the full effects” of the pandemic, said Lisa Walke, chief of the division of geriatric medicine in the Perelman School of Medicine at the University of Pennsylvania. “A lot of things that we know help with decreasing fall risk were either modified, not present, or not accessed by the people needing them.”
Falls on the rise
The classic scenario is a late-night urge to urinate that pulls an older adult out of bed. A moment of dizziness, an uneven rug, or blurry night shadows can turn a rush to get to the bathroom into a trip to the ER. Falls can occur whenever a confluence of factors — including unsteadiness, weak muscles, physical obstacles, diminished senses — brings someone toppling down. Fatal falls, in particular, usually involve some sort of head injury.
“If it was one single thing, we would have solved this,” said Carol Maritz, professor of physical therapy and associate dean of Samson College of Health Sciences at University of the Sciences.
Nationwide, the rate of fall-related fatalities among adults aged 65 and up increased by 32% from 2007-2009 to 2017-2019. This rate is estimated based on the cause of death listed on death certificates, accounting for changes in the population’s age distribution. Pennsylvania’s death rate from falls has been above national averages for more than a decade, and in recent years rates have picked up speed: Between 2015 and 2019, rates of fall-related deaths among Pennsylvanians 65 and older increased by a whopping 15%. It’s an uneven phenomenon: Fall fatalities have been lower and more constant in Philadelphia compared with such other counties as Lehigh and York, where rates have almost ballooned to double the state’s rate.
And unlike COVID-19, which took a disproportionate toll on communities of color, fall-related deaths are more common among white seniors. The fall-related death rate for older white adults in the state was 77.1 deaths per 100,000 in 2019, more than twice the rate for older Black adults at 34.3. The rate for men in 2019 — 90.5 per 100,000 — outpaced the rate of 62.6 in women.
Unsurprisingly, many people who die in falls have other health problems. In more than a quarter of senior fall deaths in the state, heart disease was a contributing factor.
Hospitals are seeing the trend up close. According to St. Luke’s University Hospital, the share of patients over age 65 at their adult Level 1 trauma center in Bethlehem leapt from 32% to 55% between 2010 and 2019, and about 80% were admitted because of trauma sustained in a fall. In 2019, more than 2,000 older adults came in with fall-related injuries: almost 700 more than in 2018. These patients accounted for almost all the growth of St. Luke’s trauma population that year.
Florastine Byarms, manager of community health and outreach for Paoli Hospital and Main Line Health King of Prussia, said she has noticed growing interest in fall prevention programs in recent years, even among people in their 50s.
Why the death rates are rising is still unclear to physicians. It may be partially due to better reporting, Walke said, as doctors become more aware of the importance of tracking falls.
Experts also attribute these increases to a rapidly aging population, especially in Pennsylvania, where residents over 65 are predicted to make up more than one-fifth of the population by 2025. People are living longer — but not necessarily healthier.
“We’re managing heart disease, strokes, and diabetes better,” said Tuesday Trudel, a nurse practitioner specializing in geriatric medicine at St. Luke’s University Health Network, which is based in Bethlehem. “Because of that they’re living longer but they still have all these underlying conditions.”
In 2017, more than one-quarter of older adults in the U.S. had diabetes, which can damage nerves in their feet, blur their vision, and make them more likely to take a tumble.
Older adults are also likely to be on multiple medications — many taking more than four prescription drugs, according to a 2019 survey from the Kaiser Family Foundation — which can cause dizziness or mental fog that increases fall risk.
Medications also can make falls more deadly. Blood thinners are commonly used to reduce the risk of clots, but also increase the likelihood that head trauma will lead to bleeding in the brain, Walke said. The rate of fatal falls is accelerating even faster than the rate of fall injuries reported by the Pennsylvania Department of Public Health, meaning that falls among older adults may be getting worse.
“We should be more worried about falls than we are,” said Megan Todd, a public health scientist and director of the Philadelphia Department of Public Health’s Division of Chronic Disease and Injury Prevention’s Data Lab. “We just don’t have great data on it.”
Tackling twin epidemics
If falls weren’t complicated enough, add COVID-19 to the mix.
Before the pandemic, Maritz led an exercise class at Mount Zion Baptist Church in Southwest Philadelphia for a group of older Black adults, called Southwest Elders Exercising Together, or SWEET. Designed to increase strength and balance, the class had an intensity interval structure like CrossFit, and even though the 20-member class consisted of people in their 80s and 90s — the oldest recently turned 97 — Maritz didn’t go easy on them.
“They might do 40 seconds of squats, followed by a rest, then 40 seconds of upper-body exercise with some hand weights,” Maritz said. “They do exercises that some of my colleagues and students [at University of the Sciences] struggle with.”
Their last class was in March 2020, before it became impossible to have a group of COVID-19-vulnerable seniors huffing and puffing in close quarters. Maritz considered offering the class on Zoom, but many of the older participants didn’t have internet access or didn’t feel comfortable with the technology.
Linda Saunders joined Maritz’s class when it first began 10 years ago as a way to get exercise while having fun with friends — reducing fall risk was an added benefit. Her favorite part of class was a closing exercise, in which Maritz would call out instructions in rapid succession (“Right foot forward, left foot back, right foot sideways”), as giggling participants raced to keep up.
Since the class stopped, Saunders, 78, hasn’t been exercising, and she’s starting to notice physical changes. She takes fewer walks and finds that she is more out of breath than before. “Every so often I’ll pick up my ball or weight and do something,” she said. “Most of us haven’t been doing much exercising.”
Other fall prevention and exercise classes in Philadelphia went on hiatus in 2020, leaving their participants with minimal opportunities for physical activity — the most effective way to avoid falls, Trudel noted. Meanwhile, chronic conditions that are common co-morbidities of falls, such as diabetes and dementia, gained ground as the COVID-19 pandemic pushed people to postpone preventive care.
So far, estimates through September 2020 show a continued, but not hastened, increase in the rate of fall-related deaths among adults over 65. However, there might be more to the story than these numbers, Trudel said.
In March 2020, she noticed an initial decline in the number of older patients coming to St. Luke’s with falls as people stayed at home to socially distance. A few weeks later, however, numbers increased again and she started to notice a change: Patients had more problems with mobility and balance, signs of deconditioning, or growing less fit.
It takes as little as three days of disuse for muscles to grow weaker, Walke said, and the effects of the COVID-19 pandemic have lasted more than a year. As months passed without exercise classes, physical therapy, or even casual walks around the block, older adults lost muscle and increased their risk of falling.
Before the pandemic, Maritz measured her students’ strength four years apart and found that it stayed constant rather than deteriorating with age. But in the year since the class last met in March 2020, Saunders has heard that at least two participants have had falls that resulted in broken bones.
Walke also worries that older patients may not have told their doctor about minor falls during the last year, missing a crucial opportunity to assess their fall risk and intervene before more severe — and potentially fatal — injuries occur. Interventions as simple as improving lighting and removing throw rugs can reduce fall risk, and doctors may review patients’ medications or refer them for physical or occupational therapy. Those who survived more serious trauma due to falls were hesitant to follow recommendations for inpatient physical therapy due to lockdown procedures that limited visitors.
“A lot of people who would benefit from rehab chose not to go to rehab because of the restrictions that were in place,” said Alyson Michener, medical director at the Penn Presbyterian Center for Continuing Care.
Applying lessons of the pandemic
Taking a cue from their pandemic experience, some providers are designing fall prevention programs that participants can do both in a traditional class and from home. Ellen Weekes, health and wellness coordinator at the Lancaster County Office of Aging, said their virtual programming helped them reach new audiences.
“It’s a different group of people that we’re reaching through the virtual [senior] center,” Weekes said. “They’re the people who weren’t attending brick and mortar senior centers.”
Weekes ran a virtual version of a four-hour fall prevention program for the first time on Zoom in mid-June. Participants had to be seated in clear view of their camera so the instructors could monitor their safety, and received extra help setting up their technology.
Geriatricians have used telehealth appointments during the pandemic to advise patients on the best ways to avoid fall risk. Vision exams and medication reviews are key safety tools. A home assessment from an occupational therapist can offer safety tips such as adding hand rails, removing throw rugs, or adding nightlights and grab bars in the bathroom. In households with pets or young children, extra vigilance is needed to keep random toys out of high-traffic areas.
Walke writes exercise recommendations for her patients just as she would a medication prescription — that’s how important movement is both for fitness and socializing, she said.
“You may not be at the same level you were at before, particularly if you didn’t keep doing anything on your own at home, but do not let that discourage you,” she advises. “You need to continue with it.”
Saunders, for one, is excited for the day when her biweekly workouts with Maritz resume. But after a year of less activity, she knows it won’t be easy.
“At this point, I think we’d all have to start from the beginning,” Saunders said. “I don’t think we’ll be able to do what we were doing when we left. We have to work up to that.”