Monday, March 23, 2009

What is a "Fall"?

10/15/08: According to certain popular thought, when an elderly person falls it represents the beginning of the end, but when a younger person falls the threat is vastly less. Why is this? In the discussion below, I will share some of my thoughts. I hope you will respond by sharing some of your thoughts. (Note that except for my own personal experience, the identities of people mentioned have been changed to disguise them.)

The difference appears to have to do with the meaning of the fall in the overall cycle of life. A fall for a young person may lead to a broken wrist or a broken leg, but there is the sense that the break will heal. There is only temporary inconvenience and pain. There is a lack of a sense of fragility. For an elderly person the reverse is true. There is almost always the sense of vulnerability.

Part of this is the naivety of very young people about risk and death. It is young people who volunteer for the military, and who are sought after by the military, in part because they are naïve to the risks, believing that they will not die for a long time.

But let’s look at some examples of falls in my personal experience.

Two years ago I went cross country skiing on a day when the trails were icy. This is a problem with downhill skis. It is an even greater problem with cross country skis. I skied down a hill and started to bend to the left when my slight timidity on the ice was just enough to cause some instability, and I started to go down. I held myself up with mighty effort with my left ski pole. The pole broke about six inches below my hand, and I started going down. My feet were held in position by my skis, so that I could not twist to land on a fleshy part of my body. There was not much time, but there was enough so that the thought went through my head, “We’re going to find out how sturdy my hip bone is.” Well it was fine after the fall, but my left shoulder, the second point of impact, took a year to recover from the muscle and ligament trauma. It was a painful nuisance working with the shoulder while the muscles and ligaments gradually healed and then released their tension. However, it never offered even a hint of the beginning of the end of life. This was a hard fall, but it was not a “Fall.”

Patty is 94 and she falls regularly. Her caretaker stays up and listens for her to get up at night to go to the bathroom. At least once a month Patty will fall on her way to the bathroom, and her caretaker will come upstairs to help her. Staying up is wearing on the caretaker. Patty’s children are very worried and solicitous for her well-being. But Patty is very practical and matter-of-fact about her falling. She is not threatened by it, perhaps because she has never broken a bone by falling. She is stubbornly independent, and drove her car until just after her 90th birthday. These falls are certainly significant, and they do signify that the beginning of the endgame has started. However, none of them is a “Fall.” At the same time, everyone is watchful in the anticipation of a serious fall that will change things.

Mary is in her early 80s and suffered a serious fall in her apartment. She does not know what she tripped on, but she does know that she went unconscious for a matter of hours. A friend called her apartment, expecting her to be home, and found there was no answer. At that point the police came and rescued her. Mary knows that this fall was therefore life threatening. It was a “Fall” in that it changed her lifestyle. It also changed her lifestyle in the sense that she had to undergo therapy for more than a year afterwards, with anxiety about whether she would ever regain full dexterity in her affected limbs. Before she fully recovered she had another fall while walking on a poorly maintained sidewalk. She broke her hip, had hip replacement surgery, and went through therapy. She recovered rapidly in a physical sense, but this was a “Fall” psychologically for her, because of the threat and the difficulty of recovery. However, it was also not a “Fall,” in the sense that she mustered her resources and made a strong personal commitment to recover. It seems to me then, as I think about this, that the commitment of the person to recover is a key part of whether a fall is a “Fall.” If the person is committed to recovery, and likely to recover if she makes the effort, then there is a fall rather than a “Fall.”

Ann is well into her 90s, and was living with fierce independence in an apartment contiguous with her daughter’s house, when she fell and could not get up. She ended up in the hospital for a week or so, and then shifted to the medium term care facility. There was concern in the community that this strong, independent woman might be failing, and that she might spend the remainder of her lifetime in the medium care facility. However, it remained ambiguous just what kind of condition Ann was in. Those who visited her indicated that she still had plenty of pluck. A couple of months later, Ann fell while using her walker in the hall. She had immediate surgery for a broken hip. The interesting thing is that this did not seem to change her attitude or the community’s attitude toward her condition. Clearly the two falls were both “Falls,” but it remains unlikely that they signal her oncoming death, at least in the imminent future.

Contrast this with James, who fell off his bicycle when he was about 60. He was almost stationary at the time, and his feet were clipped in, so that his hip took the brunt of the fall and was smashed. His hip and femur were replaced with titanium versions, leading to extensive therapy on the associated muscles, which had ceased to know how to function. A few agonizing years later, he was back to normal. He died two years later as a result of a flu turning into pneumonia, and that becoming septic. Was the fall in any sense a “Fall?” I think not, because no matter how extreme the damage was, there was always the sense that he would recover from the fall, and he did. Further, his death was not related to the fall, even if it is perhaps interesting that it happened not so many years after the fall.

Consider Pat, a seventy year old woman who had misstepped at the top of her cellar stairs, and fallen hard to the cement floor, injuring herself. She, too, recovered, but she could be argued to have suffered a “Fall” in the sense that she was intimidated years later. She walked with special care and some asymmetries as a result of her fear of falling. She did this because she was extraordinarily anxious about another fall. Her Fall had led her to realize her vulnerability and the need for her to take great care, even though to my eye she was not actually frail, nor did she need to take that much care.

So what is a “Fall” as contrasted to a fall? It seems that some of the distinguishing factors are: • Whether the person has a sense of confidence about being able to recover. • Whether the person remains quite anxious about falling again. • Whether the person is near the end of his lifespan with or without the fall. • How frail or vulnerable the person seems to be during the time before and after the fall. • The degree to which the fall is purely accidental, or is caused by increasing physical disability. • How members of the community see the person in these same dimensions.

Thus when the therapeutic community uses the Dynamic Gait Index (DGI) to determine the risk of an elderly person falling, the fall if it happens for someone with a low DGI indicates that the person has been gradually failing and that the fall probably does not happen by accident. Such a fall marks a juncture in the elderly person’s life. There are interventions that can readily lead to a reversal of the decline. The person must make a decision about whether to invest the money and effort into those interventions. If the decision is not to attempt to reverse the decline, then the fall is truly a “Fall” and the endgame has truly begun.

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