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Seeking Safer Ground


“The cost is substantial, and [falls] have a tremendous impact on quality of life and mortality. Yet, we know fall-prevention strategies can make a big difference.”

THE AGING OF THE U.S. POPULATION and the economic strains this brings to the health care system underscore the importance of public health approaches emphasizing prevention and community-level strategies to keep older adults healthy.

That’s the conclusion of Geoffrey Hoffman (MPH ’08, PhD ’15), supported by the research that he and others have conducted on fall-related injuries, a major public health concern affecting elders.

Balance and gait training can reduce fall risk for older adults.

Doctor visits to assess medications and fall risk are part of the solution, but we also need to support social and community approaches, both for financial reasons and to ensure that we are effective in reducing risk and allowing older adults to maintain their independence,” Hoffman says.

Currently a postdoctoral research fellow at the University of Michigan School of Nursing, Hoffman became interested in studying falls after earning his MPH from FSPH’s Department of Health Policy and Management and then completing a two-year Presidential Management Fellowship in the executive branch of the federal government in Washington, DC. Working in the Veterans Health Administration’s Office of Geriatrics and Extended Care, Hoffman gained practical policy experience in aging-related issues before moving on to the Congressional Research Service, where he assisted Congress members and staff in understanding Medicare provisions of the Affordable Care Act and their potential impact on older adults. Hoffman then returned to the Fielding School for his PhD, focusing his dissertation on risk predictors and outcomes of falls and fall-related injuries. The topics he addressed, and continues to study at the University of Michigan, include the impact of caregiving on fall risk, the relationship between depressive symptoms and falls, and the broader economic cost of falls.

“From a health-economics research perspective, we’re always interested in issues in which actions can make a difference for many people,” Hoffman says. “Falls affect a sizable proportion of the population, the cost to the health care system is substantial, and they have a tremendous impact on quality of life and mortality. Yet, we know fall-prevention strategies can make a big difference.”

Hoffman notes that each year in the United States, more than one-third of adults 65 and older who are living independently experience at least one accidental fall. Of those who do, 20-30 percent are injured, in many cases leading to rapid declines in their health and functional independence. Annually, more than 2 million older adults visit the hospital emergency department as a result of a fall, one-third of whom are hospitalized. Nearly two-thirds of older adults who are hospitalized for a fall-related injury are later admitted to a long-term care facility, and one-third of those who fracture their hip die within a year of their injury. Fall rates among older adults are increasing, as is the number of older adults in the U.S. population.

Not surprisingly, Hoffman says, this is resulting in not just a rise in fall-related disability and deaths, but mounting costs – from $19 billion in fall-related emergency department and hospitalization costs in 2006 to a projected $43 billion by 2020. Hoffman has found that the average cost to Medicare per fall-related injury is $9,389 in the first year, with out-of-pocket costs to the patient of approximately $1,350.

Much of this is preventable. Hoffman explains that falls are related to “geriatric syndrome,” or the decline in a number of bodily systems affecting balance and gait, cognitive impairments, vision, reflexes and muscle strength as people grow old. “But falls don’t just involve clinical factors; they are also related to social factors and the environment in which older adults live,” Hoffman says.

He explains that physicians have an important role to play, particularly when it comes to management of medications, the side effects of which can lead to dizziness or other symptoms that can increase fall risk. But other strategies shown to reduce risk include balance and gait training, physical fitness, use of assistive devices when needed, and modification of the home environment for optimal safety – such as installing handrails, removing carpeting that can pose a tripping hazard, and keeping all items within easy reach.

Hoffman has even found that treating depression can reduce risk, since it increases the focus of older adults when walking. He is currently focusing on whether caregivers, both informal (such as family members) and paid, help to reduce the fall risk of older adults.

“Medicare was built as a hospital-based system to provide acute care, but at the time it was established, life expectancy was 67 years,” Hoffman says. “We need to move toward a system that better addresses the needs of older adults who are living in the community and trying to stay healthy. Falls are a social phenomenon as well as a clinical one, and we can address them using some low-tech social solutions. By focusing on the scalability and sustainability of the community-based falls-prevention programs that we know are effective, we can potentially save the system a huge amount while keeping older adults independent and healthy.”