As we age, our risk of falling rises – and that means a greater threat of broken bones and other injuries that can change the way we live.
“Falls are one of the leading reasons why older people lose their independence and end up institutionalized,” says Elizabeth Goldberg, MD, ScM, FACEP, an associate professor and associate vice chair for research in the University of Colorado Anschutz Department of Emergency Medicine and a leading investigator in fall prevention.
“Any emergency department doctor will tell you that about 10% of what they see every day is falls,” Goldberg adds. “It’s the most common injury-related complaint that we see among older adults.”
“About half of adults over the age of 85 have had a fall in the last year,” says Cari Levy, MD, PhD, head of the CU Anschutz Department of Medicine’s Division of Geriatric Medicine and director of the CU Anschutz Multidisciplinary Center on Aging (MCoA). “It’s a very life-changing event if it results in a serious injury, because it’s often a trigger for moving folks out of their current home into a more supervised environment. And if there’s a broken bone, there are big consequences. Mortality after a hip fracture is very high in our over-75 population.”
In 2023, more than 158,000 older Coloradans went to the emergency department because of falls. Colorado’s death rate from falls is higher than the national average.
Both Goldberg and Levy say that the best way to address the problems caused by falls is to prevent falls in the first place. That’s why they have joined forces with their colleague Bethany Kwan, PhD, MSPH, a professor and associate vice chair for research in the Department of Emergency Medicine, on a major project to expand capacity across Colorado to deliver fall prevention programs to older adults, including in rural areas and other underserved communities.
Their initiative is known as STEP in Colorado, for “Scaling Trusted Evidence-based Prevention.” And it recently secured a $4.65 million, four-year funding award from the U.S. Department of Health and Human Services’ Administration for Community Living – the only grant to be awarded in a nationwide call for proposals.
Goldberg was on vacation when Levy spotted the grant announcement and sent it to her. Goldberg had only a few weeks to write the grant because of a tight deadline.
She says she was “surprised, shocked, and so happy” the grant was awarded at a time of uncertainty about medical-science research funding. It made her think back to when she began her career as “a simple emergency medicine physician treating whatever condition walked in the door, and thinking it was really important to pay more attention to people coming in with falls,” she says.
In talking about STEP, all three project leads spoke in personal terms about the impact of falls on family members and patients.
“My grandmother went through this scenario,” says Kwan, director of dissemination and implementation science at the Colorado Clinical & Translational Sciences Institute (CCTSI) and an investigator with the CU Adult & Child Center for Outcomes Research and Delivery Science (ACCORDS). “This is a really common problem that meets many of us, not only at the end of our life, but even early in life. It affects our parents and grandparents. This is a deeply personal issue for many of us, as well as being a significant public health problem.”
Levy talks of a close relative who “fell in her garage, shattered her shoulder, had to have a shoulder replacement, and hasn’t been the same since. She had cognitive issues and a stroke fairly soon after that. A fall is often a cascade event.”
Goldberg’s research has identified a few key factors behind falls that lead to emergency department visits. One is medication – “you were recently put on a medication that affects your brain, is psychoactive, causes sedation, and might have reduced your ability to respond quickly and react quickly to your surroundings,” she says.
Another is diminishing physical function – “things such as lower-extremity strength issues, like you don’t get up off the sofa much, so you don’t have much by way of quads or hamstrings, and your balance is affected.”
People with Parkinson’s disease and dementia are at greater risk of falling, Goldberg says. In fact, she says, sometimes emergency department staff, such as physical therapists, identify probable Parkinson’s when people come in after falls.
Until recently, Goldberg says, “these people would continue to be discharged from the emergency department, and then they’d come back again with another fall. The rate of recurrent falls is very high.”
In recent years, she says, “we’re starting to recognize that if we find out in the emergency department why patients fell, then we could potentially reduce downstream falls.”
There are evidence-based fall-prevention programs available, such as A Matter of Balance, Stepping On, and CAPABLE. For example, A Matter of Balance seeks to help older adults reduce their fear of falling by learning to view falls as controllable. The program trains at-risk people to set goals for increasing their activity levels, make small changes to reduce fall risks at home, and exercise to increase strength and balance.
But Goldberg, Kwan, and Levy say that programs of this sort aren’t being used as widely as they should. They say emergency departments rarely refer patients to these programs, even though older adults who come to the ED after a fall are likely to fall again.
Also, only about one in four older adults who fall tell their primary care doctors about a fall – partly because of shame, stigma, and fear of losing independence – which means few of them get connected to a prevention program by referral.
Under private and federal insurance programs, clinicians and hospitals “aren’t really that incentivized to look at these questions of prevention,” Goldberg says. “And a lot of primary care doctors will tell you they don’t have time to do a full fall risk assessment,” which might identify issues at home that could lead to falls.
But the need to prevent falls is crucial, Goldberg says. “If you fall, have a hip fracture, and end up in the emergency department, then you get a surgery, and then you have a protracted recovery from that surgery, and then you need way more caregiver support than you ever needed. Some people never get back to their baseline function. So as a clinician, I think it’s worth all the effort that we can put in to prevent people from falling off that functional cliff.”
Earlier this year, with a small initial grant, Levy and her colleagues launched the Colorado Statewide Falls Coalition, partnering with the state Department of Human Services and the Area Agencies on Aging serving each Colorado county.
“In preparing the coalition, we saw that there are excellent programs around the state, but they are not connected, especially in rural areas, and often it’s hard for people to know what’s available in their community,” Levy says. “So after they fall and they go to the emergency room and then back home, they don’t know about a program they can access.”
The STEP program will work with the coalition, which aims to bring together experts and community members to help address falls and provide resources. Thomas Johnson, MD, an assistant professor of geriatrics and leader of UCHealth’s falls clinic, heads the coalition and is a co-collaborator on STEP.
The four-year STEP project’s key goals are to connect older Coloradans with proven community fall-prevention programs, strengthen statewide partnerships, and generate knowledge that can inform national policy and practice. It emphasizes developing ways to spread and sustain fall-prevention programs so they’ll be used widely, including in rural areas and underserved communities.
STEP aims to help older people access fall-prevention programs through increased referrals by emergency and primary-care providers and through community outreach via flyers, events and media. A network of older adults across the state will be trained to help connect older adults to the programs.
Kwan says the dissemination-and-implementation part of the project will draw on “methods and materials we developed and refined during the COVID-19 pandemic for novel treatments for COVID. We’re building on the research investment from those times by applying the same frameworks to this project.”
One objective is to make it easier for doctors to refer patients to fall-prevention programs. A tool has already been developed within the electronic health records system used by UCHealth, which sees more than 600,000 emergency-department patients per year, that automatically refers at-risk patients to fall-prevention programs.
STEP will draw on 10 partner groups in communities across Colorado that already offer a fall-prevention program or are willing to start. The new federal grant will help the project provide training, funding, and outreach materials to help these sites succeed, as well as to offer support services such as transportation, home care, and meals to make programs more accessible.
As the project unfolds, the fall-prevention programs it promotes will be tested to see how well they reach people, get adopted, and are sustained.
Ultimately, the STEP collaborators hope to engage up to 750,000 older adults in Colorado in fall-prevention programs over the next three years through referrals and outreach. STEP will gauge results by assessing whether emergency-department visits decrease, and by surveying participants to determine whether they feel safer, more independent, and less isolated.
STEP’s collaborators plan to share their results through publications and nationwide so the program can be adopted elsewhere.
“Our goal is that you don’t need to come to the emergency department,” Goldberg says. “We want you to see that there are exercise programs in your community to optimize your physical health, so you can spend time with your grandkids outdoors, go to graduation ceremonies, and do all the things that are important to your quality of life.”