Kevin Y. Kawamoto
Special to The Hawai‘i Herald
The Japanese have a saying: “Nana korobi, ya oki – Fall down seven times, rise up eight.” In other words, no matter how many times you fail to attain an objective, don’t give up. Get up and try again! As far as proverbs go, this is inspirational and uplifting. But physically getting up from a fall is not always easy, especially as one gets older.
The Centers for Disease Control and Prevention reports that each year, millions of people 65 and older fall, but less than half of them tell their doctor. They might not think it’s a big deal, but the CDC also finds that falling just one time doubles an older person’s chances of falling again; that 20% of all falls lead to serious injuries such as broken bones and head injuries.
“These injuries,” the CDC warns, “can make it hard for a person to get around, do everyday activities, or live on their own.”
Many people probably know someone whose quality of life declined, or who died, after a fall. Nationally, fall death rates have increased by 30% from 2007 to 2016. For these reasons, it is important to enhance fall-prevention awareness and create a safer walking environment both inside and outside the home.
What Leads to Falls?
A wide range of factors could lead to an older person falling, such as lower-body weakness and lack of balance. These two things may have worsened this past year as many older people limited their physical activity by staying at home and not getting as much exercise as they normally did in pre-pandemic times.
While to shelter in place as much as possible was following sensible public-health guidelines, it may have also contributed to older people’s loss of skeletal-muscle mass, a condition known as “sarcopenia.” You’ve probably heard the admonition: “Use it or lose it!” This also applies to one’s muscles. The less you use your leg muscles, for example, the weaker they get, making it more difficult to walk steady and with confidence. Alarmingly, more than 800,000 people nationally end up in the hospital each year due to an injury caused by a fall, and 300,000 older people are hospitalized as the result of a hip fracture after falling. If these people remain immobile for too long, it will likely negatively affect their overall health and ability to regain their previous ability to function, which is why surgery and physical therapy are often recommended soon after a person is hospitalized with a hip fracture.
Though we think of our home as our haven, that same home can become a dangerous place for an older person to move around in. When it comes to creating a safer home environment for older people, Mike Hirano has a number of good ideas. Hirano is the longtime Fall Prevention Assessment expert at Project Dana, a community non-profit dedicated to helping frail elders and the disabled maintain their wellbeing, independence and dignity.
“Everybody’s house is different,” Hirano explained in an interview with the Herald. But he recommends these common areas of improvement based on his many years of visiting homes to do a fall-prevention assessment. (Due to the pandemic, Project Dana is not conducting in-person home assessments until further notice.)
One common danger Hirano often notices on the floor is area rugs, sometimes called throw rugs. “Most of the time, these rugs move or they bunch up,” creating a tripping hazard, he said. He recommends eliminating them and removing any other obstacles on the floor that could result in an older person losing his or her balance.
Hirano has also observed that many homes have coffee tables that are positioned too close — within 12 inches, for example — of the sofa. When someone sitting on the sofa gets up, he or she has to walk sideways to move away from the sofa and get to elsewhere in the house. This abnormal sideway walking can lead to a fall or loss of balance. Sometimes they have a rug under the coffee table, compounding the fall potential.
A simple solution is to move the coffee table further away from the sofa, but even that may not be the end of the story. If the coffee table is cluttered, small objects could easily fall from the top of the table onto the floor and be difficult for an older person to see. When stepped on, they might cause the startled older person to lose balance and fall.
Hirano studies the foot-traffic patterns in a home and wants to know what are the most used pathways that occupants use to get from one place to another. He recalls a lesson from basic math.
“The shortest distance between two points is a straight line,” he said. He recommends clearing these well-traveled pathways in the home so the walker does not have to step around anything and risk tripping.
Hirano also notes that homes can change over the course of the day. At one point of the day, for example, it may be clear of obstacles in common pathways. But then someone comes home, like a grandchild, and now there is a backpack or other items placed on the ground along those same pathways. All the occupants of the house need education about fall prevention.
A clean, neat house is usually a good thing, but it is possible to be overly conscientious about cleaning. For example, a newly waxed and polished floor can be a slippery surface to walk on for someone wearing socks.
Of course, one’s ill-fitting footwear could lead to tripping, and homes where rubber slippers, sandals, shoes and other items are tossed haphazardly in front of door entrances are an accident waiting to happen. Residents of such homes might consider the example of many Japanese homes (in Japan) where footwear is placed neatly in cubbyholes and the ones at entrances are kept to a minimum and carefully pointed in the outward direction so that one can easily step into them when leaving the house.
Because Hirano has just about seen it all, he brings up possible fall hazards that most people might not even think of. For example, he notes that some type of bed clothing — like silk pajamas — can be slippery, especially when used on a bed that has slippery fabric sheets covering it. A person could slide right off the bed in the morning (as they are getting up) and fall onto the ground, possibly causing serious injury.
Creating a safer environment in the home does not have to be costly and burdensome. The use of nightlights, for example, to improve lighting in rooms and hallways is a relatively inexpensive modification. Other low- to moderate-cost improvements include the purchase of non-slip mats, non-skid strips, a shower seat, a portable tub rail, a commode, a raised toilet seat and the rearrangement of tangled phone and power cords out in the open.
Properly installed grab bars in the bathroom and elsewhere that they are needed can provide an extra level of support in high-risk areas for falls.
Other modifications may require more costly purchases and the services of trained professionals for proper installation. Some older people have invested in bathroom modifications that replace conventional bathtubs with step-in showers.
Finally, an indoor fall-safety assessment is not only about the home’s physical structure and contents. It is also about the person living in the home. How is that person’s health? Getting a medical check-up is important in catching any problems that could increase the likelihood of a fall and the degree of injury that follows. Vision and balance are two examples of potential problems that a health check-up can help identify. A bone-density test can reveal the presence of osteoporosis, a disease that makes bones more fragile and prone to fractures. Pain or weakness in the feet and legs needs to be examined by a foot specialist. If a person is experiencing dizziness, the doctor can try and determine what is causing that to occur. Medications? Low blood pressure? A medical disorder? Are they eating properly and drinking enough water? Maintaining a healthy lifestyle can aid in fall prevention.
Outside the House
Falls can happen outside the home as well. Yards with uneven terrain or protruding tree roots can be tripping hazards. Walking is good exercise, but city sidewalks can have large cracks or ledges where a person’s foot could get lodged. Falling on a sidewalk or while crossing the street is particularly dangerous because of the hard concrete or asphalt below.
Hirano has some good advice for walking outdoors. Of course, you have to watch what’s right in front of you, he said, but also be looking ahead for any changes coming up so they don’t take you by surprise. Again, be aware, he said. “Pay attention.”
Many older people walk at shopping malls or other places with consistently level terrain. These venues may become popular for safe-walking exercise as it becomes acceptable to congregate in public places again. A pair of good quality, comfortable shoes is advised for walking in any environment.
Teaching students in gerontological social work to care for older adults, I ask them to commit this mantra to memory: Rushing is the enemy of safety and serenity. This simple thought could prevent accidents from happening and turning into an unintended medical emergency.
Caregivers and older adults alike should not rush when trying to get somewhere; this can cause a person to fall and injure himself or herself. Sometimes caregivers get impatient because it is taking too long for a parent or grandparent to get ready to go somewhere. They might give off an angry, impatient attitude meant to hurry that older person along.
“Come on, let’s go, we’re late!” the caregiver may say between clenched teeth. Not only does that attitude create anxiety and negative energy between both the caregiver and care recipient, but it also sets the older person up for a possible fall from trying to move at an unsafe pace, all to save a few minutes. It is not worth a hip fracture or brain injury, just to avoid being late. So remember: NO RUSHING! If you have a caregiver who rushes you, hand them this article. By the same token, if you’re the one being cared for, don’t rush beyond what you can manage, but do not guzu guzu (procrastinate, dawdle along), either. Both the caregiver and the care recipient have to be respectful of each other’s time.
Ask a health-care professional about how to improve balance, good posture, gait, and strength conditioning to decrease the risk of falling or serious injury from a fall. They may recommend things like yoga, tai chi, physical therapy, chair exercises and other interventions to keep your body and mind as healthy as possible.
As part of your home-safety awareness, have a plan in place if you should fall. If you’ve assessed your own body and think you are able to get up, how should you do so safely? If there is no one around to help, this may involve first crawling on all fours to a chair and using the chair to support you as you carefully regain your bearings. How will you get to the nearest phone? Should you subscribe to a medical-alert service? If you don’t have a medical-alert button, can you devise a way to keep your cell phone close at hand in the event of a fall? Can you keep a loud bell or whistle around near the ground level to let neighbors or other members of your household know you need help? (This all assumes you remain conscious after falling, which may not always be the case.)
Preventing a fall from occurring in the first place is the top priority, but having a plan in place in case a fall does occur could save valuable minutes and avert a worse emergency from occurring.
The State of Hawai‘i’s EMS & Injury Prevention System Branch, which is part of the Department of Health, shares sobering statistics on its website: “As a result of falls every year in Hawai‘i, on average 130 seniors die, 1,900 are hospitalized and 9,400 are treated in emergency departments resulting in almost $207 million dollars in hospital and physician charges.
“Falls disproportionately affect the elderly and increase dramatically in the years after age 65. Falls and fall-related injuries impose an enormous burden on individuals, society and Hawaii’s health care system.” Project Dana’s Mike Hirano wants to help improve those numbers through education and awareness, which is also the point of this article.
Being aware of fall risks inside and outside the home can help prevent falls, but being overly fearful of falling carries its own dangers. It may cause a person to avoid any kind of physical activity, which — as mentioned above — can lead to muscle loss and weakness. The key is finding the right set of behaviors to balance being active and being safe. In that sense, “Nana korobi, ya oki” makes good sense. Despite any setbacks, keep trying to find a way to be active while at the same time being safe.
Kevin Y. Kawamoto, MSW, Ph.D., is a gerontological social–work educator and longtime contributor to The Hawai‘i Herald.