Illustration by Bryan Gee (source images: iStock)
Sandra Martin is author of A Good Death: Making the Most of Our Final Choices, which won the B.C. National Award for Canadian Non-Fiction in 2017 and was a finalist for both the Donner Prize in Public Policy and the J.W. Dafoe Book Prize.
“Don’t fall,” all the experts say. But I do. Three times in six years. That isn’t a huge number, but each time, I have broken something: my pelvis in 2012, an elbow in 2014 and a shoulder this past autumn.
Although I have always considered myself left-leaning politically, I fall to the right, my dominant side, a tendency that caused some soul-searching in what I now refer to as my denial phase. Despite my protests – I was walking too fast; the pavement was uneven; I tripped over a dog leash – I am now officially a faller.
Falls are a major public-health problem. The World Health Organization estimates there are 646,000 fatal falls each year – only road traffic accidents top falling as the cause of death from an unintentional injury.
Falls don’t care who you are or what you are doing, especially if you are elderly and infirm. Leonard Cohen was already in poor health, but it was a fall in his home in Los Angeles on Nov. 7, 2016, that precipitated his death at 82. The same was true of the seemingly invincible Harry Leslie Smith, the self-proclaimed “world’s oldest rebel.” Mr. Smith, who was born in England in 1923, and lived in Canada since the 1950s, had a hardscrabble existence during the Great Depression, fought the Nazis in the Second World War and published his first book, a memoir, at 87. An internet sensation, with a podcast and more than 250,000 Twitter followers, Mr. Smith was a vocal champion of the poor, the sick and the dispossessed. At the age of 95, he was still campaigning. Then he fell – hard. His tumble triggered pneumonia, which landed him in hospital in Belleville, Ont., where he died, on Nov. 28.
As we get older, our bones and muscles become thinner and more prone to break, especially after falling. In Canada, between 20 per cent and 30 per cent of people over the age of 65 fall annually, threatening their independence and general well-being and costing the health-care system an estimated $2.2-billion dollars in hospitalizations, surgeries, rehabilitation programs and other expenses, according to a 2016 report from the Alliance for a National Seniors Strategy. If current demographic trends continue, and the population of older people nearly doubles from 5.9 million (the number in the 2016 census) to more than 10 million over the next 20 years, then the costs associated with falling could increase to a $4.4-billion issue – a sobering prospect.
People most at risk of falling are those over 65. That’s me. Like somebody who has built a house on the San Andreas fault, I am bracing for the big one – a broken hip. We all know that nightmare scenario: Granny falls in her kitchen, nobody finds her for three days, she is admitted to hospital for surgery and acquires an antibiotic-resistant infection. By the time she is discharged several months later, she needs a walker and is deemed too frail to live alone. Her family institutionalizes Granny in a “safe” residence that soothes their anxiety, but robs her of independence, speeds her decline into fractious dementia and results in many more hospitalizations at a huge cost to the health system.
I don’t want to be that person. Forget drink, sweets, even the dreaded downsizing, my New Year’s resolution for 2019 is to give up falling. The problem is how.
“Down, down, down. Would the fall never come to an end!” Lewis Carroll writes in Alice’s Adventures In Wonderland. But eventually it did, jolting Alice into an alternate reality which has been captivating generations of readers for more than 100 years. Unlike Alice, most of us land with a thud. Even what seems like a humdrum slip can have huge consequences, as Torontonian Tammy Agueci learned when she fell in her apartment in January, 2016. She was 64. “It was the most inconsequential fall you could have,” she recalled recently. She had gotten up from the couch in her den to go to the kitchen.
“I can’t even remember now what I was going to get. I felt dizzy and put my hand out to steady myself against the wall, missed the wall and fell to the floor.” She had landed on her left leg, but the impact shattered her right femur. She couldn’t get up, so she slithered along the floor until she reached the telephone and called the superintendent of the building, who dialed 911. An ambulance took her to hospital where she spent five days in the emergency department, waiting for an operating room.
After recovering from surgery, Ms. Agueci, who was confined to a wheel chair, spent three months in a long-term-care facility, followed by a month in rehabilitation facility run by Sunnybrook Health Sciences Centre in Toronto.
“I was a wreck,” she said, admitting she “was in a self-pity party for a few weeks.” She couldn’t put any weight on her leg and she had to depend on somebody to help her go to the bathroom. “My balance was so bad, I had to stay with my 92-year-old mother,” she said. “I had the pratfall down pat.”
Three years later, Ms. Agueci has recovered enough mobility to return to her apartment and is attending a falls-prevention program at St. John’s Rehab at Sunnybrook. The program has three components: a home visit by an occupational therapist to assess threats such as stairs, slippery throw rugs, the lack of railings and bars in bathtubs and showers and other obstacles; a pharmaceutical review of medications; and an exercise program under the direction of a team of physiotherapists.
The day I met Ms. Agueci, she had arrived late for class because a light snowfall had delayed her publicly funded Wheel Trans. She burst into the exercise room with her cane and headed to the walking track to make up for lost time. The exercise class had taught her that her balance is “way off,” partly because the muscles on her left side had deteriorated because she was overcompensating on her right side while she waited for hip-replacement surgery several years ago, “I was doing that for a long time,” she said, noting that she isn’t yet back where she was before her accident three years ago.
“They would like to see me using a walker,” she said, “but I refuse to do it – yet. If I can strengthen my muscles and readjust my balance and maintain myself on my cane, I will settle for that.”
“Did you ever think you would be using a cane in your mid-60s?” I asked her.
“Heavens no. I thought I would be tripping around the world at this point.”
You aren’t alone, I thought glumly, observing her diminutive frame.
Women over 50, especially those who are petite like Ms. Agueci, are four times more likely to get osteoporosis than men because they have lighter, thinner bones. Still, my robust frame – I am at least a foot taller and 50 pounds heavier than Ms. Agueci – didn’t protect me back in 2012, when I tripped and fell dashing home from work on a Friday evening. I also ended up in the emergency department. I broke my pelvis rather than a hip, so I didn’t need surgery, and I smashed a bracelet rather than a wrist, so I was able to manipulate a walker. Yes, a walker – how humbling is that – which I purchased from the hospital that very night. I was able to recuperate at home rather than in hospital or a long-term-care facility because I could use my hands to feed myself, I have a two-piece bathroom on the ground floor of my house and, best of all, I have a husband and grown children willing to take care of me. Why, I wonder now, didn’t I see that fall as a warning rather than a fluke? As I slowly and painfully recover from another tumble in the streets of Toronto, I realize that arrogance and an overweening sense of invincibility are not just the purview of the young.
Years ago, my female friends and I talked about birth control, breastfeeding and nursery schools. Now, we compare notes about our consumption of yoghurt, vitamin D, sardines, low-fat cheese and kefir. These conversations bored me silly, until late this September, when I entered a new and riskier reality, three weeks before my daughter’s wedding day.
My husband and I were walking home after a glorious Tafelmusik concert, celebrating the group’s 40th anniversary with a performance of Mozart’s 40th symphony. The evening was clear, I was wearing sturdy walking shoes, but instead of strolling amiably with my husband discussing the merits of Mozart’s Bassoon Concerto in B-flat Major, I succumbed to my old foibles: Exhilarated by the music, I strode ahead at a furious pace, revising an essay in my head while composing the guest list for the postwedding brunch.
Who knows what caused me to trip? Who cares?
My heart plummeted to my wayward feet as I desperately tried to halt my forward propulsion. No use. I crashed on my right side with enough of a bang to dislodge people from their phones. “You better get that arm X-rayed tomorrow morning,” a woman observed before the light changed and she set off across the street at a purposeful stride. As I tried to figure out how to right myself, a man drove up to the curb, emerged from his car wearing regulation camouflage fatigues and silently extended a muscled arm on my left side for me to use as an impromptu railing.
Like a debutante with rival beaux at a ball, I said, “Sorry, I’m opting for the army,” to my well-meaning husband, who was trying to haul me upright. Once, on my feet, I knew he and I were doomed to spend the rest of the night in the emergency department.
I was lucky. I hadn’t rebroken my pelvis or the elbow I had chipped in 2014, when I had stupidly donned a pair of oversize Wellies to walk my son’s dog and misjudged the height of a curb. This time, I injured a new part of my body. My right shoulder was “smashed” according to the orthopedic surgeon who read my X-rays at the humming fracture clinic a couple of days later. By then, the edema had stretched into my finger tips and the bruising was so furious that I looked as though the Mafia had paid me a midnight visit, leaving a handprint on my upper right arm as a diabolical warning.
“I’m not going to tell you that you aren’t going to need extensive physiotherapy once your shoulder has healed,” the surgeon explained. At the time, I was more concerned about upstaging the bride, so I resolved to get out of my sling and into the outfit she had organized for me to wear. And that has been my life ever since: physio twice a week, daily stretching exercises with pulleys, using my fingers like a Sisyphean spider to creep up walls and flexing and clenching with small weights to jolt the strength in my atrophied triceps. And, of course, typing. Neglect the routine for a day and I slink back into pain and immobility.
The good news is that I avoided surgery for the tear in my rotator cuff, and I don’t have a frozen shoulder, a fiendish term for excruciating pain and an inability to raise, swing or stretch the affected arm, as in wiping your own bum, fastening your bra, holding a newborn or taking the turkey out of the oven.
The bad news is despair and denial. I feared mishaps such as my broken shoulder as I entered my 80s, not my 70s. Too soon, not fair, I whined behind a defiant demeanour. Even as I showed off my arm raises like a precocious kid with a boring party trick, I kept making excuses, refusing to acknowledge that ghastly term “osteoporosis,” the clinical term for brittle and weak bones. My bone-density risk, although it was creeping up, was still in the moderate range. Alas, even bones that aren’t alarmingly porous can be brittle.
“It’s not my bones, it’s the velocity with which I fall that causes my fractures,” I opined to my osteoporosis consultant. “Other people fall, and they don’t break things,” she explained patiently as she prescribed a pill that I now take once a week on an empty stomach, washed down with lots of water while I remain upright, counting down the requisite 60 minutes until I can finally have a sip of coffee. Not my idea of a good time.
I still walk the streets of Toronto, but like a former runner watching from the sidelines as marathoners pant over the finish line, I envy women with distracted expressions as they dash and weave through crowds. I recognize the look: They are organizing play dates for their children, planning submissions for project approvals, racing to a hairdresser to get their roots retouched, fretting about which retirement home to choose for their parents. I miss the pressure, but I am trying to let it go. My hurtling days are over – at least until somebody can figure out an answer to my forward-propulsion problem.
That somebody could be Geoffrey Fernie, senior scientist and director of the research institute at the Toronto Rehabilitation Institute (TRI), a part of University Health Network. He has a slew of other credentials that he mobilizes to find practical solutions to hurdles people confront in order to continue living in their own homes as they age: products such as lifting devices, bathroom railings, mobility products and non-slip winter footwear.
“Although we are the No. 1 research institute in the world for rehabilitation, on the basis of publications and citations,” Prof. Fernie says, “what we are most proud of is that everything we do has a practical result. We are driven to solve common problems, such as removing groceries and devices such as walkers from automobile trunks.” In the process, Prof. Fernie and his team – nearly 50 scientists and 125 graduate students – have taken some of their inventions from the laboratory to the market place with four startup companies and more than 22 patents to their credit.
The goal is to keep people from turning into patients as they age and to find practical solutions that will enable them to stay in their own homes without putting too much stress on family caregivers. Prof. Fernie gives me a tour of a huge simulator that recreates the terror of driving in the rain in the glare of oncoming headlights, smaller installations that focus on problems that people encounter climbing stairs, getting in and out of bathtubs without slipping, navigating streetscapes with hearing and visual impairments, and the one that draws my attention: falling.
TRI has more than 10 projects on tripping. One of the biggest is Winter Lab, a simulator with a base that tips to create a hill and a floor that can be pumped full of glycol to identify the non-slip qualities of commercial boots on various kinds of ice. On an average winter in Toronto, he says, more than 20,000 people end up in the emergency department of a hospital because “they are wearing crappy shoes.” Why would you “go out in the winter in icy conditions without shoes that have good adhesion to the ground?” he asks rhetorically. “It is like driving a car with bald tires.”
I watch a volunteer wearing a winter coat and a harness attached to the ceiling walk up and down on the icy floor as it gradually tips until she can’t remain upright. Winter Lab has allowed Prof. Fernie’s team to test the effectiveness of boots on melting versus cold, black ice and rank them on a website called RateMyTreads.com. Now in its third winter season, the website has changed the buying habits of Canadians, according to Prof. Fernie. “By Christmas of the first winter,” he says, “all the boots that they recommended – and there weren’t very many – were sold out.”
Prof. Fernie’s preoccupation with falling has a personal aspect. After a hip replacement a few years ago, he began falling – but not breaking bones, I note. He hired a trainer for two 90-minute sessions a week. “It is a lot of investment, a lot of effort and very uncomfortable,” he admits, “but I haven’t tripped in a while.” Good for him, I think, before trotting out my own falling woes. Gratifyingly, he agrees about the dangers of forward propulsion. When you are walking along, the swinging foot is moving quite fast, he explains, but if your foot catches on something on the ground, you are already moving on to that foot and you don’t have the strength to get it out from under and move it forward at the same time. “Slow down,” he advises, until he can come up with a solution.
As we get older, we tend not to lift our feet as high, so even clearing a half-inch obstacle on the pavement can be a problem. TRI is doing research using laser beams to measure how close people’s feet typically are to the ground, scanning footpaths to warn municipalities when there is a tripping hazard and conducting experiments with intelligent footwear that beep when you are in danger of tripping. The idea is to train people to make more of an effort to lift their feet and to make walking more of an occupation and a little less automatic, yet another lesson in becoming more deliberate and less spontaneous – one of the many trade-offs of getting older.
There are scarcely 300 geriatricians in Canada, an alarmingly small number considering the primary edge of the baby-boom bulge will hit 85 in fewer than 15 years. Even Samir Sinha, the architect of Senior Strategies at both the provincial (Ontario) and federal level, admits that geriatrics “was the least sexy of the options” he faced as a medical student.
His crowded office on the second floor of Mount Sinai Hospital in Toronto looks like Granny’s apartment on the eve of a massive decluttering exercise. Instead of modular office furniture, Dr. Sinha has a highly polished dining-room table and chairs, a sideboard, even a stack of china cups and saucers nestled among the offprints and committee reports. He collected it all at an antique store around the corner from his digs in Baltimore when he was doing a fellowship in geriatrics at Johns Hopkins University a decade ago. He brought it back to Toronto in 2012, when he was appointed director of geriatrics at Mount Sinai and the University Health Network in Toronto, along with the presumption that gerontology should be a priority.
Older adults account for 60 per cent of all hospital days in Canada, he tells me. “If you were Google or Microsoft and 60 per cent of your volume was by demographic,” he argues, “everything would be tailored to people 65 or older.” Instead, he says our acute-care medical culture hasn’t changed since it was set up in the 1960s, when the average age was 27, even though the typical patient is older, “medically complex and has functional issues.”
His antique furniture is a conversational hit with the over-65 set, many of whom know a Chippendale from a Hepplewhite. That lets Dr. Sinha ease into more difficult discussions about medical issues such as falling. “Ask yourself,” he said gently, but directly after I described my most recent topple, “if you fell like that when you were 20, would you have broken anything?”
To which my answer is chagrined silence.
One of the obvious, albeit counterproductive, ways to prevent falls, especially in hospitals or residential long-term facilities, is to immobilize patients by putting them to bed, tying them down physically with gentle restraints or sedating them with drugs. That makes it easier for caregivers and medical staff to control mom or dad, but it deconditions patients, reduces their mobility and increases the risk of falling.
That’s why Dr. Sinha’s philosophy is to keep patients moving. He likes to say that Mount Sinai is a hospital and not a hotel where they give you breakfast, lunch and dinner in bed. Activity is not only tolerated; it is encouraged. By shifting even very ill patients out of bed and into chairs to eat all their meals sitting upright, you are promoting strength and recovery.
One in three “community dwelling older adults,” by which he means people such as me who live in their own homes, are likely to fall every year. That number jumps to 50 per cent for people living in nursing or retirement homes because they are likely to be older, frailer, have hearing or visual problems and a greater degree of cognitive impairment. Dementia can result in a diminished spatial capacity because your brain is not talking to your body well.
One of the easiest questions in terms of predicting falls, Dr. Sinha says, is to ask: Have you had one or more falls in the past 90 days? If the answer is yes, then the chances of falling again are high, because a previous fall predicts a future fall. That’s why fall prevention is a key item on his agenda and the thinking behind his successful campaign to persuade the government of Ontario to fund a $10-million program every year to establish free fall-prevention programs around the province.
The math is elementary, he argues. If I break a hip and land in the hospital, it will cost the health-care system tens of thousands of dollars, potentially shortening my life and increasing my risk of being dead in a year. At the very least, I am likely not going back to my former independent life. The system is already spending $2.2-billion dollars a year doing that, he says. Conversely, by spending $10-million on fall-prevention classes in the community, which at last count were attended by more than 100,000 Ontarians, the province is helping people with strength and balance training and potentially “putting a dent” in the millions it spends annually on treating fall-related injuries.
And, Dr. Sinha says, there is a hidden benefit. “If you go to the fall-prevention class, you might make a friend, who you can call on to help you get your prescriptions filled, pick up your groceries or reduce social isolation.”
That part appeals to me even more than the exercise. Making new friends was something that happened naturally in the schoolyard and the workplace, but now that I work from home, I need to make a conscious effort to expand my circle. That’s one of the reasons I have signed on for a walking tour of northern Spain in late spring with a friend and a group of strangers. I’ll be near the back, slowly and deliberately lifting my feet and marking my progress with my recently acquired walking poles – a New Year’s gift to myself.