WHY FALL PREVENTION HASN’T WORKED
Spoiler Alert – they haven’t incorporated dual-tasking to improve reflexive balance.
Investing in fall prevention programs is not new. Senior centers, senior living communities, local aging organizations and population health providers have invested millions in fall prevention programs over the past 10 years, all with the best intentions to prevent falls. Many programs are even “evidence-based” and therefore should have made a significant impact on falls.
Despite all these efforts, falls have only gotten worse.
In fact, the CDC reports that “the overall rate of older adult deaths from falls increased 31% from 2007 to 2016”. Cost per person for falls has gone up, not down.
Why haven’t these fall prevention programs worked?
Fall prevention programs have typically had three components: 1) fall screens to determine if the patient is at risk of falls, 2) balance improvement interventions such as classes and exercise programs and 3) environmental changes (adding grab bars, etc.) that make the home safer by removing typical fall hazards and installing devices such as grab bars and non skid carpets. Each have significant issues when looked at from the overall goal of reducing falls.
The problems with fall screens
Medicare providers offer everyone over 65 an annual wellness visit (AWV), of which a key component is a “fall screen”. A fall screen is a test, often just a few verbal questions, to see if the patient is at risk of falls. It makes logical sense to screen people because if we can identify people at risk of falls, we can intervene on those at risk. But this well-meaning effort has actually had some negative effects. First, screens are binary – either the patient is at risk of falls, or they’re not. Fall screens therefore have had to be extra conservative so that there was little chance that a person identified as not at risk shouldn’t have been and injured themselves from a fall.
The practical impact of fall screens is that patients who were identified as not at risk of falls got a “get out of jail free” card, and had no incentive to do anything about their balance. And those at risk of falls often became so fearful of falling that they didn’t want to leave their homes or participate in programs that could help them improve balance! Fear drives reduction in activity, and creates a self-fulfilling prophesy: the more one is afraid of falling, the more one falls.
Nymbl believes that fall screens should not be binary. Balance should be measured, given a numerical score, and tracked over time. Just like all of our other vital signs.
The problems with balance classes
Nearly everyone over 65 has been invited to a balance exercise class. Many Medicare Advantage programs and healthcare organizations offer them free of charge. So why haven’t these classes reduced the number of falls?
First of all, getting to a class is often difficult. The journey tends to require getting in a car or bus, traveling to a YMCA, gym or Senior Center, spending an hour in the class, and then getting home. That’s just too much work, and intimidating for those who feel unstable. So balance classes can have a negative self-selection process – those who most need it can’t or won’t go. The balance intervention is done most by those who need it the least. We are in no way advocating that everyone cancel their balance classes -they do a great amount of good, but 1 hour classes 1-2 times per week are not going to have the impact we need to truly make a dent in the number of falls.
Second, and more importantly, balance classes train “executive function” balance – balance that you’re concentrating on. The attendee is told to do an exercise and concentrate on doing it correctly. But this doesn’t train for the real world where people fall because they are distracted, and their reflexive balance is not sufficient to stop the fall.
In order for balance improvement programs to be successful, they need to train reflexive balance through dual-task exercises, and they must be done frequently – at least 3-5 times a week. The intervention can be short, ten minutes are sufficient, but must be regular to see improvement. Weekly balance classes don’t accomplish this. The only cost-effective means of delivering ten minute interventions that can be done in the home is through through technology. That’s why Nymbl exists – and in fact dual-task balance interventions using smartphones is what Nymbl has patented!
The problems with environmental interventions
Environmental interventions focus on removing typical causes of falls in the home and adding safety features such as grab bars, non-skid carpets and better lighting. The problem with environmental interventions is that they create a “cocoon” around the older adult that is safer than outside.
This has two detrimental effects. One, the person no longer has to navigate obstacles that may be deemed dangerous, so that balance reflex declines from lack of use. And second, it can have the effect of scaring people from ever leaving their cocoons. That’s not the desired effect!
The process of “sterilizing” the home can also be deeply upsetting to the older adult. Similar to taking away their car or drivers license, it’s another demeaning sign that they are old and broken and not able to take care of themselves properly.
What can be done?
The Nymbl premise is based on giving older adults effective balance interventions based on established dual-tasking science, that can be done in 10 minutes a day virtually anywhere. What this means is give them what they “will do” not what they “should do”. This requires an engagement with the older adult that is fun, rewarding and engaging. By necessity, it also needs to be delivered through some technological means, as it’s simply too expensive and impractical to have healthcare professionals and caregivers deliver these interventions.
This puts the onus on Nymbl to deliver the dual-tasking science that has proven to be effective in a very engaging way. This requires combining the user experience with fun content that older adults will want to use regularly, and that makes them feel highly satisfied every day when they complete their exercises.
Most importantly, older adults need to feel that their time investment is worth it – that their balance is noticeably improved so that they are less fearful and more motivated to participate in healthy daily routines where they enjoy the world as opposed to being sheltered from it. All of this is required for Nymbl to reach our goal of preventing 1 million falls.
For more on how Nymbl works, see our article on the science behind how dual-task training works .
Learn more about fall prevention and dual-tasking in our free webinar!