HOLISTIC SOLUTIONS PROTECT ELDERLY FROM FALLS
647K are hurt every year
NELIA was 78 years old when she fell from a short flight of stairs in her house in rural Laguna in 2017. She could not move.
Screaming for help didn’t work as her nearest neighbor was 2 blocks away on one side, and a block down on the other. In front of her house was a noisy highway.
Her only son was out of town on assignment and was on the flight home from Italy when the fall happened. He was a good 28 hours away. Unable to crawl to reach for a phone, she lay on the cold, tiled floor for overnight, before her son found her when he arrived. She lay in a pool of her own urine.
"I suddenly felt dizzy and lost my balance," Nelia said.
She broke a femur, had concussions on her face, and dislocated her right shoulder from a fall barely five steps high. Were it not for medical intervention she would have died from insulin shock and even a low-level hypothermia, said the paramedics who arrived to the scene. She was at the verge of septic shock when she was found.
At the 13th World Conference on Injury Prevention and Safety Promotion (Safety 2018) in Bangkok, prevention strategies against falls were discussed at length in various sessions.
According to the World Health Organization (WHO) around 37.3 million falls that are severe enough to require medical attention occur each year. Of that number some 646,000 individuals die from falls around the globe, translating to over 14 percent of injury-related deaths, making it the second leading cause of accidental or unintentional injury deaths.
Eighty percent of the deadly falls occurred in low- and middle-income countries, including the Philippines, and adults older than 65 years of age suffer the greatest number of deadly falls.
A fall is defined as "an event that results in a person coming to rest inadvertently on the ground or floor or other lower level." Fall-related injuries may be fatal though most are non-fatal but injurious specially to seniors. And it usually happens to the elderly because of a loss of balance.
"A break or lapse in equilibirum of the person is the most usual cause of a fall," Dr. David Meddings, Head of the Department for Management of NCDs, Disability, Violence and Injury Prevention of the WHO said in a workshop-briefing for journalists attending the Safety 2018 conference.
He also mentioned how the risk factors for falls include muscle weakness, use of several prescription medications, lack of an assistive device, arthritis, and impairments in gait, balance, cognition, vision. Mental issues such as depression is also an important cause. Oftentimes, as in the case of Nelia, simple activities of daily living like going up the stairs or an incline can cause a fall. Age ranks high as a reason for falling with people above 70 years old occupying top rank.
Being a diabetic, the doctors did not recommend invasive surgery to repair Nelia's broken hip. A retired schoolteacher, she considered her condition being as “good as dead.” Her normal day was just walking around visiting friends and going to church or to the market. After her fall she could not walk and could not even sit for extended periods.
"My life has ended after my fall. I am damaged. I cannot do anything at all except stare at the ceiling," Nelia, who was diagnosed with having depression after her fall.
Her doctors said that if she was found within 5 to 15 minutes after the fall, first aid procedures could have been undertaken and she and her hip could have partially or naturally restored itself fully, enough for her to sit down and walk for short distances.
These technologies included a robot designed by the National Center for Geriatrics and Gerontology (NCGG) Department for Injury Prevention, Longevity and Good Health in Elders based in Tokyo, Japan.
Dr. Izumi Kondo of the NGCC presented the working concepts of a modified walking stick that also serves as a wheelchair and a Segway-like mobility assistant.
“These technologies are designed to (help) against falling for the seniors. This walking stick for example helps to bring back balance based on the hip sway which is an indicator of not being balanced,” Izumi explained in a post-plenary interview. He however said that oftentimes assistive devices may be disruptive because of its size and weight which is something that they are working on at the NGCC.
Smartphones and mobile devices can provide an instant connection to loved ones or caregivers for seniors who live on their own. The use of the simplest smartphone with a medical alert app, can be a lifesaver. Many of these are designed for individuals who need immediate medical assistance. Even though fall prevention is the best solution, many technology based remedies are available to warn caregivers that the elderly did fall. In more advanced countries, immediate response 911-like emergency personnel be immediately dispatched to the location of the affected person within a few minutes.
“There are a lot of advantages to technology, and we have to look at what that might be good in particular cases…one of the things that we need to be very careful about is not to assume that just because it is technology, that it’s good,” Professor Rebecca Ivers of the George Institute for Global Health said in an interview.
She chaired a breakout session on the comparative effectiveness of published interventions for elderly fall prevention at Safety 2018. She also pointed out that technologies need to be effective in the preventive side which is why she recommends for people to make good evaluations and judge the actual benefits versus the claims.
Ivers shared information about new developments that either warn affected elderly people of disequilibrium using specific devices, but insisted that the best solution is a preventive one.
“A holistic solution to this problem does not necessarily mean technologies. Developing commnunities wherein old people can get together to do some exercises In the session earlier there were examples of keeping the elderly mobile and moving, such as exercises like Tai Chi,” Ivers mentioned.
Stressing that a true and effective campaign should emphasize education, training for creating safer environments, Ivers added that prioritizing fall-related research and establishing effective policies to reduce risk are the base. Effective fall prevention programs espoused by the WHO aim to reduce the number of people who fall, the rate of falls and the severity of injury should a fall occur.
Possible solutions to prevent or reduce falls in the elderly must be comprehensive and multifaceted, said Dr. Meddings. The following are recommended preventive solutions that can quickly achieve this objective:
- Screening within living environments for risks of falls. Surprisingly this is not an obvious solution in most locations. Furnitures, cables, doors, handrails, staircases and even clothing and shoes can be causes of falls. For example, it is best that the elderly stay in a level, unelevated space with no steps or risers.
Inclines and ramps are preferred over stairs. Handrails are necessary in locations such as the toilet. A full home assessment and environmental modification for those with known risk factors or a history of falling.
After an investigation following her fall Nelia narrated how she tripped on the last riser of a 5-step staircase. Her loose footwear caught on the edge of the step causing her to slip. She grabbed at the baluster which wasn’t much use. She fell backwards landing on the hip. She forced herself to get up by grabbing the newel posts of the stairs in an attempt to reach the phone which was located on the mezzanine floor where her room was. The extra effort to move herself around caused her femur to fracture more. She slipped again and this time broke her shouder.
- Clinical interventions to identify risk factors. The WHO recommends a review of medication or treatments, and if needed the modification of medications for the treatment of low blood pressure, vitamin D and calcium supplementation, treatment of correctable visual impairment.
- The prescription of appropriate assistive and monitoring devices to address physical and sensory impairments. This may include canes and crutches or even walkers and push chairs. There are also several technology-based solutions for to achieve this objective.
One such solution is the Aachen Fall Prevention App which empowers older patients to self-assess their individual fall risk. The self-assessment is based a standardized questionnaire. This is followed by a ten-second test of free standing without compensatory movement. Then rating their subjective fall risk on a 10-point Likert scale, based on the results of steps one and two. The purpose of this app is to “offer a low-threshold service through which individuals can independently monitor their individual fall risk and, collect data about for fall risk assessment is used in the field.”
Another app solution is called the Senior Safety App. This is a free-to-download, pay-to-use app available over Google Play (as of presstime no iOS version yet). It is an unobtrusive app that resides quietly in the smartphone or tablet of a senior. It remotely monitors phone location and is used to protect or warn against falls (using the phone acceleranometer), prevents wandering, (via the GPS locator) online scams & abuse around the clock. Currently available in 97 countries. hundreds of thousands of users, across 97 countries, including the Philippines.
- Muscle strengthening and balance retraining prescribed by a trained health professional for applicable elderly. The purpose of this solution is to keep the elderly as active as possible during a longer period of their life.
Tai-chi exercises has been recommended time and again at Safety 2018 as a way to regain and maintain equilibrium. The slow movements of tai-chi are not physically demanding but stimulating to the cardiovascular system. Since it is a regimen that is applicable to multiple muscle groups Tai-chi is able to stimulate the body that will in turn promote activities like walking. And in the course of regular exercise cycle a lot of emphasis is given to getting into a passive meditative state that in turn relaxes the mind.
- Community-based group programs which may incorporate fall prevention education and Tai Chi-type exercises or dynamic balance and strength training.
- The use of hip protectors for those at risk of a hip fracture due to a fall. Nelia’s fractured hip not only caused her so much pain, it led to depression which escalated to such as extent that she didn’t like to eat and grew weaker and weaker.
Her son said that if only he was aware of these solutions his mother would not have been injured in such a way. She passed away just this November 12, 2018 from complications indirectly related to her falling injury that were exacerbated by pneumonia and diabetes. If she were able to move around more, she would have lived much longer, her doctors said.
This story was made possible with support from the ICFJ-WHO Safety 2018 Reporting Fellowship Program and Bloomberg Philanthropies
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Caveat, the treachery of water
Drowning is a public health issue, never an accident.
NOLI'S backyard faces one of the small tributaries of the many rivers and streams of the majestic Mt. Banahaw. The roof over his head is the thick forest cover that makes this place so quiet, idyllic and wet.
During summer the stream infront of his house trickles quietly. During the rainy season it turns into a raging river.
“My house is far enough from the river,” he said. Noli (he prefers to be anonymous) works as a plumber in the town of Dolores. To get there he walks up 1.5 kilometers to the main road where he takes a bike to work in town, 8 kilometers down.
Considered a sacred place found in the interior of south Luzon in the Philippines, “Ang Banal na Bundok,” (The Holy Mountain) is also is notorious, having a reputation for “taking lives as it pleases,” says the natives, including drowning many people.
Noli is father to three, a 13 year old boy, a 10 year old girl, and another boy, his eldest, Nikko who should be 16 now, had he not perished 10 years ago.
LOSING LITTLE NIKKO. He recalls that August day when Nikko, just 6 years old went off to the nearby open well to bathe with his mother. The July typhoon filled the open well with fresh water (it was a spring fed, not fed from run off) and was made of two 3-foot concrete culverts put one on top of the other.
Lorna, the mother, just chatted with a neighbor on their way to the well. Not more than 5 minutes later she was saw Nikko struggling inside the well.
Though built from a culvert, he top portion was not tall enough though and it had no cover. Little Nikko had enough spunk to hurdle over the barrier and fell five feet down into the cold water.
In less than a minute after that watery struggle, in what felt like, according to Noli’s wife Lydia, “an hour of helplessness,” Nikko drowned.
He was already unconscious and not breathing when extricated from the well. There was no one with first aid skills to empty his lungs of water. He never woke up from his unconsciousness. Nikko was already rigor mortis on the way to the hospital.
At the 13th World Conference on Injury Prevention and Safety Promotion held in Bangkok recently, drowning was in the spotlight not only because it kills so many people, but more so how quickly and stealthily it does it.
“Water is treacherous,” Dr. David Meddings, a medical doctor and epidemiologist who also head the Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention (NVI) at the WHO.
WATER IS A KILLER. Drowning kills 360,000 people annually. According to a 2015 report from the World Health Organization (WHO) it is the 3rd leading cause of unintentional injury death, accounting for 7 percent of all injury-related deaths worldwide.
Nilo and his family lives in a settlement at the foot of Mt. Banahaw. His family and other residents there are all illegal settlers, having no permit to reside there. Yet for 18 years they have been there. They live in a small wooden shanty. Water, fruits and root crops are plentiful. The area is however far from the main road, but also inaccessible to basic services and utilities such as electricity.
This situation is aligns perfectly to the WHO report that states that 90 percent of unintentional drowning deaths happen in the “low- and middle-income countries, and over half of the world's drowning incidents occur in…the Southeast Asian, and Western Pacific areas.”
Reading the logbooks at the barangay hall in the village of Kinabuhayan there are an average of about 10 drowning injuries reported (or discovered) in a year. Of that, least one is fatal.
The Philippine Statistics Authority (PSA) said that 6 to 7 of every 100,000 deaths in the Philippines are caused by submersion and drowning.
The national average specifies that during the period from 2006 to 2013 the highest month for drowning deaths occur in April, which coincides with the summer vacation. This is when most families are out of town in beaches and swimming pools.
In Kinabuhayan most of the deaths happened around July to August which is at the onset of the rainy season when the water in the river runs high and rapidly.
Age is another risk factor for drowning. 52 percent of the occurrences happening to 15 to 64 years old range and 41 percent in the 1–14 years age bracket. The balance covers incidents involving seniors.
Though no empirical data exists of the reasons for drowning of the 7 percent of deaths in the 65 and above range, data from the National Civil Registry and the data listed in the Department of Health (DOH) seem to point to two main reasons why the elderly drown.
First is inability to swim caused by health complications and second is by personal carelessness including the desire to be “young again.”
One example is Gregorio Carpela from San Pablo City.
SENIOR DROWING. Last May 4, 2017 he decided to visit the Holy Mountain, a trek he has done since his childhood. He has suffered a stroke years earlier. But that did not stop him from walking and trekking. He decided to go on that trip to Banahaw that fateful Thursday morning.
He was reported missing a day after.
Villagers from Dolores, at the foothills of Banahaw found his decomposing body in a river 12 kilometers downstream from where he started trekking. He was found 10 days later.
Carpela was adventurous even at 87 years old.
Banahaw is just one jeepney ride away from San Pablo City. He would frequent the springs in the mountain for its supposed healing properties. This time the Banal na Bundok failed him.
Another instance is Joe C., a retired physician from Pila, also in Laguna.
At 72 years old, he could pass off as 60. He enjoyed life, and often travelled to places just around Laguna and Cavite by bus.
He stopped driving at 60 years old, which his daughter Cecila thought was a good decision as he had become rheumatic. He loved walking to counter the disease and swears by it.
In August 2015, he went to one of the hot spring resorts in Calamba, Laguna to meet doctor-friends who came from Canada. It was his last swim. While in the low end of the pool he decides to move to chest deep waters when cramps attacked. He was alone in the pool as everyone was having a noisy dinner.
They found him submerged in the pool half floating.
His doctor friends did CPR to try to revive him. It was too late.
FILIPINOS AND DROWNING. According to a study by Maria Rosario Sylvia Z. Uy, MD of the DOH, Filipino males are three times more especially at risk of drowning than females topping the global average by one.
In a WHO study, it was indicated that males are more likely to be hospitalized than females for non-fatal drowning. Studies suggest that the higher drowning rates among males are due to increased exposure to water and riskier behavior such as swimming alone, drinking alcohol before swimming alone and boating.
There is again, an issue with recording and data gathering of deaths caused by drowning in the country. In the same study by Dr. Maria Rosario, it was determined that it is likely that the actual numbers are underestimated.
This situation though is not prevalent to the Philippines only. There is also a wide range of uncertainty around the number of global drowning deaths. Official data categorization methods for drowning exclude intentional drowning deaths (suicide or homicide) and drowning deaths caused by flood disasters and water transport incidents.
Data from high-income countries suggest these categorization methods result in significant underrepresentation of the full drowning toll by up to 50% in some high-income countries. Non-fatal drowning statistics in many countries are not readily available or are unreliable.
DISASTER DROWING. The biggest maritime disaster happened in the Philippines in 1987 when ferry-converted-to-people carrier M/V Doña Paz struck an oil tanker mid-ocean killing over 4,000 people. It remains to be biggest ocean tragedy in peacetime history.
But the Philippines has not learned.
From 2007 to 2015 there was an average of 3 maritime vessels sinking in one of the many coastlines, including inland lakes in the country.
At around this time last year eight people, including two children, died after the boat they were riding sank in Laguna de Bay, the biggest inland lake in the country.
It was an alumni get-together the passengers of the capsized banca were going to when the tragedy struck.
Thirteen former high school classmates and some of their family members perished on route to a private fish pen to celebrate the birthday of one of the passengers.
According to Noel Celestra of the Municipal Disaster Risk Reduction and Management Office (MDRRMO) of Binangonan, Rizal the boat capsized due to imbalance. Passengers were busy taking group selfies and caused the boat to shift to one causing it to lose its balance before quickly sinking in the lake.
Passengers were given no life vests and the boat itself was not certified to carry people.
There are more.
WHAT’S NEXT PHILIPPINES? Nikko, Mang Gorio, Joe and the 13 family members deaths by drowning were all preventable.
A properly covered well, consciousness of not trekking alone or at a certain age, familiarity with one's physical condition, or the issuance of proper life vests would have save these lives.
In the next article read what the WHO definitions and solutions towards drowning prevention.
This story was made possible with support from the ICFJ-WHO Safety 2018 Reporting Fellowship Program and Bloomberg Philanthropies
OVERCOMING DROWNING
The WHO HAS specific recommendations on drowning prevention
DEFINITION OF DROWING. Based on the WHO-issued Global Report on Drowning: Preventing a Leading Killer, drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid; outcomes are classified as death, morbidity and no morbidity.
The main risk factors to drowning include (text listed from the WHO official document Global Report on Drowning: Preventing a Leading Killer) as follows:
Access to water. Increased access to water is another risk factor for drowning. Individuals with occupations such as commercial fishing or fishing for subsistence, using small boats in low-income countries are more prone to drowning. Children who live near open water sources, such as ditches, ponds, irrigation channels, or pools are especially at risk.
Flood disasters. Drowning accounts for 75 percent of deaths in flood disasters. Flood disasters are becoming more frequent and this trend is expected to continue. Drowning risks increase with floods particularly in low- and middle-income countries where people live in flood prone areas and the ability to warn, evacuate, or protect communities from floods is weak or only just developing.
Travelling on water. Daily commuting and journeys made by migrants or asylum seekers often take place on overcrowded, unsafe vessels lacking safety equipment or are operated by personnel untrained in dealing with transport incidents or navigation. Personnel under the influence of alcohol or drugs are also a risk.
Other risk factors. There are other factors that are associated with an increased risk of drowning, such as:
- lower socioeconomic status, being a member of an ethnic minority, lack of higher education, and rural populations all tend to be associated, although this association can vary across countries;
- infants left unsupervised or alone with another child around water;
- alcohol use, near or in the water;
- medical conditions, such as epilepsy;
- tourists unfamiliar with local water risks and features;
Prevention. There are many actions to prevent drowning. Installing barriers (e.g. covering wells, using doorway barriers and playpens, fencing swimming pools etc.) to control access to water hazards, or removing water hazards entirely greatly reduces water hazard exposure and risk.
Community-based, supervised child care for pre-school children can reduce drowning risk and has other proven health benefits. Teaching school-age children basic swimming, water safety and safe rescue skills is another approach. But these efforts must be undertaken with an emphasis on safety, and an overall risk management that includes a safety-tested curricula, a safe training area, screening and student selection, and student-instructor ratios established for safety.
Effective policies and legislation are also important for drowning prevention. Setting and enforcing safe boating, shipping and ferry regulations is an important part of improving safety on the water and preventing drowning. Building resilience to flooding and managing flood risks through better disaster preparedness planning, land use planning, and early warning systems can prevent drowning during flood disasters.
Developing a national water safety strategy can raise awareness of safety around water, build consensus around solutions, provide strategic direction and a framework to guide multisectoral action and allow for monitoring and evaluation of efforts.
WHO response. The WHO released the Global report on drowning in November 2014. This was the first time WHO had developed a report dedicated exclusively to drowning. The report pointed out that drowning has been highly overlooked to date, and that a great deal more should be done by governments and the research and policy communities to prioritize drowning prevention and its integration with other public health agendas.
The Global report on drowning provides recommendations to governments to tailor and implement effective drowning prevention programmes to their settings, improve data about drowning, and develop national water safety plans. The report also points out the multisectoral nature of drowning and calls for greater coordination and collaboration among UN agencies, governments, key NGOs and academic institutions to prevent drowning.
In May 2017, WHO released Preventing drowning: an implementation guide.
(Read: “Preventing drowning: an implementation guide.)
This publication builds on the Global report on drowning and provides concrete guidance for drowning prevention practitioners on how to implement drowning prevention interventions.
At country level, WHO has worked with Ministries of Health in some low- and middle-income countries to prevent drowning through the use of barriers controlling access to water and the establishment of day care centres for pre-school children.
In addition, WHO has also funded research in low-income countries exploring priority questions related to drowning prevention. At a regional level, WHO organizes training programmes and convenes workshops to draw together representatives of governments, NGOs and UN agencies working on drowning prevention.
This story was made possible with support from the ICFJ-WHO Safety 2018 Reporting Fellowship Program and Bloomberg Philanthropies
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The perils of drowning are plenty. But the solutions to overcome them are suprisingly simple.