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Published October 19, 2023
As we age, we become more susceptible to accidental injury. What may seem like a minor slip, trip, or fall could cause severe bruising, breaks, or even death among older adults. In fact, falls are the leading cause of accidental injury and death in adults over age 65. For the American Occupational Therapy Association, creating innovative solutions for daily living is critical in preventing falls.
Joining us to explore fall prevention is occupational therapist Dr. Scott Trudeau. Dr. Trudeau has committed his career to ensuring that older adults “thrive in place.” As the Director of Practice Engagement at the American Occupational Therapy Association, Dr. Trudeau addresses the risk factors that lead to falls and empowers patients to live each day confidently, independently, and safely.
Welcome to This Is Growing Old, the podcast all about the universal human experience of aging. My name is Katie Riley, vice president of communications at the Alliance for Aging Research and I’ll be your host today. On this episode we are going to talk about fall prevention. Falls are the leading cause of accidental injury and death in adults over age 65. But unlike medical conditions and ailments that may arise as we age, falls are preventable.
I’m pleased to introduce today’s guest, my former colleague and friend, Dr. Scott Trudeau, who is an occupational therapist with more than 40 years in the field, much of which he has specialized in fall prevention, home modification, and community mobility for older adults. He is currently the Director of Practice Engagement at the American Occupational Therapy Association. As an occupational therapist he focuses on everyday occupations, the activities that occupy our time and how to help older adults to not only feel safer, more independent and confident in their daily lives, but to thrive in place. Dr. Trudeau, Scott, thank you for joining us today.
Dr. Scott Trudeau:
Thrilled to be here. Thanks for having me.
Why don’t we jump right into the questions. We’re in the season of fall. It’s a great time to think about fall prevention in the sense of avoiding falls and tripping and falling. All of us trip and fall at times. It’s something that happens to some more than others on a daily basis. What is it about aging that causes this risk to increase?
Dr. Scott Trudeau:
The risk increases with aging, but as you mentioned in the intro, it’s really important to understand that falls in general are preventable so those risk factors really become critical to understand. So things like deteriorating strength, deteriorating balance, changes in sensory perceptions, visual or hearing can sometimes set up situations where we might be more prone to miscues in our environment and have a problem. But there are things we can do about it. So if we think about things like strength and balance, you can do exercise, you can get out and walk, you can do more activity to actually help you address that. Aging has an increase in those risk factors, but it’s not a direct causal effect. So it’s not because I am a certain age, I am more likely to fall. It’s a much more complex equation and we have to think about all the variables that are going to actually contribute to, am I personally at risk of a fall? Just because I’m 72 doesn’t mean I’m at risk for a fall if I’m fit and active and have thought about how I set up my environment so that I don’t trip over things. That’s going to go a long way to preventing those falls.
Great. And how about medical conditions that increase fall risk? We know occupational therapy practitioners look at the whole person. So they may be working with someone on a specific medical condition and be addressing fall risk during that intervention. Can you talk a little bit about that?
Dr. Scott Trudeau:
Sure. That’s the other contributor, right? As we age, we often tend to accumulate more chronic conditions. I may now have diabetes or hypertension or things that I may not have experienced when I was younger or didn’t bother to go to the doctor to notice when I was younger. And so now that I’m older I’m going to have more of these things to contend with. Well with additional diagnoses often comes additional medications. And medications and interactions with medications can be a huge contributor to falls risk. Whenever we talk about blood pressure, blood pressure is an important factor in terms of fall risk because if we get up too fast and our blood pressure drops and so do we, that’s a high risk for falls. Well that may be exacerbated or made worse by the fact that we’re on blood pressure medication and the timing of when we take that blood pressure medication, all of these factors have to be weighed in and considered when you’re looking at that.
Now, more specific to your question, when an OT is working with somebody who’s had a major acute situation … So a medical condition that has come up, which is not one of these more chronic insidious things, but something big like a stroke or a cardiac event. That process of rebuilding your strength and rebuilding your balance and being able to tolerate just sitting at the edge of the bed not even getting up, all of that is going to be challenged and all of the factors that we’ve already talked about are going to contribute to that. So I may be on all sorts of different medications that my body’s never had to deal with, so my body doesn’t even know how to adjust when I sit up so I have to be very careful that I don’t pass out or I don’t lose my balance on the edge of the bed. Those kinds of things.
So the one trap to all of these conversations for me is always one size just doesn’t fit all and how important it is to understand the constellation of factors that an individual is dealing with that would increase or decrease their personal fall risk. And so that’s why when we look at checklists online, they’re a helpful thing to start with, but they don’t often help you to individualize your own personal risk as much as you might benefit from. So there is a falls free checklist that the National Council on Aging has. And now I think the CDC is actually getting involved in working with the national council on this as well. That checklist can be a great starting point for people to identify that they may be at risk for a fall, but then what? Then what’s your next step? So you’ve got to figure out then how do you activate getting more information, getting an evaluation done by a healthcare provider that’s going to actually help you to address some of those risk factors.
It’s not an easy thing to fix, but it’s really critical to keep going back to what you said at the beginning, falls should be preventable in most situations, so we should be able to figure out … And you mentioned earlier that when people may in the course of their routine experience a fall, that too is one of those risk factors. That’s a really important risk factor. If you have fallen in the past, you’re more likely to fall again unless you address the reason why you fell in the first place. And that becomes really critical to understand.
I also use the term near miss with people when I work with them. So you may not have fallen all the way to the floor, you may not have broken a bone or had a more significant incident, but if you’ve found as you were standing up from the chair, you fell back down into the chair and you didn’t hurt yourself, but that’s a near miss. That’s a warning flag that people want to be taking note of and understanding well, if it could happen then it might happen again, but I might not be so lucky to just land in the chair. I might land on the floor. I need to take action. I need to think about what was going on? Why did that happen? How do I understand that? Again, do I need to seek help with understanding that from my healthcare team?
And that’s a great segue. You covered a lot of the whole medical reasoning for a lot of this and how that can increase your fall risk, but what about an everyday person, the biggest risk factors in the home? What are some of those big ticket items that you evaluate when you go into a home or other OT professionals that would increase the likelihood of a trip and fall incident and what measures can be taken to reduce those risks?
Dr. Scott Trudeau:
As human beings, I think we all accumulate bad habits sometimes over the years. So maybe I like to collect magazines and maybe I have piles of magazines near my chair. That may be fine if they’re positioned in a place and they’re secured in a place where they’re not going to be in your way, but that’s not always the case in the way we set up our homes. We have them so that we can reach them and I may have to walk around them to get to the chair. And those kinds of things are the simple things that we can think about. Clearing pathways. Clearing clutter. Again, a lot easier said than done. I’ve lived like this for 80 years, why would I not want to have that where I can access it the way I always have? Why should I have to move it? So it’s not easy to make some of these changes, which sounds simple, right? Just clear the environment, clear up all the clutter. But that has important implications for individuals sometimes.
The other thing that I often think about when I think globally about fall risk is lighting. And again, we all have patterns of how much light do I use, how much electricity do I use? All of those kinds of things come into play. I say to people all the time … And this was true in my clinical work a few years ago, so I bet it probably hasn’t changed a whole lot. People get very concerned when you talk about increasing lighting because they see that as increasing the cost of electricity in their home and for some people that’s a real challenge. But there’s these nifty things that technology has invented called LED lights, which allow you to get better illumination with less electricity use. And there’s a few things that I particularly like from a safety perspective about LED lighting. One is that they burn cool. I don’t know if you’ve ever gone to change a light bulb after it’s burnt out and you don’t even think because it’s not on anymore and you just touch it and it’s hot. You burn yourself. These don’t do that. They don’t get hot. So if god forbid a curtain should be sitting on it, it’s not going to light on fire. Those kinds of things. So that’s a good safety trick.
But the other piece of it is that they don’t burn out as fast so you don’t have to change light bulbs as frequently. And again, if you have overhead lighting or if you’re climbing on things to change light bulbs, you’re putting yourself potentially at a risk for a fall. And not just a routine little stumble. That could be a fall off of a stepladder or off of a stool that could be more significant and could result in bigger injuries. So the more we can minimize people climbing and having to change light bulbs, that’s a good thing as well.
So those are a couple of things. The other concepts that I like people to think about is not just tolerating your environment but actually thinking about it and setting it up. We all know there are things … I use a cast iron skillet every morning to make eggs and bacon. Just throw that out there. So why do I store the cast iron skillet in the cabinet that’s uncomfortable for me to get at in the morning and I’m bending over and I’m reaching and I’m lifting and I’m … Leave it on the counter. Leave it on the stove. It’s part of my decor. I have the skillet on the stove. The reason why I use the example of cast iron is because it’s heavy. It’s not an easy thing to move oftentimes. So there’s no need to keep putting that away.
It’s the same kind of thing with any kind of dishware or any kind of … Why are things up overhead when I could put them at face value or I could even put them on the counter to easily access them and not have to do the kinds of movements and the kind of balancing acts that we do on a routine basis just to get through the day. So those are a couple of concepts that people can think about. Clutter, lighting, and accessibility of the stuff that I frequently use.
Those are fantastic. Just such practical tips. All of us, even if we’re not really at risk for falls and we’re listening to this podcast and thinking about the older people in our life, can use those same tips about keeping things accessible and handy and just make life easier too. I know one of the tips that you’ve shared in the past had to do with stairs. Maybe coming out of a garage into the home and providing more contrast like a piece of tape. Can you talk a little bit about something like that that’s common in a lot of homes? I know in my home we have some stone steps off of our porch and the people who lived here before us had these little black mats on the stairs because there was a child who lived here with special needs and we’ve left them there because it makes sense for the older people in our lives when they come to visit that there’s more contrast so they can see it. Is that something that you encounter regularly or have in practice?
Dr. Scott Trudeau:
That actually relates back to one of the risk factors that we talked about at the beginning related to aging is that over time our visual acuity does diminish. That’s a normal part of aging. And so with our ability to see clearly, oftentimes one of the challenges with that is that our ability to perceive depth also gets compromised. And so we see that diminish sometimes with age and sometimes with people like me who actually have a need for visual prosthetics, I guess they call this. But the idea that a little bit of contrast can go a long way to helping me discern how many steps there are. It was interesting because I was at a doctor’s appointment the other day and I was leaving the doctor’s office and going down the steps. And I started down the steps and I looked and all of a sudden the steps just were all just one color. It was carpeted steps. Literally, I grabbed the handrail and I took a deep breath because it was like, okay, wait a minute. It just surprised me. Because it was like I didn’t really notice. I knew what I was doing, I knew there were steps there and I knew I was going down, but I had to stop and readjust because of that visual issue.
And so in situations like that, one of the real easy and relatively inexpensive tricks that we use is to use two inch duct tape on the edge of the stairs tread. And the reason why I say two inch duct tape is that it allows you to put one inch across the top of the tread and to fold one inch over the edge of the tread. And so whether you’re coming up the stairs or going down the stairs, you’ve got a clear demarcation across the stair tread of a contrasting color. So the ability to perceive is heightened. And it may not even be important that I can perceive that there’s a nine-inch lift versus a 12-inch lift. That might be helpful. But I might not even get that particular about it. But just knowing that there are three steps and not five is really important. Because again, when we’re walking, we’re counting internally, whether we’re counting it consciously or not. We have the motor plan to go up three steps. That’s very different. How many of us have gotten to the bottom step and have maybe lost count or lost track? You don’t realize there’s one more step and you step off and you go all the way down and you say, “Ooh, I missed a step.” That can be a huge problem, especially if you’re carrying groceries or there’s something else going on.
So that becomes really important that we address that visual contrast as much as we can. But do it in a way that is not … So again, if somebody has a stone step that’s basically gray, well then using gray duct tape isn’t a good plan. They make all different color duct tape though. So you can get white to contrast with the gray or you can get red to contrast with something. So you can use your judgment of what’s going to actually stand out and maybe even not be offensive depending on your aesthetic. And that’s actually one of the tricks to that stair trick is the idea that you don’t want to chintz out and do just a portion of the stair tread. You want to go all the way across the entire tread. And the reason for that is again, this optical illusion problem that as you’re standing at … Especially if it’s a full flight of stairs. As you’re standing at the top of the tread, if they’re not even they’re going to go like this as you look down and it’s going to make you a little sick to your stomach. And so go all the way across. You’ll see them clearly and you’ll be able to maneuver and count more easily.
Yeah. Those are fantastic tips. I think some would think, oh, I’m marking the steps, that’s enough, but our vision does things to us, especially as we age so that’s important. Let’s pivot and talk a little bit about the occupational therapy profession. This is a profession that I absolutely adore. I’ve worked in this area for a long time and you’ve worked 40 some years at this point in this profession, and I know you love it as well. What sets an OT or an OTA apart from other professions? How are OT practitioners working with older adults in terms of fall prevention and community mobility?
Dr. Scott Trudeau:
Whenever I talk about fall prevention … Again, I mentioned this earlier. The idea that there’s a checklist or there’s environmental modifications that just follow this list and pick up all your scatter rugs and blah, blah, blah. Those lists concern me because people may be living more restricted lives or less comfortable lives than they really need to because nobody’s interpreted that for that individual. And so the piece that I think is really critical is that folks work with professionals who can help you not just see what the suggestions are on the list, but which ones make sense? Which are the priorities for you given your circumstances and your situation?
So I use the example all the time, Katie, of scatter rugs. I hear it from my healthcare providers too. Oh, make sure you pick up scatter rugs and don’t … The reality is that there are places where area rugs or scatter rugs are really important. In front of a kitchen sink or at the stove or in a bathroom near a sink or outside a shower. There are places where they’re important because the risk of not having them may actually increase the fall risk as opposed to decrease it. So it’s not as easy as just saying, pick up all your scatter rugs, it’s, be strategic. Look at your environment. Figure out what you need and how you function in that space in order to figure out what are the best options for you. So there are scatter rugs that have rubber backs that might be important in front of a sink or in front of a bathtub, but in general, maybe not so important.
I had a situation. I was working with a family and I’d gone into the home in the morning, the first visit I had with them and I went through the house and we made some suggestions. And one of the suggestions I had made was there was an oriental runner down a hallway. And I said, “Oh, that’s probably not the best option to have that runner in the hallway. He’s using a walker now. Maybe we should think about getting rid of that runner.” Well, the second time I went back, she had removed the runner and the hardwood floor was exposed, but it was now later in the afternoon and the sun that was coming through the windows was reflecting like madness off of this glossy hardwood floor and it looked like a miracle was happening in their hallway. Her husband, who also had a little bit of cognitive problems, was afraid to go down the hall now because there was this reflection that was happening in the afternoon.
And we very quickly said, “Okay, we’ve got to put the carpet back. Let’s get the carpet back there because it absorbed the light and it wasn’t an issue.” And so we put the carpet back, we put it with some carpet tape to keep it secure and so forth, but that was a better option for them than just removing the scatter rug. So those kinds of situations I really worry that people, again, don’t have the … People who don’t access the trained professionals when they need them don’t have access to that level of interpretation and individualization. And that’s one of the things as you know about occupational therapy as a profession is that we are nothing if we are not client centered. Our work is never one size fits all. It’s always what’s important to you as an individual? What are your priorities? What do you need to be able to do on a daily basis to feel meaning and have a sense of purpose in your life? And how can we help you set up your space, your body, the sequencing of the tasks that you’re doing in order to allow you to do that most successfully and safely? And at its core that’s what falls prevention is about. It’s not just about decreasing fall risk, it’s about allowing people to live comfortably and productively while minimizing that risk.
Yeah. And like you mentioned in your example of understanding the cognitive challenges that this gentleman had, anyone can install a grab bar in a shower and just put it where they think it belongs but a trained professional can understand, okay, this is how they may react when they want to grab something and this is the way that they would fall if they were to slip or if they were to get dizzy and all of those different factors into that.
Dr. Scott Trudeau:
Yeah. That’s the piece that I love about being an OT is that I’m able to … What’s really important is the personal individual story that we need to help tell, but I also understand the impact of diagnoses, the impact of anatomy and physiology. And I have a bigger sense of what might be coming down the pike for individuals. So again, if somebody has a cognitive impairment or if somebody has diabetes, well these chronic conditions are not likely to get a lot better and in fact things may continue to deteriorate over time. What can we do today to help set that person up, not just to get through today but to be prepared should something else continue to deteriorate? How are they going to be able to continue to do this activity?
So I use the example all the time of getting in and out of a tub and you raised the idea of a grab bar. But in a lot of situations with older adults, I really like to introduce what’s called a tub transfer bench. So again, think about stepping over the edge of your tub. There is literally no other time in your day that you will ever experience a step that’s that high. So unless you have a sunken tub in your bathroom, you’re never going to have that big a step. So in terms of the routine of being able to surmount that hurdle, literally, you don’t practice that in your daily life. There’s no other time that You’re expected to do that. So why would we expect people to be able to do that safely and successfully once or twice a week when they want to get it in and out of the tub or take a shower?
And so having a tub transfer bench that allows people to sit down outside the tub and swing their legs into the tub as opposed to climbing into the tub is a much safer and over the long-term going to be a much more effective strategy than putting up rigs and pulleys and grab bars to allow people to climb in safely. And so to me, that’s a much better option. But again, we don’t have the opportunity to tell people that unless we know what their individual needs are in their own situation. So a lot of times we talk about environmental modifications, we talk about falls prevention as if they’re somehow their own little box of things. And what is fun about being an OT practitioner is that we do all of that all of the time. And so we’re always thinking about, what is it about the environment that’s going to allow this person to do this? What is it about their interest in particular activities? I have people who like to fill bird feeders, but they hang them up high. Well, we set up pulley systems so they can drop it down. Instead of climbing up to the bird feeder to fill it, bring the bird feeder down. So you’ve got to understand what the person is going to need to do in that space in order to really individualize that approach.
The one piece that I wanted to mention that I don’t think I mentioned is … And We’ve alluded to it. Occupational therapy as a profession is very holistic because unlike some professions in more rehab therapies that are more just physical function focused, occupational therapy is more holistic in that we think about the mind, we think about people’s cognitive status, we think about their perceptual status, we think about even their emotional status. How does it feel if you can’t do that? How does it feel when you can do that? Those kinds of things become very important in our assessment and our intervention. We want to make sure that people are … What is it they say about engines? They’re firing on all cylinders. We want to make sure that all of those things that are important to us as real whole human beings, all of those things are satisfied in the interventions that we provide, which is really a unique perspective, I think, to bring to bear, especially as we get older.
Yeah. And I think everyone agrees we want to live to our fullest potential for as long as we can and it sounds like this is a way to do that. So if Someone’s listening and they’re concerned about their own fall risk or the fall risk of a loved one, where should they start? Should they just try to find an OT? Do they start with their primary care? What’s the process?
Dr. Scott Trudeau:
One of the first things that I always like to encourage people to do is … We’ve already mentioned it, but the National Council on Aging and the CDC have important information about falls. So finding a checklist, evaluating, doing a self-check to see what your mom’s fall risk factors are, begins to give you some information about what you might want to do next. So if you’ve identified some fall risks, the CDC actually has some important information. They call it STEADI. It’s stopping older adults falling and unintentional injuries from falls. So the idea that the STEADI toolkit has some screening tools. The National Council on Aging has the falls free checklist that I mentioned. Those are great places to start to then give you some ammunition if you will, to bring to the doctor to say, “Okay, I sat down with mom or we talked about this and this is where we were thinking we’re at. We would like to know what we can do to move the needle on decreasing her risk for falls.”
I strongly encourage … And one of the things that doesn’t happen enough in my opinion for people who are getting older is that, again, we find ways to be more holistic in addressing the needs of our older adults. So instead of saying, oh, falls are dependent on strength and balance, the physician is going to think, oh, I should refer to physical therapy to get this person strength and balance tested and improved. That’s pretty shortsighted in a lot of situations. Because again, as we’ve talked about, it’s the complexity not only of moving and the physical status, but it’s all of these other factors, environmental and even emotional and cognitive and perceptual that are going to play into that real risk. And so any intervention that is shortsighted in addressing those needs is going to be less than optimum.
So referring to occupational therapy for maybe an evaluation that talks about independent living as opposed to falls. How does the individual maneuver in their environment, maneuver in their day-to-day life that supports their ability to be optimally independent? That really is a much more productive referral, I think, than thinking just about falls. And so I strongly … I guess it’s self-serving. But the idea that we need consumers, we need patients, we need folks to know that they don’t want a physical therapy evaluation for this. They really want a broader perspective, a bigger picture analysis to understand what they can do now and what they might want to think about for the future in order to continue to thrive in place. That’s often folks’ goals. I don’t want to move out of this space. I want to figure out how to continue to be happy and how healthy here. And that really requires, in my opinion, that more holistic perspective in order to support people to do that.
So I would encourage listeners to ask for occupational therapy specifically and to push back if somebody says, “Oh, no, physical therapy does falls.” We’re pretty clear that if that were the case, then we probably would have less of a falls problem than we have. And it continues to be, as you said in the intro, it continues to be a major factor for folks in spite of all kinds of interventions because it’s so complex and it’s so complicated and it really requires that more broad perspective to address it successfully.
Thank you Scott. That’s a lot of really great information. I love your take on aging in place by thriving in place. I think that’s something that we don’t say as frequently in this industry as we probably should. So that’s a great reminder that we don’t just want to age in place, we want to thrive in place and that’s a wonderful thing.
Dr. Scott Trudeau:
Right. And that’s being happy, healthy, and safe.
Well now I want to turn to our closing questions. So we’ve got all this great stuff about falls prevention. You’ve mentioned the CDC resources and the National Council on Aging. We have resources on our website as well. Agingresearch.org. We’ll plug AOTAs at the end here. But I want to turn to our closing questions that we like to ask all of our guests. There’s no wrong answer to either of these questions. They’re just fun things that we like to ask everyone. So first, Scott, when you were a kid, what did you imagine growing older would be like?
Dr. Scott Trudeau:
It’s an interesting question. The word hope comes to mind. The idea that when I’m older I’ll be able to do all of these things that I can’t do now or I’m not adequate at yet. And so the idea that somehow getting older was a very hopeful prospect and something that I actually … Very vividly, I remember well when I’m 15 and a half and I get my Learner’s permit, I’ll be able to drive. All of those developmental milestones that we think about that actually contribute to that burgeoning autonomy. My individuality comes to bear. So the notion that I was very hopeful and optimistic about what getting older was going to be about and really looked forward to … When I look back, I probably wished it away. Wished away my youth a little sooner than I could have should have. I remember I got my first work permit when I turned 14 and I’ve been working ever since. And so maybe I should have been less hopeful about what getting older was going to be. But that’s what comes to mind is this notion of hope and opportunity, but really in terms of my own personal autonomy.
Yeah. Yeah. I think we all have a semblance of that as we think about that question. What about now? What do you enjoy most about growing older now?
Dr. Scott Trudeau:
It’s funny, I just alluded to it, but it’s that perspective. It’s the perspective when I look back at realizing how naive I was or how foolish I was to have wished that away. I still do feel like there’s a lot of hope. I’m getting to the point where I’m thinking about retirement and I’m thinking about the later stages of my life but I still feel very hopeful and optimistic. So I do think that when I think about thriving, I think about how do we support people to feel that hope, to feel that optimism about themselves and their own life? And what is it that gives them the meaning that allows them to see their promise to its full potential?
Well, Scott, thank you so much for joining us today and being our guest and sharing the incredibly meaningful work that not only you, but the whole profession of occupational therapy does on a daily basis to empower older adults. It’s such a wonderful niche and we’re grateful that you do this work. If you’d like to learn more about occupational therapy, be sure to visit the American Occupational Therapy Association’s website at aota.org. Thanks, Scott.
Dr. Scott Trudeau:
Thank you, Katie.