The Genius Behind Fall Prevention

Genius, noun: a person endowed with native intellectual power of an exalted type; instinctive and extraordinary capacity for imaginative creation, original thought, invention, or discovery.

Ever wonder how you can be officially recognized as one? It turns out that every year, the John D. and Catherine T. MacArthur Foundation acknowledges such exceptional people with the MacArthur Fel­lowship, nicknamed the “Genius Award.” Membership in this Fellows Program comes not only with the satisfaction of being honored as an innovative leader in your field, but also includes an unrestricted, “no strings attached” stipend of $500,000.

As expected, receiving the MacArthur Genius Award is no easy feat. Each year, the MacArthur Fellows Program invites over a hundred nominators who then choose nominees for the Fellowship. After a highly competitive selection process, twenty to thirty fellows are recognized for their work, which can be in a wide range of fields, including science, art, social science, humanism, education, and entrepreneur­ship. The work can be accomplished with or without institutional affiliations.

This year, Yale can proudly say that one of its own has joined the ranks of these MacArthur geniuses.

A Pioneer in Geriatrics

Dr. Mary E. Tinetti did not become a MacArthur genius overnight. An under­graduate at the University of Michigan at Ann Arbor, Tinetti continued to earn her M.D. from the University of Michigan Medical School in 1978. Afterwards, Tinetti was in the Kaiser Clinical Epidemiology and Geriatrics Fellowship at the University of Rochester in New York.

Tinetti joined the Yale community in 1984. Eight years later, she became the principal investigator of the Yale Pepper Center, which is funded by the National Institute on Aging. She is currently the Gladys Phillips Crofoot Professor of Medi­cine, Epidemiology, and Public Health in the Division of Geriatrics at Yale School of Medicine and is also the director of the Yale Program on Aging.

In addition to being an accomplished pro­fessor, Tinetti is also a prolific researcher-physician, having authored or coauthored over one hundred publications on health issues affecting the elderly. It comes as no surprise that the MacArthur Foundation has recognized her “exceptional creativity, promise for important future advances based on a track record of significant accomplishment, and potential for the fellowship to facilitate subsequent creative work,” the three criteria for selection of Fellows.

One of Tinetti’s most outstanding accomplishments is her research on elderly morbidity due to falls. When asked why she entered geriatrics, Tinetti replied, “I have always been intrigued with health problems of older people. The problem with older people is that they have so many problems going on at once. It is hard to find treatment that makes them better without making something else worse…[making this field] most intellectually challenging.”

Tinetti also mentioned that she enjoyed “being in a new field and being at the ground floor.”

Indeed, Tinetti’s work on fall prevention has innovatively juggled various health fac­tors, including previous and current medi­cations, vision, hearing, blood pressure, cognition, depression, muscle strength, balance, and gait.

In particular, walking upright cannot be taken for granted. This human ability requires precise coordination of many dif­ferent systems in the body. Bipedalism can be traced in the evolution of mankind, and Tinetti observed that the elderly’s declining function could be construed as devolution.

Dr. Tinetti is currently a Gladys Phillips Crofoot Professor of Medicine, Epidemiology and Public Health in the Division of Geriatrics at Yale School of Medicine. She is also the director of the Yale Program on Aging and is a 2009 MacArthur Fellow.

The Factors Increasing Fall Risk

Tinetti’s first study of fall prevention took place from the mid to late 1980s. Named Project Safety, the observational study randomly selected 1000 subjects aged 70 or older within the New Haven community.

One unique aspect of the study was that it was conducted in the homes of the sub­jects rather than at Yale. There were several reasons for this decision. First, more par­ticipants were expected to participate if the study were held in a convenient location. Second, as volunteering often comes with a selection bias, with volunteers exhibiting some distinct characteristics from the larger population, the researchers wanted a more representative spectrum of subjects. Finally, the team also wanted to observe subjects in their normal environments.

Researchers went to the subjects’ homes and spent one and a half hours asking about health problems, examining conditions of memory, vision, hearing and thinking, and studying tripping hazards in the homes. Participants were given monthly calendars to fill out every day for three years to see if they fell or not (F or N). (These falls could occur anywhere, from at home to on a sidewalk to in a grocery store.) The results were tallied and compared to the number of pre-existing health problems.

Host factors (factors within the people), environmental factors, and behavioral fac­tors (circumstantial actions) were compared between the participants who fell and those who did not and between those who suf­fered a serious injury, such as a hip fracture, and those who did not.

Eight percent of the subjects had falls if they did not have any significant health problems. The probability of falling dou­bled with two previous health problems and continued to double with increasing medi­cal issues. Increasing age was also found to correlate with increasing likelihood of falling, and women were observed to fall more often than men.

While African-Americans and Cauca­sians had a similar likelihood to fall, white women were more likely to get a fracture due to the high prevalence of osteoporosis. Older African-American men tended to suffer head injuries after falling. Men in general were more prone to injuries because of a behavioral component; they were more likely to be engaged in hazardous activities, such as climbing a ladder. It was concluded that people can compensate for many diseases and impairments, but this ability to compensate deteriorates quickly when such complications accumulate.

These results from one of Dr. Tinetti’s large-scale Connecticut studies show that the number of pre-existing health problems is directly correlated to the likelihood of falling.

Post Project Safety: Intervention for Prevention

After Project Safety, Tinetti and others continued this research into the early- to mid-1990s, changing the focus slightly to investigate the possibility of a decrease in number or severity of impairments decreas­ing the likelihood of falling. Working with a team of sixteen primary care physicians, the researchers ran a randomized controlled trial of 300 people under the care of half of the physicians and an intervention trial of 300 subjects under the care of the other half of physicians.

While the control group maintained a normal life, the group that received inter­vention had a detailed regimen to follow. They participated in a progressive bal­ance program and a muscle-strengthening program, worked with their physicians to reduce medication intake, used behavioral strategies to reduce blood pressure drops when getting up from a sitting position, and made their houses more fall-proof.

After one year of observation, the inter­vention group was found to be one third less likely to fall. This suggests that falling is not an inevitable product of aging.

The next step was to apply this evidence to the medical care of older people. In col­laboration with Dorothy I. Baker, Ph.D., R.N., C.S., Tinetti performed a study apply­ing the previous experiment to a much larger sample size. The state of Connecticut was divided into two: the greater Hartford area was the intervention group and south­ern Connecticut, including the New Haven area, was the control group.

Researchers went to primary care offices, hospitals, physical therapy centers, and related places to spread fall prevention methods and strategies for the intervention group. While ideally all of the health care providers would have used the techniques, only about half of the doctors and most of the nurses and physical therapists were willing to meet with the team and implement the practices.

After four years, the team looked at emer­gency department and hospital visits for elderly people due to falls. Such collected data showed that the incorporation of fall prevention led to ten percent fewer head injuries, hip fractures, and other injuries in the intervention area compared with the control area, thus confirming the prevent­ability of falling.

From Tinetti’s 1988 study, this data compactly shows how the amount of risk factors dramatically relates to the rate of falling. While risk factors like age and previous falls in the past cannot be changed, there are indeed risk factors that can be treated to lower the chance of falling. These include “problems with walking or movement, postural hypotension, usage of over 4 medications or any psychoactive medications, unsafe footwear or foot problems, visual problems, and environmental hazards.”

Future Directions and Heightening Awareness

Tinetti’s work has certainly been ground­breaking. The MacArthur Fellowship is further validation of her successful efforts to break down a deceptively simple phe­nomenon into manageable and applicable treatment methods. While the field of geri­atrics is a “low technology field” and has not received particular attention recently, Tinetti is “as optimistic as [she has] ever been” in the continuing advances of care and treatment for the elderly.

In light of healthcare reform debate, Tinetti commented on a significant dis­crepancy in Medicare between what the elderly need and what is actually covered. Ironically, she says, the most important ser­vices like disease prevention and long-term care (nursing homes, etc.) are not included. Older people need coordination of differ­ent treatments and the combined efforts of various different specialists in order to best treat their many ailments.

“The problem isn’t the amount of fund­ing in the healthcare. The problem is where that money goes because [what is being done] might not best benefit older people,” Tinetti says. She hopes to take advantage of her prestigious award to bring more attention to this field and the need for more efficient and appropriate delivery of care.

The unrestricted funding from the MacArthur Fellowship was initially quite overwhelming for Tinetti, for she and other researchers are used strict grants that require stringent bookkeeping and accounting. Such freedom will certainly not be taken for granted. While Tinetti has not made concrete plans for the $500,000, she has expressed the desire to “push work forward where it is hard.”

A current project that she is pursuing with others in the Yale Program on Aging studies multiple diseases simultaneously and their combined contribution to mortal­ity. To avoid the politics surrounding death, Tinetti and her team are looking at national datasets on tens of thousands of people to gather information. Tinetti also empha­sizes the need to study universal health outcomes to really see which ones need close monitoring for effective treatment.

Tinetti’s efforts to revitalize geriatrics and introduce novel, streamlined methods have been revolutionary. Her unwavering determination to further the effectiveness of healthcare is a model for both aspiring health professionals and current medical personnel.

In Tinetti’s wise words, “We as physicians have to get beyond the best treatments for individual disease. We need the best treat­ments for individuals.”

About the Author
GENNIFER TSOI is a sophomore in Morse College pursuing a double major in Molecular Biophysics and Biochemistry and Economics. She also researches at the Harris lab at the Yale Cancer Center and is involved in Demos and Nourish Interna­tional.

The author would like to thank Dr. Mary Tinetti for her generosity in explain­ing her research, her dedication to fall prevention, and her pioneering work as a geriatrist.

Further Reading

  • Fortinsky et al. Fall-Risk Assessment and Management in Clinical Practice: Views From Healthcare Providers. Journal of the American Geriatrics Society 52(9): 1552-1526, 2004.
  • Guideline for the Prevention of Falls in Older Persons: American Geriatrics Society Panel on Fall Prevention. Journal of the American Geriatrics Society 49: 664-672, 2001.
  • Tinetti, Mary E. Preventing Falls in Elderly Persons. New England Journal of Medicine 348(1): 42-49, 2003.
  • Tinetti et al. A Multifactorial Intervention to Reduce the Risk of Falling Among Elderly People Living in the Community. New England Journal of Medicine 331(13): 821-7, 1994.