Elderly man lying on floor after fall

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On May 22nd, Sen. Angus King of Maine held up an $11 bath mat on the Senate floor and stated, “Send out 20 or 30 million of these and that $100 million cost of falls would fall significantly.” His proposal is for Medicare to cover basic bathroom safety equipment, such as grab bars and nonslip mats, arguing that the math is straightforward: prevention costs far less than hospitalizations and rehabilitation. As of today, Medicare covers the cost of a broken hip, but not the equipment that might have prevented injury.

The senator’s instinct reflects a broader and underappreciated reality I see far too often in the emergency department. Trauma in our elderly population is not simply an isolated accident – it is often the smoke signal that divides a life into “before the fall” and “after the fall.”

How Serious are Fall-Related Injuries in the Elderly?

“Hip fractures are the injury that most families worry about, and the mortality data is sobering,” says Dr. Kalpana Shankar, Assistant Professor of Emergency Medicine at Harvard Medical School and Brigham and Women’s Hospital. “Families often walk into the ED thinking they’re dealing with a broken bone,” says Shankar. “We’re sometimes dealing with the beginning of the end.” One-year mortality after hip fracture in older adults is approximately 22%, and climbs substantially when dementia or frailty is already present. But hip fractures are not the only dangerous injury in the elderly population.

Shankar tells me that falls are the leading cause of traumatic brain injury in older adults, accounting for 51% of TBI cases. Adults 75 and older carry the highest rates of TBI-related hospitalizations and death. A significant proportion of elderly patients are on medications that thin their blood – called anticoagulation – for conditions like atrial fibrillation or stroke prevention. When a patient on anticoagulation falls, they have a risk of intracranial hemorrhage, which carries a mortality rate of 15.5% among hospitalized elderly patients.

What makes TBI particularly dangerous in this population is how easily it is underestimated. Ground-level falls might seem benign, but are the most common cause of traumatic intracranial hemorrhage in older adults. I have cared for patients who arrived days after a fall with progressive confusion and vomiting and were found to have an intracranial hemorrhage. Shankar notes that these patients who fall from standing carry significantly higher long-term mortality than those with TBI from higher-impact mechanisms, yet the mechanism itself leads clinicians and families alike to underestimate the severity.

Rib fractures, spinal fractures, and wrist fractures are also common. Spinal fractures are particularly deceptive as they might not be immediately life-threatening but can produce chronic pain, lack of movement, and a gradual functional decline that families do not always connect to the original fall. Rib fractures hurt sufficiently that patients avoid deep breathing, creating conditions for pneumonia.

What Does Decline Look Like After Injury?

“For older adults, whether it is due to traumatic injury or medical illnesses, ED visits signal a change in life trajectories,” says Dr. Kei Ouchi, Associate Professor of Emergency Medicine at Harvard Medical School. The consequences of a fall extend well beyond the acute injury. Among older adults admitted to the ICU, 53.4% experience functional decline or early death. Among older ICU survivors, fewer than half achieve meaningful functional recovery within six months. Notably, even older adults who visit the emergency department but are not hospitalized experience functional decline at a rate of 17% at six months.

"The evidence consistently shows that traumatic injury in older adults triggers functional decline that is persistent and often irreversible," says Ouchi, "particularly in those with pre-existing frailty or cognitive impairment."

Shankar adds that there is also a psychological dimension that receives insufficient attention. Fear of falling that develops after an injury can be as damaging as the physical trauma itself. “Patients reduce activity to feel safer, lose muscle mass and balance in the process, and become more likely to fall than they were before,” she adds.

Ouchi describes the complexity of answering questions about prognosis or recovery after a fall. "We don’t always know if they will recover. We don’t want to scare them," says Ouchi. He shares that instead of having an honest conversation about the patient’s injury and future, physicians often "punt this responsibility to the next doctor — who equally will not do it." The result is that families enter recovery expecting a return to prior function. When they find out otherwise, Ouchi says, "suffering for the family is inevitable."

Advance care planning — the practice of documenting patient wishes before a crisis — was designed to solve exactly this problem. In theory, a completed directive would spare families from impossible decisions at the bedside. In practice, it has largely failed. Documents get lost, ignored, or completed so far in advance that they no longer reflect what a patient actually wants in the hospital. The field has since shifted toward something more practical: 'in-the-moment’ decision-making guided by real-time conversations.

Where Do the System Falls Short?

Shankar shares that fewer than half of older adults who fall report it to their physician, often out of embarrassment or fear of losing independence. “More than 60% of primary care physicians screen for fall risk but only when a patient raises the concern directly”, she adds. This reactive posture may miss most patients who need intervention. Emergency physicians, focused on the presenting injury, rarely ask why the fall happened. Older adults who come to the ED after a fall have a 30% higher chance of falling again within six months than age-matched controls, yet the standard workup does not systematically address underlying risk. As Sen. Angus King picked up, insurers will cover a hip replacement but lag on physical therapy, medication reviews, and community exercise programs that carry strong evidence for prevention. The public environment, uneven sidewalks, inadequate street lighting, limited places to rest, also contributes to fall risk at a population level that clinical interventions alone cannot address.

What Can Adult Children Do Today?

The evidence on prevention is more actionable than most families realize.

Review medications. Between 65% and 93% of patients admitted after a fall were actively taking fall-risk-increasing drugs at the time of injury. The list of medications that can lead to falls is longer than people might suspect, such as loop diuretics, antidepressants, benzodiazepines, antipsychotics, and opioids. “The problem is that most of these medications were prescribed by different specialists who have no visibility into each other’s prescribing,” says Shankar. She recommends asking the primary care physician to review the full medication list with fall risk explicitly in mind.

Prioritize exercise. "I think exercise should be written on a prescription pad," says Shankar. A meta-analysis of 24 randomized controlled trials found that Tai Chi reduces fall risk by approximately 24%, with results improving with longer and more frequent practice. It addresses balance, proprioception, and leg strength simultaneously, critical functions that deteriorate with age. Ouchi recommends constant physical strengthening, specifically weight lifting.

Address vision. Expedited cataract surgery has been identified as a cost-effective fall prevention strategy.

Modify the home. An environmental safety evaluation is key. Review the house for rugs, cords, or uneven surfaces that can cause a slip. Place a mat around smooth surfaces that are often wet, in the kitchen and bathroom, for instance. If stairs are a risk, consider safer bedroom placement. If falls happen at night during bathroom trips, consider a bedside commode.

After a fall, ask why it happened. Advocate for a medication review and physical therapy referral before discharge. Watch for signs of cognitive or functional decline in the weeks that follow, even when the acute injury appears resolved.

Have the values conversation early. Ouchi’s work focuses on helping patients articulate their goals and acceptable trade-offs before a crisis forces those decisions under pressure. He recommends using conversation guides as families answer difficult questions: What does quality of life mean to your parent? What would they be willing to endure — and what would they not? These questions are substantially easier to answer before a fall than in an emergency department. He states that the goal is to maintain the patient’s dignity and reduce suffering.