2 women fell. Only 1 got up.
A tale of 2 seniors shows how unpredictable recovery from a fall can be.
By John Leland
New York Times
Posted: Monday, Nov. 17, 2008
Slideshow

DENNIS BALOGH – McCLATCHY-TRIBUNE ILLUSTRATION

Katherine Aliminosa, 93, exercises in Medford, N.J., last month. She broke her leg in a fall in April but has regained strength and limited mobility, as well as optimism. Falls, considered an inevitable part of aging, are now being recognized as complex, often preventable events with multiple causes and consequences. JESSICA KOURKOUNIS – NEW YORK TIMES PHOTO

More Information
Preventing falls at home
Remove throw rugs or secure them with double-sided tape or non-slip backing.

Move often-used kitchen items to low shelves in cabinets.

Install grab bars in bathtub and beside toilet.

Make sure a lamp is within easy reach of your bed.

Use night-lights in areas of the house where you walk at night.

Wear shoes instead of slippers indoors.

Ask doctor or pharmacist to review your medicines (including over-the-counter ones) to see if any make you sleepy or dizzy.

For more tips: www.cdc.gov, type “Home Fall Prevention Checklist for Older Adults” into the search window.

Kathy Haight

SOURCE: Centers for Disease Control and Prevention
MEDFORD, N.J. Katherine Aliminosa, 93, shattered her lower leg while getting snacks for her nieces.

Susan Arnold, 87, broke her hip hanging a photograph.

In mid-July, in a nursing unit of a retirement community, the two women were at the start of a recovery process that both hoped would return them to their previous lives.

Their progress over the next few months, and their divergent outcomes, illustrate the unpredictable impact that common falls can have on older people.

By early autumn, Aliminosa had graduated to an independent living apartment and was able to get around with a walker. She looked more robust, content.

Though six years younger, Arnold never recovered her strength after hip surgery. Her muscles atrophied from inactivity, and she developed pneumonia. She died Sept. 6.

Each year, 1.8 million Americans over age 65 are injured in falls, according to the Centers for Disease Control and Prevention. Some totally recover. But for some, the fall sets off a downward spiral of physical and emotional problems that become too much for their bodies.

Once considered an inevitable part of aging, falls are now recognized as complex, often preventable events with multiple causes and consequences, calling for a wide range of interventions.

Feelings of vulnerability

In 2005, the last year for which statistics are available, 433,000 people over 65 were admitted to hospitals after falling, and 15,800 died as a direct result of the fall. Less visible are the many who survive the fall but not the indirect consequences.

When first interviewed in mid-July, Aliminosa and Arnold felt vulnerable, their world diminished. Both had led accomplished professional lives – Arnold as a school psychologist, Aliminosa as a medical researcher – and had been active in the community’s independent living apartments. But neither could be confident about the future.

Aliminosa said she was depressed, and able to walk only in very small stretches. She seemed defeated. “It’s made me very aware of my age, and that’s hard to accept.”

Arnold, by contrast, was full of emotional energy, so angry about her broken hip that she kicked out for emphasis as she talked. Arnold was up against the longer odds. One in five hip-fracture patients over age 65 die within a year after surgery, according to the CDC; one in four spend a year or more in a nursing home. Underlying conditions, like heart disease or respiratory problems, increase the chances of a downward health spiral.

Arnold had a history of pulmonary disease and had been a heavy smoker.

But lung problems did not keep her down. In 2006, she took a 10-day trip to Sweden. Even after she fell and fractured a hip that autumn, she lived independently. That day in mid-July, even as she talked about depression, she was jubilant about photographs of her grandchildren and great-grandchildren. If Arnold were a machine, it would be simple to draw a straight line between her lung disease, her hip surgery and her chances of recovery. Older bodies typically have several weakened systems that are dependent on one another, and rely on drugs that may or may not work well together. “If you take 70-year-olds, on average they’re taking five medications,” said Dr. Mary Tinetti, a falls expert at Yale University medical school. “When you get to 10 medications” – as a patient might after a fall – “the likelihood of adverse effects is close to 100 percent.”

The psychological factors can be just as devastating, Dr. Tinetti said. “It’s the fear of falling, the lost confidence. Good walkers stop walking, stop going to church. They become socially isolated and depressed.”

After Arnold’s first broken hip, she had reduced feeling in one foot, adding to the likelihood that she would fall again.

On July 6 this year, she fell and fractured her hip bone.

“I’m outraged,” she said a week after the fall. Her breathing was interrupted by coughing spasms. She said she was determined not to end up using an electric cart. “Disappointment,” she said, accenting each syllable. “I had a very good life.”

“But your life isn’t over,” said Deanna Gray-Miceli, an expert in geriatric falls who was looking in on Arnold.

“Well, it bloody well is,” Arnold said. “I have no strength.” The period of immobility after a fall is particularly dangerous, said Dr. Gray-Miceli. “Being immobile, you’re not taking deep breaths, you’re more prone to orthostatic pneumonia, or older people can develop urinary incontinence. And that can have a whole cascade of emotional consequences. …”

‘It was just one more nail’

Shortly after surgery Arnold grew depressed and fatalistic, said her daughter, Margery Creek.

In August, Arnold developed pneumonia. Though she responded well to the medications, Creek said: “It was just one more nail. She said she was ready to be with Dad.”

The last time Creek called her, in early September, Arnold could recognize her voice but not respond, Creek said. “I think she just said, ‘I’ve had it, I’m checking out.’ ”

Down the hall, Aliminosa’s response after her leg fracture was just as unpredictable.

On April 4, she was enjoying a visit from two favorite nieces when she found herself on the floor of her apartment, she said. She had no memory of how she fell.

She needed a metal rod in her leg and began a slow process of physical rehabilitation. Dr. Gray-Miceli said it was important for doctors and nurses to keep the patient focused on tangible signs of progress, “so she can say: ‘Today I got up by the side of the chair and took five steps. Yesterday I only took four steps.’”

With improvement, Aliminosa gained a sense of optimism and control.

She smiled; she joked. On a recent morning, she groused amiably about her fitness program, but finished. “I’m walking,” she said, “I wouldn’t say to my satisfaction, because I used to be a hiker. I can’t expect that yet, but I’m hoping for it.”

MINORITY STAFF
COMMITTEE ON GOVERNMENT REFORM
U.S. HOUSE OF REPRESENTATIVES
NOVEMBER 2005
Summary
The Nursing Home Staffing Act of 2005
BACKGROUND
Numerous studies have found that the 17,000 nursing homes in this country are severely understaffed. In March 2002, researchers at the Department of Health and Human Services (HHS) concluded that 90% of nursing homes have staffing levels that are too low to provide quality care. The researchers identified specific minimum staffing levels that would improve thecare received by nursing home residents. However, these staffing levels have not been implemented. In order to ensure that this important research is not ignored, the Nursing Home Staffing Act of 2005 would establish the minimum nurse staffing levels identified by HHS researchers.
MANDATORY NURSE STAFFING LEVELS
The bill requires that nursing homes comply with HHS-identified staffing levels for registered nurses, licensed nurses, and certified nurse aides. These staffing levels would require that all nursing home residents receive at least 4.1 hours of nursing care each day. Under the bill, these
staffing levels must be achieved within two years after the date of enactment, except that if the HHS Secretary determines that a two-year implementation period is not feasible, he can delay implementation until five years after the date of enactment.
INCREASED FUNDING
The bill increases resources to nursing homes to comply with these staffing levels. The bill reinstates the “Boren Amendment,” which, until its repeal by Congress in 1997, guaranteed “reasonable and adequate” Medicaid reimbursements for providing quality care. The bill also
helps fund the additional staffing by increasing the federal Medicaid match to states for payment of health care services by 1.5%.

FINANCIALACCOUNTABILITY
In order to ensure that the increased federal resources are being used to hire additional nursing staff, the bill authorizes state inspectors to examine the financial records of nursing homes.
ORGANIZATIONAL SUPPORT
The bill has been endorsed by the following groups: the National Coalition for Nursing Home Reform, the American Nurses Association, the Service Employees International Union, and the Alliance for Retired Americans.

High court hears Medicaid dispute
Counties sue state over how the cost is shared

By DANIEL BARRICK Monitor staff
________________________________________
November 13, 2008 - 12:00 am

In a case that both sides say could have a big impact on taxpayers, the Supreme Court heard arguments yesterday in a lawsuit brought against the state by the New Hampshire Association of Counties over the way Medicaid bills are shared.
The state’s 10 counties sued the state over a 2007 law that required county governments to cover what had previously been the state’s share of Medicaid expenses for nursing home and home-based-care patients. Previously, the state and counties split evenly the 50 percent of Medicaid costs that are not covered by the federal government.
A change in the law last year requires the individual counties to cover all of those nonfederal costs; in exchange, the state agreed to cover the counties’ share of other health programs. Proponents of the deal say it simplified what had been a burdensome and complicated administrative system.
But representatives for the counties say they’re getting the worse end of the deal, since Medicaid and nursing home expenses are expected to increase far more in coming years than other health programs. The counties also argue that the shift in responsibilities was forced on them by lawmakers looking to cut their expenses - and that will mean big increases in county taxes in the near future.
“The question is, who gets to decide whether local property taxes should be used to fund state-mandated programs?” Robert Dunn, a lawyer representing the New Hampshire Association of Counties, told the justices yesterday.
The details of the case may seem obscure and technical, but the underlying questions are important, reflecting both the challenges posed by New Hampshire’s aging population and the ongoing tension between the state and smaller municipalities over what the state’s financial responsibilities are.
Demographers say New Hampshire’s population is aging at a rapid rate that will put increasing pressure on the state’s health care costs, especially programs such as Medicaid, which provides health coverage for many elderly and disabled residents.
The case also reflects long-standing fights between state and local officials over issues such as education funding and health care. Cities, towns and school districts say state officials are increasingly “downshifting” their share of those expenses to the smaller municipalities.
Those municipalities, in turn, have no way to cover those additional costs other than increasing local property taxes.
“That’s the reason we’re nearly in a local taxpayer revolt,” said Ted Comstock, executive director of the New Hampshire School Boards Association.
The counties say the new Medicaid arrangement is a violation of the state constitution’s provision against unfunded mandates. That provision forbids the state from assigning additional costs to municipalities without the consent of that local body.
Andrew Livernois, the lawyer representing the state before the Supreme Court yesterday, told the justices that the new Medicaid arrangement was not an unfunded mandate since the counties have paid a portion of Medicaid costs for several years - the change simply increased the counties’ share.
“The increase of the dollar amount alone does not constitute a new responsibility,” Livernois said.
Sen. Kathleen Sgambati, a Tilton Democrat who helped write last year’s law that changed the Medicaid sharing arrangement, said the Legislature added a provision to cap the counties’ expenses at their current level for the first two years.
“The intent was to ensure the counties that this was not a cost shift,” Sgambati said yesterday. “The state assumes all the risk in this situation.”

If the justices rule in favor of the counties and determine the new sharing system to be unconstitutional, Sgambati said, it could add millions of dollars in expenses to the state budget over the next two years.
Earlier this year, a Merrimack County Superior Court judge ruled against the counties, saying the new Medicaid arrangement was not an unfunded mandate, because the counties had not yet seen any additional costs. Judge Carol Ann Conboy did say the counties could renew their claim in a few years if they did see Medicaid costs increase.
But Supreme Court justices appeared skeptical of the state’s case yesterday, repeatedly questioning claims that the change in Medicaid obligations was not an expansion of the counties’ financial burden.
“This is all about dollars and cents,” said Justice James Duggan. “It’s all about someone being forced to pay something.”

Extendicare Class Action Lawsuit Filed over Nursing Home Neglect in Wisconsin.

Nursing home operator Extendicare faces a third class action suit, this time filed on behalf of all residents of their nursing homes in Wisconsin. Similar Extendicare class action lawsuits have been filed in Washington and Minnesota, with all of the cases alleging that the company places profits over patient care by admitting residents that they are not properly equipped to handle.
The Wisconsin Extendicare lawsuit was filed Friday in the Circuit Court for Milwaukee County by one resident, but seeks class action status on behalf of all residents who have been treated at 26 different nursing homes operated by Extendicare in the state.
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Extendicare is one of the largest nursing home operators in the United States and Canada, with as many as 226 homes in North America and over 30,000 beds.
The lawsuit alleges that Extendicare fraudulently advertises services that they are not capable of performing and admits ill residents without hiring the necessary staff to provide even adequate care.
According to a July 2008 article in the Milwaukee Journal-Sentinel, 20 out of the 26 Extendicare nursing homes in Wisconsin have been cited for at least one serious violation in care over the past three years and the nursing home operator has paid over $2.3 million to settle violations that led to the 2003 death of one Wisconsin resident.
Similar Extendicare class action lawsuits were filed in August 2008 in Washington and last month in Minnesota.
All of the cases highlight Extendicare’s “24/7 Extendicare Admission Policy”, which green flags individuals with serious medical conditions for immediate admission without proper assessment of the facility’s ability to meet the patient’s needs or the needs of other residents who are already living in the nursing home. This places elderly and ill individuals at risk for serious injury caused by nursing home neglect.
Extendicare has indicated that they intend to defend all of the nursing home class action lawsuits, and they have called the allegations incorrect and misleading.
Reported by AboutLawsuits.com.