One of Cleveland’s most critical workout classes is taught by an almost 80-year-old, suited up in a button down, khakis and an Apple watch.  

The class is central in the fight to prevent older adults from falls that can result in serious traumatic injuries. Called Matter of Balance, it teaches exercises and strategies to reduce the risk and fear of taking a spill. 

Joe Ferritto co-teaches the class at Fairhill Partners, a social service agency focused on seniors. He dispenses advice (“Never, ever exercise in flip flops”) while leading the class in shoulder rolls, foot circles and knee raises.  

Ferritto himself took a serious tumble years ago. He wasn’t following his own lessons from the class, he said, carrying too many items while he was tired from work. 

“Didn’t break anything, fortunately, but they still wanted me checked out at the ER because they were afraid of internal bleeding and or possible concussion,” Ferritto said. He agreed to go after an EMT told him about a similar patient who was bleeding internally after a fall. 

The Cleveland Clinic’s recent announcement about plans to open a third Level I trauma center in the city opened up a larger conversation about the need for trauma care. The centers are typically associated with car crashes and gunshots, but falls are the primary way trauma patients are injured around the U.S. In Northeast Ohio, falls are the leading cause of trauma, and they’re rising – something experts attribute in part to an aging population and a growing recognition of the seriousness of geriatric falls. 

Clinic officials have pointed to the high volume of falls as one of several factors as they’ve made a public case for another trauma center. In Northeast Ohio, those numbers have ballooned: the number of traumatic falls recorded by the state grew 60% between 2018 and 2024. Starting in 2022 and ever since, falls surpassed traffic and transportation accidents as the top type of traumatic injury Cleveland EMS transported. 

MetroHealth, which operates its own Level I trauma department in Cleveland, disputes that a rise in falls necessitates a new center. The hospital has opposed the Clinic’s plan, arguing that smaller patient volumes at each center would lead to worse outcomes overall. Trauma teams achieve better survival rates when they see higher volumes of patients, the hospital’s CEO has said. The same argument goes for treating patients who fall, said Dr. Vanessa Ho, a trauma surgeon at MetroHealth.   

To become a trauma center, hospitals must see at least 1,200 patients with traumatic injuries annually. At a meeting in March, leaders of the Cleveland Clinic’s new trauma center said it could meet that metric. 

“Unfortunately in this area we need that for our trauma patients, especially as more and more people are falling,” said Dr. Jeffrey Claridge, a trauma surgeon who heads trauma care at the Cleveland Clinic’s main campus, at the meeting. 

And if you ask patients or their family? To several of them, trauma care means better, faster care – an easy sell. Marjorie Wickard, one of Ferritto’s students, said her mother and sister both went to the hospital after falling. Both saw trauma teams, she said, and it sped up their treatment. Paula Mueller, an Ohio advocate for those in long-term care, said her uncle died in the hospital after falling in his nursing home. She wished he saw a trauma team. 

“That’s why I’m all for Cleveland Clinic starting another trauma center, because maybe more people will get the care that they need,” said Mueller, who lives in Parma.

An aging population is more prone to falling, injuries

In class, Ferritto repeated a motto he practically lives by: “A body in motion, stays in motion.” Gray Skechers peeked out beneath his khakis. He estimates he walks between 7,500 to 14,000 steps a day. 

But he’s not immune to the effects of aging, like arthritis. 

“I’m going to be 80. I’ve got to accept certain things. They’re not going to go away,” Ferritto told the class. “But you have to deal with it the best you can.”

He’s not alone. The population in Northeast Ohio is aging, too. 

More than a decade ago, kids under 18 outnumbered adults over 65 in Northeast Ohio, according to census data of the region. That metric flipped in 2023. Though the region’s total population has stayed relatively stagnant, the number of people over 65 grew by more than 100,000 between 2010 and 2024 in the region. 

The demographic shift is happening globally, said Dr. Mira Ghneim, a trauma surgeon at R. Adams Cowley Shock Trauma Center in Baltimore who also researches geriatric trauma. It’s driving a change in who shows up in trauma centers: more than ever, it’s older adults. Falls are far-and-away the most common cause of their traumatic injuries, she said. 

Older adults have two strikes against them when it comes to falls. For one, adults are more likely to fall as they age, as their eyesight, hearing, reflexes and muscle mass worsen, Ghneim said. Plus, older adults are more likely to be taking medications that can make them dizzy. 

Then, changes to older adults’ bodies mean the repercussions of falling are often worse than for younger people. Older adults’ bones are more likely to be frailer, so they’re more likely to break or fracture. The brain shrinks as people age, which can make them more susceptible to brain bleeds if they hit their head. And if an older person is on blood thinners, that makes a fall even more dangerous, said Dr. Robert Hughes, vice chair of Emergency Medicine for University Hospitals, because it increases the risk of excessive bleeding.  

Hospitals shift to treat geriatric patients more seriously 

Trauma historically has been thought of as a “disease of young people,” Ghneim said. 

But in the last several decades, trauma surgeons, hospitals and researchers began to study how older adults with injuries got treated. One set of studies found elderly trauma patients were often “undertriaged,” meaning older patients were less likely to be taken to a trauma center or have a trauma team activated despite the need. At the same time, older adults had better chances at surviving when taken to a trauma center, research showed. 

Why? Trauma patients often bypass long emergency department wait times. They have access to specialized staff, quickly. Trauma patients are also more likely to get imaging like CT scans, rapidly, which helps identify all their injuries, said Ho at MetroHealth.

Because of this, there’s been a push to educate emergency medicine networks in Northeast Ohio about how to treat older adults with potentially traumatic injuries, Hughes said. The organization that coordinates trauma care in the region, the Northern Ohio Trauma System, has hosted multiple educational sessions emphasizing the need to treat what may seem minor as serious injuries in older adults.

“It is a very heavy education push for people to understand that it does not require a very high mechanism of injury in order to actually cause injury for a patient when they get older,” Hughes said. “It just doesn’t take much.”

At the national level, that body of research also helped emergency responders and hospitals establish special criteria to ensure certain older patients get seen by trauma centers and counted by trauma registries, Ghneim said. 

That’s shown up in different ways in Northeast Ohio. For one, in the last 15 years, the age at which emergency medical responders in the area are advised to use special consideration when deciding whether to take someone to a trauma center dropped from 70 to 65. 

Many hospitals in Northeast Ohio also began counting patients with hip fractures in 2021 as part of their reporting to the state trauma registry, a database that tracks the number and types of injuries that occur. Hip fractures are most commonly caused by falls amongst older adults from the ground level. Adding these patients into the trauma registry meant a higher count of fall-related injuries, according to a report by the Northern Ohio Trauma System. 

“With that change, there are not more hip fractures occurring, but more being captured and coded as traumatic injuries,” wrote Andrea Pacetti, a spokesperson for the Cleveland Clinic. 

When a patient is included on the trauma registry, the state requires that hospitals rigorously monitor and report how they fared. This approach helps ensure high‑quality care for seriously injured patients, Pacetti wrote. 

The shift, in part, was because the national nonprofit that accredits trauma centers began placing more emphasis on treating falls in its education efforts. 

Each hospital responds to falls amongst older adults differently

Each hospital sets standards for when to activate a trauma team when treating an older adult injured after a fall. It’s a tricky decision because it can be difficult to know right away how severe a fall for an older adult is, said Dr. Cathleen Khandelwal, the trauma medical director at Fairview Hospital, in a 2023 presentation. 

“How do you know that somebody that fell off the curb on the way home from their [blood thinner] clinic actually needs to go to Fairview Hospital, or whether that person can just walk it off?” said Khandelwal. “It creates a major problem: who do we activate as a trauma? Who gets the entire resources of a trauma system?” 

The city’s three major hospital systems differ slightly in when they treat a fall by an older adult as a trauma. 

At MetroHealth, any adult over the age of 65 who experienced a trauma, including a fall, in the last 48 hours are seen by the entire trauma team, said Ho, a trauma surgeon there. That could include an adult over 65 who was found “down” without clarity on how they got hurt, Ho said. 

“Many trauma centers decide not to pull all those resources for falls, because many of those falls end up having not as many injuries,” Ho said. “But we really want to make sure we’re not missing the ones who have severe injuries. So we come in hot and then relax.”

At Cleveland Clinic – which operates two lower-level trauma centers in Cuyahoga County – a trauma team is activated for people over 65 when they fall from higher than 10 feet, are taking blood thinners or have an obvious injury, according to Pacetti. These criteria closely reflect what’s laid out by the regional trauma system, Pacetti wrote. 

“Our teams are extra cautious when triaging geriatric patients coming in for falls and may be more aggressive in activating a trauma for this population,” Khandelwal wrote in an email to Signal Cleveland.   

University Hospitals said a trauma is activated at their lower-level trauma centers when adults over 75 fall from higher than ground level or when someone of any age hits their head and is on blood thinners, according to a spokesperson for the hospital. The hospital did not provide specific criteria for which falls activate trauma protocols at its Level I trauma center in Cleveland. 

What about fall prevention?  

While debate about the need for a new trauma center continues, medical and social service leaders say preventing falls before hospitalization is also important.

That work can happen inside and outside hospitals. University Hospitals has a program in partnership with the City of Lakewood to identify patients who might be at risk of falling. City paramedics can then go check out the person’s home for fall risks. MetroHealth leads Tai Chi and exercise classes for seniors, which help strengthen patients and improve their balance. That can help prevent falls, said Anthony Zalewski, the injury prevention and outreach coordinator at MetroHealth. 

“A lot of things that people can do to address trauma – falls, specifically – don’t have to involve opening a trauma center but are things like we are already doing,” Zalewski said. “Its education, its resources, its injury prevention.”

Level I trauma centers are required by the trauma accrediting agency to work to prevent injuries, too. The Cleveland Clinic recently started a new injury prevention program, Pacetti, the spokesperson, wrote in an email. It includes a free monthly clinic that assesses older adults’ frailty and provides at-home interventions to prevent hospitalizations. It also brought Fairhill’s Matter of Balance class on-site to the Cleveland Clinic. 

Some fall prevention work, though, is tied to major societal challenges that individual hospital systems may have a tough time addressing. For example, there’s simply a shortage of people like family service aides and nursing staff to help care for the region’s aging population, said Brenda Richardson, the director of nursing at Cuyahoga County’s division of senior and adult services. She leads a program that offers home aides to older adults for a couple hours a week. 

“We have some clients that their only issue is … that they have fallen three or four times getting in, and out of, the bathtub,” Richardson said. “So their care plan, their two to four hours a week, is a bath twice a week.”

Mueller, whose 80-year-old uncle died eight years ago after a fall in the bathroom of his nursing home, recalled waiting with him in the emergency room for 36 hours before he was admitted. He was scraped up and struggling to breathe. 

Mueller later formed a group called Elderly Advocates to push for more staffing in nursing homes, which she thinks would have helped prevent her uncle’s fall. But a trauma team also would have helped, she believes – admitted him faster, allowed him to see specialists rapidly, bandaged his wounds more quickly to protect against infection. 

The addition of another trauma center in town gives her hope that older adults who fall will be treated with the utmost seriousness.  

“The more places they can go, the better,” Mueller said of the proposed new trauma center.