A steadying influence

To say that Mary E. Tinetti, M.D., never thought she would find herself in New Haven, hailed as a leading researcher for her breakthrough studies of falling in older people, would be an understatement.

The Flint, Mich., native entered medical school at the University of Michigan fully expecting to practice family medicine on her home state's remote Upper Peninsula. But when she interacted with older patients during her residency in internal medicine at the University of Minnesota, Tinetti was struck by a difference in perspective that sparked her interest in geriatrics, then a relatively new field.

“The patients were concerned with how they were feeling and how they were doing, but we as internists would be concerned with what their blood pressure looked like,” recalls Tinetti, now the Gladys Phillips Crofoot Professor of Medicine and professor of epidemiology and public health. “The dichotomy between what physicians and patients were interested in made me think there's got to be a way to bring these together. Geriatrics is the field that does that.”

Tinetti began a fellowship at the University of Rochester under renowned geriatrics researcher T. Frank Williams, M.D., but admits she was nonplussed when Williams suggested she study falls.

“I'd just come from a high-powered internal medicine program, and I was almost embarrassed about working on something like falls! It wasn't prestigious, and it wasn't some fancy disease,” Tinetti says. “But Frank is a compelling individual, and to placate him I told him I'd work on it for a year or two, thinking I'd either stop doing research altogether or find something more meaningful.”

But when Tinetti began to look closely, she found that studying falls provided just the sort of clinical richness that single measures like blood pressure could never achieve. “In the usual scientific method, you isolate a single factor, and you control for all the other differences. But as people grow older, they don't become more the same, they become more different,” Tinetti says. “People fall when a lot of things go wrong. It's a combination of their balance, plus their gait, plus their strength, plus their vision, plus confusion, plus blood pressure changes, plus things in the environment.”

Tinetti believed that these multiple factors could be measured, and that falls could be predicted and prevented. She came to Yale to test this idea under the tutelage of the late Alvan Feinstein, M.D., whose rigor in studying patients had spawned the field of clinical epidemiology. For 20 years, Tinetti's work on falls at the medical school's Program on Aging has advanced the view that the multiple medical conditions seen in older people directly compete with or mutually reinforce one another. “If you give people antihypertensives, you may decrease the risk of stroke, but the resulting dizziness can increase the risk of hip fracture, and there are many other examples,” she says.

In collaborations with nurses and occupational and physical therapists, Tinetti has pioneered treatment strategies that are tailored to individual patients rather than individual diseases. By simultaneously combining several interventions—a reduction in medication, balance exercises, and the removal of environmental hazards, for example—she has shown that falls, and the debilitation and decline that often follow, can indeed be prevented.

“Sometimes little things can make a big difference,” Tinetti says. “When you've taken a complex problem and figured out what to do about it, and you can see it make a difference right before your eyes, that's very satisfying.”