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Melanie Cole (Host):  Falls are one of the most serious health risks for older adults. They’re not only the leading cause of injury related deaths in this population, but they’re also a significant cause of disability. Welcome to ChristianaCare’s Swank Memory Care podcast series. I’m Melanie Cole and today, we’re talking about fall prevention in patients with dementia, advice for caregivers. Our speakers in this podcast series represent the Swank Center for Memory Care and Geriatrics, Delaware’s first and most comprehensive outpatient program dedicated to the assessment and assistance of older adults and their caregivers coping with dementia and other neurocognitive disorders. We’re joined today by Dr. Lynsey Brandt. She’s an Associate Medical Director at the Swank Center for Memory Care and Geriatric Consultation at ChristianaCare. Dr. Brandt, I’m so glad to have you with us today. Let’s talk about falls in the older population. How common is this?

Lynsey Brandt, MD, PharmD (Guest):  Well thank you for having me. Yes, as a geriatrician, the topic of falls is near and dear to my heart. Studies show that one in four persons over age 65 falls each year. And if that wasn’t enough, here’s what really gets me. Less than half of these people report falling to a medical provider. And I’ll also add, falling is even more of a problem in our patients with dementia.

Host:  Wow, that is a really interesting statistic. So, in patients with dementia, it may be a little bit different and their caregivers may be the ones to notice, but when do people first begin to notice balance problems? And is this something that can occur at the beginning of the onset? Is it something that kind of comes along with the frailty or the lack of movement? Tell us when we might notice these things and what we would notice.

Dr. Brandt:  Ah, well I think that’s the 64,000 dollar question right, if we could figure out what leads to all of this, then gosh we could do a probably much better job in preventing all of the complications. But I think the problem with falls is that it is multifactorial. So, some people might have underlying conditions which predispose them to having difficulties with balance. They might have arthritic conditions or neurologic conditions, neuropathy where they can’t sense their feet on the ground and that might predispose them to having problems with their balance. Or it could be something else totally extrinsic to the patient. It could be something like a medication they are taking or something else going on in their environment that might cause them to be more again, off balance or at risk for falling. So, as to when people first start to notice it, I almost want to say your guess is as good as mine. Because it’s so variable. There’s not really one kind of universal or blanket experience so to speak.

Host:  Well there certainly isn’t so then let’s talk about the risks for falling because if someone is aging in place, if they’re at home, maybe they have a caregiver; those things in the home, carpets, and stairs and shoes. There’s so much. This is a very comprehensive topic Dr. Brandt and then we’ve done a podcast you and I on medications that can affect memory, but medications can also contribute to dizziness and falls. Speak about some of these risks that you see and if there’s a way that we can mitigate some of those risks.

Dr. Brandt:  Okay. Thank you for asking. How much time do we have? We could go on forever. So, to follow up on what you said and to touch on the topic of home safety. So, we frequently will talk about home safety. Sometimes it’s kind of toward the end of the visit but I think it’s a really important thin gto think about even up front. So, people have things in their homes, throw rugs, clutter, low lighting, cords that they can trip over, oxygen tubing they could trip over, pets getting underfoot or just not having adequate handrails to grab onto. There’s a lot of room for improvement in that home environment and for people who are concerned about this, they could even request a home safety assessment to be done by a professional. Usually an occupational or sometimes a physical therapist or a visiting nurse who can actually come into the home and give them advice on these sort of things.

Also getting back to the topic of medications, medications absolutely are another factor that we evaluate when a person presents with a fall. Interestingly, a lot of the medications that can cause problems with memory or dementia, are the same medications that we focus on as risk factors for falling. So, some examples would be sleeping medications, anxiety or nerve pills, pain medications, blood pressure medications which could lower the blood pressure too much and result in dizziness and other medications that fall in a category of what we call anticholinergic which are medicines that have a wealth of effects on the body but they often result in patients feeling drowsy, dizzy, off balance. Some examples of those would be medications for stomach pains, such as dicyclomine or Bentyl or hyoscyamine or Levsin or medications for bladder control, oxybutynin, Ditropan, tolterodine, Detrol.

Also, I want to mention muscle relaxants. These are medicines that people often are placed on after they’ve had a fall or an injury. Sometimes, they’ll visit an emergency department and end up with a prescription for something called cyclobenzaprine or Flexeril. This is another medication that while it’s intended to help with pain, it can sometimes cause more dizziness, drowsiness, off-balance and lead to that next fall. So, I would encourage our patients who are listening and their caregivers to always scrutinize the medication list and when there’s been a fall, to really ask the provider to take the time and work through that medication list and see if there is something there that can be leading to the risk of falls.

Host:  Well I’m so glad that you mentioned earlier about some of those falls not even being reported. Because it’s really so important to help identify potentially modifiable risk factors, right, to prevent those future falls. There’s a lot of technology out there today Dr. Brandt. There’s the new apple watch with fall detection. Can those kinds of things help seniors and thereby if it’s in the technology there, then it does get reported. Somebody know about it.

Dr. Brandt:  I’m glad you brought that up. You’re right, there is so much technology and sometimes our seniors might be a little bit intimidated in the realm of technology. But I would encourage them to take advantage and look into what we could access. So, for example, we’ll often recommend that people use or obtain something called a personal alarm. This would be a button that they wear sometimes it’s a necklace or a watch or bracelet such that if they were to have a fall, and not be witnessed and no one be home with them, they could activate that button and then someone could come to help them. One interesting feature some of these devices actually are produced such that they would sense a change in position so that heaven forbid, if someone falls, and were to lose consciousness, the device would automatically be activated, and emergency services would be contacted. Which I think is really a great feature and something that I recommend people to look for.

In terms of other technologies, I think there are other things that are being developed for example even just monitoring falls and keeping track of the falls. There are apps and things like that that someone could use. Because when I, as a provider, see someone in the office, and I’ll say how many falls have you had in the last month or in the last six months. People really struggle sometimes to come up with that information so I think there’s a variety of technologies that patients can use to help us assess and manage them better.

Host:  Well that’s great information. So, let’s speak about if they do fall and that thing that increases the mortality, breaking a hip, breaking a bone, any of these things. Can you give us some really good advice about bone health in our seniors and how we can protect them through exercise and diet as we age?

Dr. Brandt:  Absolutely. So, bone health is such an integral part of what we must assess when we are assessing patients who are falling frequently or at risk of falling. All seniors, really as they age should have an assessment of bone health and especially those who are at increased risk of falling. So, this often would involve something called a DEXA scan which is a very noninvasive test where someone just lies on a table and has a scan of their usually their hips or their spine and that would tell us who is at risk for osteoporosis or thinning of the bones that can put one at risk for a fracture. Now if someone is found to be at increased fracture risk, there’s a lot of ways that they can strengthen the bones such as eating a diet rich in calcium, supplementing their vitamin D. these are kind of the building blocks of bones. As well as engaging in weight bearing exercise. It’s very, very critical part of keeping up their mobility, their strength, their balance and building that bone health.

And then finally, this is beyond the scope of our discussion today but there are some prescription medications that one could also use to help strengthen the bones if someone is found to have osteoporosis.

Host:  Well thank you for that. So, before we wrap up, I’d like you to tell us about the Safe Steps Program, a unique program to evaluate patients who fall frequently or who are at risk for falls. What does the program involve and what kinds of providers are involved?

Dr. Brandt:  Absolutely. And I’ll tell you about that program in one second. I do want to say I was going to mention one other thing because I think it’s important for our listeners here who might be especially interested in learning about falls relevant to dementia. If I could just mention that as well. We touched on this a bit earlier but our patients with dementia have certain risk factors that place them especially at increased risk for falling. They might have decrease in their safety awareness, decreased ability to safely use an assistive device such as a walker or a cane, they might also have changes in their walking or their balance that are inherent to the type of dementia that they have. So, I think it’s important just to recognize that our patients with dementia as I stated earlier are at increased risk of falling for those reasons. For instance, there’s some types of dementia Lew Body or Parkinson’s dementia that involve changes in their ability to regulate their blood pressure so these patients might stand up, have a drop in blood pressure and be at risk for passing out. And then also, patients with more advanced dementia may even have more difficulty just remembering or understanding how to walk safely. So I just wanted to touch on that because I know some people who tune in here maybe caregivers for patients with dementia and those caregivers are really being pressed to really do so much already and then when you’ve got someone falling, they have an even increased responsibility for supervising that person.

And back to the Safe Steps Program. Thanks for letting me mention. We are really proud of this program at ChristianaCare. This is a unique program where we evaluate patients who fall frequently or might just be at risk for falling. The patients are seen by both myself a geriatrician, and also by a physiatrist which is also called a rehab medicine doctor. So, they get two providers evaluating. I focus on the medical contributors for falling and then the rehab doctor looks more at other physical factors such as changes in their strength, their coordination, do they have one leg that’s longer than the other. Do they have a foot that drags on the ground. So, we really use our unique backgrounds to put together a plan to help prevent that future fall.

And then I’ll also add, we have a nurse from our Strong Bones program who assesses risk factors for bone health, educates patients and might even facilitate testing to screen for osteoporosis.

Host:  Well I just would like your best advice please for fall prevention in patients with dementia and fall prevention for seniors in general. Please wrap it up with a summary of what you’d like listeners to take away from hopefully preventing those falls in the first place.

Dr. Brandt:  So, I think the first thing is recognizing that a fall might be the very first and only symptom of an underlying medical condition. So, reporting that to a provider as we said at the outset, is so important because while some people might just think oh, it’s a normal part of aging. We providers don’t view that as such. And we want to look for those underlying causes. And so, looking towards fall prevention, really conducting a comprehensive evaluation is what we would do so some things we’ve mentioned already but just to kind of summarize that. A vision screen, if you haven’t been to your eye doctor recently. Checking the blood pressure making sure the blood pressure is stable both sitting and standing. And if the blood pressure does drop when someone stands, we might need to change their medications around to ameliorate or to help that. Scrutinizing the medicines as I said before.

Having a good physical exam to look for any other conditions like Parkinson ’s disease or something else that might have gone undetected until now. And then finally, that home safety assessment, possibly looking into physical therapy or other rehabilitative programs, referring for any sort of other devices if someone might need a brace to help with a foot drop. Looking at whether somebody needs a cane or a walker and whether they can use that safely. And then finally, I’ll also add for our caregivers, looking into caregiver support. So, for a caregiver who has to provide near constant supervision for someone who might be unsafe, that might be the time to look into maybe hiring somebody, someone who can come into the home and provide companionship and relieve that caregiver a little bit. I could probably go on, but I think those are most of the key points that I wanted to leave our listeners with today.

Host:  Thank you so much Dr. Brandt. It is really great information. So, important for this population especially. So thank you again for joining us and sharing your expertise. And that concludes this episode of ChristianaCare’s Swank Memory Care podcast series. To learn more about programs or services or to schedule an evaluation at the Swank Memory Center, Delaware’s first and most comprehensive outpatient program dedicated to the assessment and assistance of older adults and their caregivers coping with dementia, and other neurocognitive disorders you can call 302-320-2620 or you can visit www.christianacare.org/swankmemorycare for more information and to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other ChristianaCare podcasts. I’m Melanie Cole.