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Melanie Cole (Host): Falls are one of the most serious health risks for older adults, and I should know, my dad is 95, and it is seriously the thing that scares me the most is his falling because I know that, that can increase mortality rate for older individuals. Welcome to The GW HealthCast. I’m Melanie Cole. My guests today are Dr. Christina Prather. She’s an internist and geriatrician with the GW Medical Faculty Associates and Helaina Roisman, she’s the Trauma Services Injury Prevention and Outreach Coordinator at the George Washington University Hospital both are affiliated with The George Washington University Hospital. Welcome to the show ladies. Dr. Prather, I’d like to start with you, as a geriatrician, when do you first start to notice balance issues in older people, if they’re coming for their well visits or do their loved ones mention it to them, if they’re attending those visits, when do these things start to present themselves?

Dr. Christina Prather (Guest): That’s a great question. Hi, thank you so much for having us on today. As a geriatrician and any primary care physician who is routinely taking care of our older adult patients, we should be taking the initiative to screen for fall risk factors, and so what you’re seeing happen in the community is that anyone who’s coming in for an annual wellness visit, or even just a regular checkup with their healthcare provider, is being asked questions like are you afraid of falling? Have you had a fall? Is a fall something that you worry about? Just to make sure that we’re at least initiating a conversation about falls. Anyone is at risk of a fall regardless of age, and those falls can be very debilitating impacting function in everyday life.

Host: As we talk about some of those health risks associated with falls, Dr. Prather, sticking with you for just a minute, do you think, as I said in my intro, that this increases the mortality rate? Do you see that older individuals that fall, break a hip, fracture a hip, that it tends to, you know pretty much slow things down and add comorbidities to what otherwise they would have had going on?

Dr. Prather: Yeah, you are right on point with that question. We as a trauma center at GW, really focus on making sure we are taking comprehensive care of our older adults who fall. So people who fall are at increased risk of having future falls, and we know that about 1 in 5 falls can cause a serious injury such as a broken bone or a head injury, and in the person who has the worst outcomes, we kind of say upwards of 1 in 3 older adults could potentially have a fatal injury from a hip fracture or a head injury, and so we are constantly looking to take falls very seriously, and change how we manage patients who have had hip fractures or head injuries or arm fractures in the inpatient setting, we know they are very high risk of potentially not bouncing back quite as much as they hoped they would, and we’re doing everything we can to try to prevent any functional limitation from allowing them to return to the quality of life that they had before the injury.

Host: Helaina, do you feel, you’re a trauma services injury prevention expert, do you feel that, that ever pervasive fear of falling in older people might make them tend to move less and exercise less and go out and be more independent because they’re afraid of that fall? Is there a way to estimate a person’s risk for falling so that they maybe have a little more confidence?

Helaina Roisman (Guest): So that’s a great point and yes I think there’s actually a lot of evidence out there that shows the fear of falling does absolutely increase your risk of falling for the reasons you listed, primarily it makes you afraid to be as mobile as maybe you would otherwise be, and one of the best ways to prevent from falling is to engage in regular exercise and to be mobile. So once you start limiting your mobility, you are in fact putting yourself at a higher risk of falling. I mean I couldn’t put numbers to it, but certainly there’s kind of a fall risk checklist, and one of the questions on those general kind of checklists is are you afraid of falling? As Dr. Prather mentions that’s one of the most important things for internal medicine and general practitioners to ask their patients on any old checkup visit, is are you afraid of falling? It’s a very important question to be asking because, like we’ve talked about, just that fear of potentially falling is absolutely a risk factor for falling.

Dr. Prather: And I’d like to add to that, we can’t say one individual person is at 5% risk of falls or a 10% risk of falls, but we can absolutely do a comprehensive screen for falls that even goes beyond asking are you afraid of falling. You mentioned you have a 95-year-old father. My mom would never consider herself old. She’s in her 60s, she’s super active with my kids, and she had a fall that resulted in an injury that really changed her quality of life going forward, and so we as a medical practice have to be looking at people and going, are you on medication? That can make you at increased risk of falling. Are we overmanaging your blood pressure and then creating an increased risk of falling? Are we promoting and talking enough about the importance of maintaining mobility and keeping good strength as a way of helping prevent falls. And so we can’t individually say you’re at such a risk of falling, but we can absolutely identify risk factors that we can intervene upon to try to decrease the risk of potentially one of these devastating falls.

Host: Dr. Prather, can you assess people’s balance? Is that something that’s done along the screening lines?

Dr. Prather: So my favorite balance test actually comes from the CDC website called Steady. So the CDC, the Centers for Disease Control is an organization that works to promote health in the United States and they have on their website a whole section dedicated for falls to sort of acknowledge this is such an important health condition, and the screen that I like to do in my clinic takes less than two minutes, and it involves having me evaluate someone’s gait, watching them walk, but also we do a number of standing postures. So we stand up from the chair and then place the feet in several different positions, and that allows me to not only assess the strength in your legs and see if you’d be a good candidate for physical therapy or other strength conditioning exercises, but it also can help us assess your side to side balance, which is how a lot of adults end up falling is in a side to side position as opposed to a front to back position.

Host: Wow, that is pretty comprehensive and that’s a great answer. Thank you so much Dr. Prather. So Helaina, what are some things people can do at home – if they’ve had their visit with Dr. Prather and they’ve been assessed and they had their screening, now what do you want them to take back with them at home to decrease their risk of falling? What do you look for in the home?

Helaina: So specifically in the home you’re looking for home hazards – for tripping hazards and other kind of fall hazards which would maybe – things that require you to reach high up and maybe get up onto a step stool. You might want to relocate those items to a height that you can reach without getting up onto a step stool. Poor lighting in certain areas, you want to address that, whether it’s the hallway or any area where you’re noticing that the lighting is poor. Throw rugs are a tripping hazard, particularly if they’re not secured down to the floor with special rug tape or other mechanism, and slippery wooden staircase. People can think about getting their staircases carpeted, rather than being a slippery wood and always having something to hold onto. So if there’s any kind of stairwell without two handrails then that’s something to look at, and then people can look to outfit their bathroom to make it more friendly, hold onto grab bars near the toilet or in the shower area. So there’s some things with regard to home safety that can help prevent falls and then I also like to talk about footwear when you’re in the home. A lot people tend to wear flip flops or other types of sandals in the home and it’s just – there’s certain footwear that definitely increases your risk of tripping or falling, flip flops included primarily I guess I would say, so some people opt to look at some lightweight tennis shoes or other kind of easy to put on but not necessarily a sandal.

Dr. Prather: And I’d add to that slippers. So slip on slippers, I cannot tell you how many injuries I have taken care of resulting from slip on slippers on hardwood stairs and people say, but I’ve never fallen on the stairs and that first fall can be a really devastating injury. So bathrooms, stairs, and slippers are kind of my go to as far as safety in the home at a really high level of things we have to think about.

Host: I agree with both of you. You know shoes are such a big deal. Helaina you’re spot on with that though. Slippers are just a huge fall hazard as are stairs, and I mean it can be terrifying if you have a loved one that you’re afraid of falling. Dr. Prather, give us a little bit of your best advice about protecting our bones as we age through exercise and diet and certainly for older individuals, should they be getting their bone density checked so they see if they’re at risk for hip fractures or those kinds of injuries that would result from a fall?

Dr. Prather: Absolutely. So in the American Geriatric Society, which is the major professional organization that focuses on care of older adults, we recommend that everyone for the most part takes vitamin D every day, and that’s a conversation that you should have with your health care provider about whether that’s right for you, and to be thinking about screening for your bone health and so most older adults do benefit from having a DEXA or a bone density test. I say there’s some people that we miss, and men are often not screened for their bone density tests as they might be if they were a woman. People who have had chronic, regular alcohol use, and I’m not talking about abuse, I’m just saying a regular glass of wine routinely in the evenings or a night cap, and if that’s been a habit for a while, those people probably benefit from a bone density test, and so we need to be more active and vigilant about seeking out everyone we can potentially scan and making sure we’re talking about bone health, and those are great conversations to have with your primary care treatment team who know any individual medical needs that you might have.

Host: That’s great information. Helaina, I’d like to give you this first last word. Give us your strategies for assisting older adults and actually even telling them and working with them so that we can reduce some of that injury that might result from falls because they don’t always want to hear it, and you made all those great suggestions but they don’t always want to hear it. Give those of us that have loved ones that are in that position your best advice for how we can start that conversation, and what it is you want us to know about reducing that risk of falls.

Helaina: Yeah so basically I like to kind of pear things down to like 3 main things. If you’re going to do any 3 things, like what would you do to prevent from falling? And I also like to kind of meeting people somewhere in the middle when it comes to certain things. Like when we talk about alcohol consumption, that’s kind of a hot topic, and no one wants to hear that they shouldn’t be drinking their 2 to 3 glasses of wine each night as they’ve been doing for the last 20 something years, or their nice glass of scotch. So I don’t like to take an all or nothing approach with those things because it doesn’t go anywhere a lot of times, so I like to kind of have a back and forth conversation about it and meet people in the middle like I said, and so – but I think it’s important to get the information, and most people are willing to listen at that point, in terms of explaining that I’ll stick with the alcohol piece for now, in terms of explaining how your body metabolizes alcohol differently as you approach a different age and how kind of that works physiologically and then how it increases your risk of falling, and then coming up with a plan that we agree upon that seems reasonable moving forward, and then in terms of just covering the main 3 things that you can focus on to prevent from falling, just focus on making sure that you regularly check in with a doctor and that includes getting your vision checked, so making an appointment with an ophthalmologist or whoever you see for that, and then regular exercise and focusing on strength conditioning, particularly lower body strength, balance exercises. So we talk about yoga, if there’s no interest there we can talk about Thai Chi, if there’s no interest there we can talk about, you know be creative with the person you’re talking to and offer things that are realistic for their life. So if they happen to live near a YMCA or a senior center or whatever it is that’s going to make sense or if they’re more of the type to want to do things at home by themselves you can offer, you know there’s lots of online exercise classes you can watch and videos, all kinds of stuff nowadays online that you can just do in the comfort of your own home and you can get creative with a regular exercise routine at home and then so the final thing that I always touch on is home safety, which we covered already, so that would be the 3 things.

Host: And Dr. Prather last word to you, what would you like the listeners to take away from this segment about falls, injury prevention in older adults, and you see this as a geriatrician every day, what do you want us to know about keeping our loved ones safe?

Dr. Prather: So I guess what I would tell you is the one thing I would recommend is to take that first fall or the near miss fall seriously. It can be an opportunity to intervene on a medication list, to get enrolled in physical or occupational therapy, to check out the home and make sure that there’s not a rug that you trip on. I trip on rugs in my home too. I mean we have to be looking for opportunities to avoid potential risk factors. I know, and my trauma team members know in the hospital, that when we have an injured older adult from a fall, we’re always looking for an opportunity that we can take to change the risk factors so that the risk of falling in the future can go down. We want to see people living to the highest and fullest quality of life possible, as active and physically engaged in their communities as they want to be. We want movement and purposeful movement that helps strengthen and prevent future falls, but we also want people to be doing things that brings them joy and makes for a good quality of life, and so hopefully as you’re talking with your medical team about your risks for falls, those can be goals that you talk about how to achieve together.

Host: Thank you ladies for being with us today. It’s really so important for people like me to hear, for all of us to hear, so that we can help our loved ones prevent those falls in the first place, and that’s really what it’s all about. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Prather or Dr. Roisman or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. I’m Melanie Cole. Thanks for tuning in.