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Saturday, May 5, 2007

Not a single fall: A geriatrician’s help

She was 85, with oval glasses, a lavender shirt, and a smile. Small but sturdy, Jean Gavrilles had come in walking steadily, no support required beyond her orthopedic shoes. She said her internist had recommended she come in to see Dr. Jeurgen Bludau, a geriatrician.

She mentioned lower back pain over the last few months, arthritis in her fingers, high blood pressure, glaucoma, some recent “bathroom problems” that required her to wear a pad, and a lung nodule.

A widow with a home near Boston, she had long lived alone except for her Yorkshire terrier. She did her own cooking and cleaning, and managed her own medicine and her bills. She told Dr. Bludau about her day, and her diet, in response to his questions.

Then the doctor asked her to sit on the examining table. She struggled to climb up, her balance teetering on the step. The doctor spent much of the exam time in looking at her feet.

She was doing well, he said—mentally sharp and physically strong. The danger was losing what she had. The single most serious threat she faced was not the lung nodule or the back pain; it was falling.

The three biggest risk factors for falling are poor balance, taking more than four prescription medicines, and muscle weakness. She had two, or even three, of the risk factors, putting her at grave risk of a debilitating fall. Her balance was poor; she walked with splayed feet, and her feet were swollen, with her toenails unclipped. There were sores between the toes, and the balls of her feet had thick, rounded calluses. And she did not seem to be eating enough to keep up her strength. She admitted having lost about seven pounds in the previous six months. She was on five prescription medicines, one of which risked dehydration, which may cause dizziness.

His job was to support her quality of life—here, to help her retain as much function as possible, he said. So he had Jean see a foot doctor (a podiatrist) every four weeks, for better care of her feet. He switched one medicine so it wouldn’t cause dehydration, which could make her dizzy and maybe fall. He recommended a snack, and getting rid of the low-calorie and low-cholesterol food, and having friends or family join her at meals, so she would eat more, and build her strength.

Nine months later, Jean turned 86. She’s eating better, and has gained a pound or two. She still lives comfortably and independently in her own home. And she has not fallen, even once.

Advice for elderly people and their patient advocates: Get a geriatrician!

Read a story about a frail elderly woman, or Dr. Atul Gawande’s source story in the April 30 issue of the New Yorker.

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