Online Health Chat with Dr. Frederick Frost
September 15, 2011
Cleveland_Clinic_Host: Many caregivers involved in the elder care of aging parents don't realize how many fall hazards can be found in the common household until their elderly parent takes a bad fall, breaks a bone, and is hospitalized for months. If you care for elderly parents in the home, fall prevention must also be taken into consideration in order to provide a safe and secure living environment for your loved ones. Nearly 1/3 of seniors living in their own home or the home of adult children caregivers suffer from a serious fall at least once every year, many of whom never completely recover from the injury.
So many caregivers ask: is there anything I can do to prevent this from happening to my loved one? Yes. Falls prevention tips and therapy can help to reduce the risks to seniors.
Dr. Frederick Frost is board-certified in physiatry (physical medicine and rehabilitation) and spinal cord injury medicine, and specializes in falls prevention, as well as spinal cord and stroke rehabilitation. He is also the interim chair of the Department of Physical Medicine and Rehabilitation at Cleveland Clinic. Dr. Frost received his undergraduate degree from the University of Illinois, Urbana, IL, and his medical degree from Northwestern University Feinberg School of Medicine, Chicago, IL. He completed his residency training and fellowship training at the Rehabilitation Institute of Chicago, Chicago, IL, and completed an additional fellowship at the Midwest Regional Spinal Cord Injury System/Northwestern Memorial Hospital, Chicago, IL.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Frederick Frost. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.
Elizabeth: Where do falls among older adults occur most frequently?
Dr_Frederick_Frost: Bathroom is first. Wet surfaces are also hazardous. Sleepy, older patients walking in the middle of the night are also at risk. Stairs are the most dangerous area of the house. The Centers for Disease Control and Prevention (CDC) guidelines/handout has some nice tips to make the home safer: use of nightlights, removal of extension cords and throw rugs, etc.
Marjorie: What are the major risk factors for falls among older adults?
Dr_Frederick_Frost: There are more than 20 discreet risk factors that we screen for in our Falls Clinic. Some are obvious, some are not. Just to mention a few: age over 80, difficulty with bladder control, impaired vision and hearing, taking more than 10 medicines.
Maak: My mother (86) recently purchased a cane (because she thought it was cute!). She feels that it helps when standing up from a sitting position. She has sprained her ankle twice because her foot fell asleep while sitting. Is the cane sufficient or should we look into other things?
Dr_Frederick_Frost: It would be best to have a physical therapist evaluation. Sometimes, a cane can confuse a patient and can be an impediment. A therapist who specializes in older patients is a key member of the team. A rolling walker (like a rollator) can sometimes be a godsend. It allows the patient to exercise -- using it like a treadmill to keep the legs strong. Then the patient can put it aside if the situation dictates.
Petrica: How do you determine the need for a formal evaluation when tripping a lot, sometimes falling? Not sure if it is a balance issue or clumsiness.
Dr_Frederick_Frost: Right! Some people are just clumsy! It depends on the risk of injuring yourself. There are a lot of factors to consider -- age, bone density, etc. Normally, we screen like this: if you are over the age of 70, have fallen twice in the last year, or have fallen once with an injury requiring medical care, we would look into it.
Hoda: When walking the dog, I tripped on the sidewalk, hit my head, got cut above my eye, etc. But a couple of weeks later I fell while waiting for an elevator. Should I be evaluated and what would it involve?
Dr_Frederick_Frost: Start with your primary care doctor. He or she can screen for a number of correctable problems -- such as poor eyesight, improper footwear, patterns of weak muscles -- and can design a strategy to address these areas.
AGS: Any advice to give someone on how to get out of a car? My father-in-law fell when getting out of his car. He is not even certain how he fell. He was in the hospital after this for three weeks!
Dr_Frederick_Frost: Because this is so common, we have driver’s evaluation therapists in three locations across Cleveland. These are occupational therapists who are specially trained to assess and remedy physical problems that affect the ability of the patient to use an automobile. Car seats can be low and soft -- difficult to negotiate. Most of the time, if the patient cannot rise from a low seat, it reflects weakness in the muscles near the hip and buttocks. These can be targeted with specific exercises, but I wouldn't start them without a physical therapist. The therapist designs a custom exercise program that accommodates the patient's medical and orthopedic restrictions.
Grannyscott: What kind of exercise helps improve balance to prevent falls? Is Tai Chi helpful? I have two artificial knees, so if I fall, I have a very hard time getting up unless there is some heavy furniture there. Is aquatic exercise helpful (water walking and jogging, exercise with weights)?
Dr_Frederick_Frost: Tai Chi has been shown in multiple research studies to be very effective in preventing falls and injuries. It is a struggle to stay strong enough to rise from the floor if you fall, especially if you are older with knee replacements.
I recommend water exercise only if the patient cannot exercise on land (e.g., due to pain). Water exercises don't help keep your bones strong; you need gravity for that.
SueB: I have deteriorating disc disease and have had five back surgeries. I fall at least three times per year because I have permanent numbness in my legs and a poor sense of balance. I occasionally stagger when I walk. Is there anything specific to these conditions you would recommend to prevent falls?
Dr_Frederick_Frost: Sounds like you have had more than your share of troubles. Most people with falls have multiple problems -- neurological and skeletal. Whatever your combination of problems, it is best to make sure that the muscles that are working are strong. I'm sure that you have some home exercises from your physical therapy. We focus on strength and weight control.
Paisley: Do certain health conditions lead to falls?
Dr_Frederick_Frost: Definitely! Many health conditions and the medications that are dispensed for them are major causes of falls. Most commonly, patients with falls have subtle neurological conditions combined with an aging skeleton. There are many diseases, such as diabetes, whose side effects damage the nervous system and lead to an increase in falls and injuries.
Talking to Your Loved One
toomuch: My mother has trouble walking. She does not do much walking except where she can have something close at hand to hold on to or lean against. She'll walk with her hand along a wall, pushing a shopping cart, etc. She refuses to get a walker or cane. We worry about her. How can we convince her to get some sort of walking aid?
Dr_Frederick_Frost: We run into this situation at least two or three times a week in clinic. Sometimes, it is best to bring the parent in so he or she can hear the message from a non-family member. I usually "soft-sell" a rollator walker in this situation. I emphasize that this is an exercise device that allows them to walk quickly and increase their distances, otherwise the legs get weaker and weaker. Offer the older patient the option of using the rollator walker in private, not out in public. Also, emphasize that the patient DOESN'T become "DEPENDENT" on the walker. It is no different than going to the grocery store and using the cart. This strengthens the legs!
horatio: What are the long-term consequences (effects) of falls among older adults?
Dr_Frederick_Frost: The most serious is fractures. A hip fracture in a person over the age of 80 has profound implications. Almost half of people over 80 years who fracture a hip cannot return home from the hospital to their previous living arrangements. Other effects center mainly around the injuries, brain injuries, bleeding, etc.
BDW: Is there a formal falls prevention program at Cleveland Clinic? If so, would you provide some information about the program?
Dr_Frederick_Frost: Yes. We have had a Falls Evaluation Clinic at the Westlake Family Health Center since 2006. To access, call 440.899.5555 and ask for Physical Medicine and Rehab. We are extending our programming to an east side location in Beachwood by the end of the year. Another option is the Geriatrics Clinic (X building), where we have a falls specialist physical therapist who works alongside the geriatricians.
jasajass: Guidelines for preventing falls?
Dr_Frederick_Frost: Yes! The Centers for Disease Control and Prevention (CDC) offers a wonderful handout for patients (www.cdc.gov/).
For medical personnel, my favorite is the Otago Protocol, from Otago Medical School in New Zealand. This is a carefully researched and wonderfully organized program for medical professionals that has gained great popularity across the world (Otago Falls Prevention Programme). The website for the Otago Falls Prevention Programme is www.acc.co.nz/
jujub: My mother is very unsteady on the stairs. She takes them one at a time and we have installed sturdy railings. We are still worried that she might take a tumble, especially down the basement stairs. What else can we do to help prevent this?
Dr_Frederick_Frost: This is a big problem. Although the most common area of injury in the home is the bathroom, the stairs pose the greatest risk of severe injury. It is very hard to convince an older patient to move his or her bedroom downstairs, but the effect that this has on reducing injury risk is huge! Every house is different, but there is no way to eliminate the risk of stairs in the elderly without eliminating the stair use itself. Power stair lifts are very expensive, and usually not welcomed by our older patients.
smbart_1: Besides removing throw rugs, what other precautions need to be taken in and around the home to prevent falls?
Dr_Frederick_Frost: There is a comprehensive list on the CDC handout. Fixing leaky faucets, proper lighting, grab bars, and removing clutter are among the dozens of simple things that can be done to reduce risk.
smbart_1: If you have non-diabetic neuropathy, what steps can you take to help prevent falls?
Dr_Frederick_Frost: That depends on how the neuropathy affects you. If the problem is below the knee, there are new designs of lightweight leg braces that offer support for weak muscles, and sensory feedback if your feet have impaired sensation. Other than that, strategies focus on strengthening of the muscles that are not affected (i.e., teaching compensatory strategies). We don't have a cure for neuropathy, so we need to teach people to work around it.
stien76: When looking at a new home for an elder parent, what should a person look at to minimize falls?
Dr_Frederick_Frost: No steps. Lots of light. Paved driveway. Easy to maintain (i.e., free from ice and snow). When moving from the old house, do your best to reduce clutter of years of accumulated belongings.
stien76: Bathrooms seem to be an area that my parents seem to have problems with falling. Do you have any suggestions to make that area of the house safer?
Dr_Frederick_Frost: Yes! Of course you deal with water on the floor, throw rugs, and nightlights -- these issues. We also make sure that our older patients are receiving the best treatments for the bladder function. If you can cut down on the number of trips to the bathroom (especially at night), you can markedly reduce the risk for injuries. Older men can take medicines for enlarged prostate problems, and both men and women can benefit from bladder relaxing medicines. This is one of my favorite treatments, because the patient sleeps better and feels better, and this affects many of their health problems for the better.
jujub: In regard to the stairs again, does it help to put carpeting with extra padding on the stairs and at the bottom of the stairs to help prevent injury if she does fall? Or would this make the stairs less stable under her feet?
Dr_Frederick_Frost: Padding reduces feedback; this is bad! As a matter of fact, our therapists use soft surfaces to challenge our patients in therapy. Of course, it is wise to remove furniture with sharp/hard edges from the area and clear clutter from around the stairwell. There is some nice research on giving older patients padded hip protectors (like football players wear!). These prevent injury nicely, but not many patients will agree to wear them, and they are tough to put on and take off.
vivica: What is a falls specialist? Someone other than my primary care physician?
Dr_Frederick_Frost: Lots of doctors take an interest. At Cleveland Clinic, our interdisciplinary group includes endocrinologists, geriatricians, neurologists, ear-nose-throat specialists, doctors in physical medicine and rehabilitation, and -- of course -- our physical therapists. Most of the time, it is best to start with a primary care doctor. They tend to know the specialists in your area that take an interest.
stien76: What factors should a caregiver look for in determining whether to seek emergency treatment after a fall?
Dr_Frederick_Frost: Good question! Falls are common. Fortunately serious injuries are less common. Here, common sense plays a role. Certainly, if pain prevents the patient from engaging in their previous level of activity, some X-rays are probably in order. Of course, an injury to the head is almost always a reason to seek immediate medical attention.
sgrossi: Is it balance or just insecurity?
Dr_Frederick_Frost: That is a good point! Our patients lose their confidence and quickly become insecure and tentative after a fall or injury. That is one of the great values of physical therapy -- to help the patient get their confidence back.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Frederick Frost is now over. Thank you again, Dr. Frost, for taking the time to answer our questions today about Falls Prevention Tips and Therapy Options for Caregivers of Elderly Parents.
Dr_Frederick_Frost: Thanks so much for having me participate!
Cleveland_Clinic_Host: To make an appointment with Dr. Frost or any of the other specialists in our Department of Physical Medicine and Rehabilitation at Cleveland Clinic, please call 216.636.5860 or toll free 866.588.2264. You can also visit us online at www.clevelandclinic.org/rehab.
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This chat occurred on 9/15/2011
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