- And hello.  My name is Marje Murray and I am Director of Geriatric Services at UW Health and it is my pleasure to welcome you all to this program with Better with Age, How to Prevent Falls.  Dr. Kathleen Walsh is our presenter tonight.  Dr. Kathleen Walsh is an internal medicine physician with a specialty in geriatrics.  She practices in the Emergency Room at University Hospitals helping to make Emergency a better place to go, especially for all of our older patients.  And she is also Co-Director of the Faint and Falls Clinic at UW Health, and that might be something you'll learn a little bit more about tonight.  So let's welcome Dr. Walsh.  (applause) - But thank you for inviting me here.  It's a pleasure to be here.  I have never been at Capitol Lakes before ironically. 

 I have seen a number of patients from Capitol Lakes.  Some of you are in the room right now.  I will not point you out.  But thanks again for coming.  Today we'd like to talk about falls.  And by the end of the lecture, my goal is to help you prevent that next fall, because some of you have fallen, some of you will fall.  And our goal, though, is to even prevent that from happening.  So let's get started.   The first thing you're gonna do is meet Gloria, Robert and Alfred.  I'll introduce you to them in just a second. 

 They are not physically in this room, but you'll see them up on the screen here in just a second.  Then hey, we're gonna talk about living in Wisconsin.  How important is that?  Syndrome, what syndrome?  The fall risk equation for those mathematical minds in here.  We do have an equation we're going to go through.  Treatment and prevention.  Now seriously, what really works to prevent us from falling? There are stories, so we're gonna talk about Gloria, Robert and Alfred at the beginning and then I'll tell you what happens to them at the end of the lecture.  And then, really, the bottom line.  What do you need to take out of here after 40 minutes or 45 minutes to help you prevent from falling?  So there's Gloria.   Gloria's at the top.  Gloria has a history of high blood pressure, urinary incontinence, losing urine sometimes, osteoarthritis. 

  Gloria fell.  She's fallen twice.  Gloria fell getting out of her bed.  As soon as she got up in the morning, she sat on the edge of the bed, stood up and then got dizzy and went down.  That's one fall.  The other fall Gloria had was walking in her apartment to a specific location and that was to the bathroom.  And she fell.  We will go over why.  By the end of the talk, you'll be able to figure out why she fell.  Then, we'll review that and what we did for her. 

  Robert.   Robert's in the weight room.  I hear that you have a very nice weight, or an athletic room here, a workout room.  Robert fell twice in the workout room.  Robert has a history of osteoarthritis.  He has a history of hypertension, but he also has a history of diabetes and macular degeneration.  And some of you in this room have macular degeneration or some of your friends do and that's losing the vision slowly.  But Robert fell twice in the athletic room.  One fall was standing up and he got dizzy and he fell.  The other fall was just walking across the room to get another set of weights. 

 He tripped and he fell.  There's a reason, though, why he fell.  We'll go over that.  Finally, Alfred.  Alfred's here at the bottom.  Alfred has a history of coronary artery disease.  He has a stent, one stent.  Alfred also had to have his aortic valve replaced, so he's got a mechanical valve in.  Well, actually, he has a porcine valve.  He's on no blood thinner. 

 But Alfred not only fell, but then they realized Alfred was passing out.  He was going out and it was more than just sleeping.  He went out and he fell.   We'll go over Alfred's story at the end, too, and what happened.   So you live in Wisconsin.  Two things you may want to know:  The aging population of the state  and are we falling?  It's kinda interesting.  I like working here and there's two reasons because of this.   This is 2015.  That's last year.  How many of you ever lived up north?  Cool. 

 A few lived up north, yeah, and they came back down.  Good.  So if you lived up north, if you're looking at this map, this looks at the number of people over the 65 and older in each county.   The darker the color, the more people 65 and older.   Look at where everyone's living who's 65 and older.  Way up north, yeah.   And Dane County in 2015, there was 12 to 15% of the people that lived in Dane County that were 65 and older.   What's going to happen in a few years?  Look at that.   I would say no one is moving out of Wisconsin, are they? - Well, yeah.  You're assuming internal migration only. 

 - Internal migration only.  Thank you.  I like that.  Internal migration only.  But Dane County is still and I think...  You think about the college here and the age population so that makes a difference here, but look at that.  - Yeah.  - Isn't that amazing? Wow.   The top geriatric syndromes.  So when we teach our residents, when we teach our medical students about getting older and what you want to consider and what you want to think about when you treat or when you work with older folks, these are the top: Falls, delirium. 

 Anyone know what delirium is? Just getting a little confused.   Being frail, syncope, passing out like Alfred.  Dizziness.  And urinary incontinence.   That's no fun.  But we can usually help with these syndromes, but these are the top geriatric syndromes which we try to learn about and teach our residents and medical students.   Falls.  Did you know at the age of 65, one out of three people fall each year?  Did you know by the age of 72, a person will fall every two years?  Then it gets a little worse.  By the age of 80, a person will fall or have a fall every year, statistically.   Did you also know a fall usually represents the initial event when an older person's life can go into a serious decline or present with a new or worsening medical illness? So when someone falls, we take that very seriously because this is what can happen. 

  This is why we opened up the UW Faint and Fall Clinic, so we can prevent this from happening.   I'll get to questions right...  Let me take...  We're gonna...  Can we get it at the end, sir? Is that okay? Okay.   Are we falling?  So a lot of you doctor at the University of Wisconsin.  You may doctor at Dean Care.  You may doctor at GHC.  But what we did at the University of Wisconsin is we took a poll and in 2014, every person that came into a University of Wisconsin family medicine clinic, and our family medicine clinics at the University of Wisconsin are scattered throughout the state,  we asked them if they fell.  We screened 8,498 patients. 

  Seventy percent responded, which is great.  How many do you think of the 8,498 had fallen?  - 90%.  - 3,046.  That's a lot of people who've fallen.  How do we define a fall? And we define a fall from someone standing up or sitting and falling to the ground.  There are near-falls, just like near-syncope and then there are falls.  So what do they ask? And these are some of the questions that you may wanna ask yourself.   It's either yes or no.  I have fallen in the past year.   I use or have been advised to use a cane or a walker to get around. 

  Sometimes I feel unsteady when I am walking.   I steady myself by holding onto furniture when walking at home.   I am worried about falling.   I need to push with my hands to start up from a chair.   I have some trouble stepping up onto a curb.   I have some trouble...  Wait.  I often have to rush to the toilet.  I have lost some feeling in my feet.  I take medicine that sometimes makes me feel lightheaded and more tired than usual. 

  I often feel sad or depressed.  It's either yes or no.  And what we look at is how many in the column you've answered yes, and how many in the column you've answered no, and are you at risk for falls.  Three or more, you are at risk for a fall.   Why do some seniors fall more than others?  Because of the increase in risk factors contributing to poor balance.   Balance is the key.  It's the key to life, to keep yourself balanced.  If you think about it, every time you fall, your balance was off.  But the reason your balance is off is different for many, many people.  That's what we have to tease out when someone comes to see us at the clinic or your doctor teases out when you go see him or her. 

  Everyone's balance.  The reason why your balance may not be perfect like it was 20, 30 years ago is very different from the person sitting next to you.   How do we balance?  Vision,  inner ear,  the sensing, the proprioceptive sensing, and then strength and flexibility.  If you were to pick four things about you that we look at to keep your balance balanced, vision, your inner ear, how you sense things from your feet because your feet will sense touching the ground into your spinal cord into your brain.  Some people have terrible peripheral neuropathy.  They can't feel their feet, so then they're sensing is bad.  Some people have bad vision or poor vision.  Some people don't have...  Their hearing is off.  Their hearing aids don't work or hearing aids don't work for them. 

 This all contributes to balance.  And if we can fix one of these four things, there's more, but these are the main, we'll make your balance better.   You fell.   The devil's in the details.  So when you come to our clinic or if I were to see you in our emergency department, these are the questions that I would ask you.  Not only would I ask you, but we want you to ask yourself and then tell your doctor.   Where did you fall? Was it in the kitchen? The bathroom? The hallway? What time of day was it? Was it... Did you just get up? Were you taking a nap?  What were you doing? Were you carrying laundry? Were you reaching for something? The devil's in the details.   What were you wearing? Why is that important? What if you were wearing baggy clothing or what if you were wearing really tight clothing? Or what if you were wearing slippers that you just slipped right out of or just wearing socks?  That's really important.  Were you carrying anything? Shoes and slippers.  Were you using a cane or walker? Did you have a recent illness or have you started any new medications? Or did you forget medications?  Did you just eat a heavy meal? Do you ever... 

 What's classic about Thanksgiving? You eat a big meal.  Two hours later, where is everybody?  Right.  Taking a nap.  Hydration. Are you drinking enough fluid? Do you drink alcohol and how much? Was there anybody to witness that fall that can help? Because sometimes people fall and they'll say I have no idea what happened.  No idea.  But their friend saw it all, and we got the story so that's good.  Were there any witnesses? And then finally, did you seek medical attention after your fall? Have you ever fallen in your apartment or your home and said oh, I'm okay? I'll get up.  That happens all the time.  I've done it.  You fall, you get up, you're like, I'm okay, and two days later you see a big bruise and you hurt and that's when people sometimes go to the doctor, which is fine. 

 We wanna see you.  And were there any injuries? So when you come into the Falls Clinic or sometimes when you come into the emergency department, this is what we should go through and if we don't, if you go to your physician, please ask for this.  We get orthostatic vital signs, which means we get your blood pressure and your heart rate lying down, sitting, and standing, if you can do that.  That will tell us if you're...  sometimes if you're dehydrated or if you're taking the wrong medications that are causing problems with your blood pressure or your heart rate.  What's your visual acuity? We check your vision.  Maybe your vision's off and you didn't even know it.  We have you...  A hearing evaluation.  One of the easiest ways to test your hearing is in a very quiet room someone will come up and just rub their fingers right next to your ear. 

 Can you hear that?  Is it the same on this ear? You can test yourself or test your friend later.   Walking test.  We know that people who cannot...  How they get out of a chair and how far they can walk for three meters and come back will tell us a lot about how well they're doing.  A simple test like that.  So when a patient comes in from the waiting room back to a room in the emergency department, I watch them walk.  They don't even know I'm watching them, but I watch them walk back to the room.  I can tell a lot by how you're walking.   Mental status exam.  Cognitively, how are you doing? Do you feel like your memory is being a bit challenged? We can sometimes test that. 

  Or sometimes we will have to test that.  Did you have any recent blood work? Did you have any recent x-rays? Were you injured? Medication review.  We go over medications, medications, medications because we want to know what you're taking and if its right or if we need to maybe back off on some of these medications.  And then spouse or family input.  Here we go. Here's the equation.  Intrinsic and extrinsic factors.  Well what does that mean? Intrinsic.  What are your medical conditions? Just like Gloria, Alfred, and Robert.   We talked about their medical conditions.  Blood pressure, osteoarthritis, urinary incontinence. 

 What are your lifestyle choices? Do you choose to get up and go out to activities? Do you choose just to stay in your apartment? Do you choose to be active? And cognition.  How is your memory doing? And is your memory affected just by general aging or can it be affected by illness or can it be affected by medications? All the above.   Let's look at some of the extrinsic factors and that includes both internal and external.  And we're gonna go into those in just a minute and all I did was put pictures in, which I love.  And then there are some that you can change.  We can change some of the medications.  And then there are some that you can't.  For example, I think I said that Robert had macular degeneration.  That we cannot change.  There are some things that we just can't change. 

 Peripheral neuropathy.  I can't change that.  I can try to make it a little bit better, but I can't make it go back to what you were feeling before.  The nerves have been damaged already.  So some things we can, some things we can't.   So falls as we age.  Let's go over just a couple of the intrinsic causes, and some of you have these.  We talk about the physiologic changes with aging, medical illnesses, medications, social factors and mental status.   For example, heart disease, stroke,  incontinence,  musculoskeletal stiffness or weakness.   Glaucoma, macular degeneration,  hearing loss,  diabetes, peripheral neuropathy, and arthritis. 

 We've kinda touched on all of these already, but these can have a huge impact on how well we move around, how well our balance is.   Oh, osteoporosis.  Now this is an area that I love to really hone in on when I see a patient.  Their medications.  Less medication the better.  Less medication the better.  Because what happens is when we get older and we keep adding medications, we get into what I call a medication madness, right? It's, like, why am I taking these? Do I really need to take them all? What happens...  Just like this lady.  She's looking at the whole bottle of pills and she takes more and more medications.  We call it the cascade effect. 

  And then you get an increase in fall risk.  Which medications? Oh, before we do that, sorry.  Multiple medication madness, so another map.  I love maps.  Some of us are more visual learners, some of us more of the written, but I love the maps.  So this is a map of the United States.  The darker the orange, the more 30-day prescription medications were given.   Look at where Wisconsin is.  That's pretty dark.   Why is that? Do we like medications?  Oh, someone's picking on Kentucky now. 

 Okay.  Well look at...  It's all kind of in the Midwest.  The South right there.  That's the amount...  That's in 2014.  If you have Medicare part D.  This is Dartmouth University put this together and they looked at all the medications people were getting in a 30-day.  That's a lot.  Per year. 

  High-risk medications.  Now who is getting all the medications that can make people fall, that can make people confused? The darker the color, the more high-risk medications.  So actually we're doing a little bit better.  Right? Which is good.  But down in the southern area, a little bit worse.  We'll go over those.  I think I have them next.  These are the most common medications that can cause falls as we age and even in the younger population, if you're 30 or 40 or 20.  Same medications.  Benzodiazepines. 

 Lorazepam, Alprazolam, Clonazepam.  Anybody ever hear of these? Mm-hmm.  Yeah, Ambien.  Bad.  Why are they bad? They cause our balance to be off.  They cause our cognition, our memory, to fade.   They cause us to be dizzy.  These are bad medications.  We try to get most of our patients off of these or we decrease the dose if we can.  The next one is non... 

 the Ambien, which a gentleman just pointed out.  Antidepressants can sometimes cause this.  Water pills.  Gloria, our first lady that I mentioned, she was running to the bathroom.  She fell because she didn't want to wet her clothing.  She was on a water pill.   I would do the same thing.  I would wanna get to the bathroom as quick as I could.  Vasodilators.  Blood pressure medications. 

 When you start blood pressure medications in your 50s and 60s, a lot of times these are not looked after very often and when you get into your 80s and 90s, they probably need to be changed.   Many people are on too much medication.  Too much of the blood pressure pill.  Muscle relaxers.  Pain pills.  Herbal medications.  Oh, herbal medications.  Dangerous.  Dangerous, dangerous, dangerous.  Most of them. 

 We'll go over those in just a second.  So this is what we try to avoid.  Medication cascade.  Very common, but you need to avoid.  So we call about adverse drug events.  So for example,  if you have fallen  and you go into the emergency department or you go into your physician, they'll say oh, no problem.  I'll start you on some Ibuprofen.   A little anti-inflammatory.  Well, what happens with anti-inflammatories is they can cause your blood pressure to go high.  Oh, so now your blood pressure's high, so now we'll put you on a blood pressure pill. 

 And that blood pressure pill is a part water pill, part blood pressure pill.  Well they do the same thing, but now you're rushing to the bathroom.  Now we'll put you on a pill for your bladder because we think that your bladder's affected.  Does that make sense? So we gotta stop the cascade.  Stop the cascade.  So that is why the devil's in the details.  We go back and ask how did it all start.  We try to avoid the medication cascade.  Be careful with herbal medications.  Ooh, this can be kinda small. 

 For some of us, especially in Madison, believe it or not, a lot of herbal medications in this town.  A lot of herbal medications.  I don't know if it's a liberal...  (laughter) I won't go there.  I won't go there.  But for example, if you're on Coumadin, if you're on Plavix, you want to avoid garlic.  Ginkgo, St. John's Wort, ginseng, Saw palmetto, ginger, cranberry.  These can all affect that.  Now most of you are told that by the pharmacy when you go and get your medication.  The other one, anti-convulsants. 

 Again, St. John's Wort, Valerian, Digoxin.  They can all have an effect with all these herbal medications and some people...  I've had many patients come in and they'll say, "I buy the best herbal medications.  "They're the most expensive.  "They're the best.  They're..." No.  No, no, no.  I don't care if it's the most expensive.  Herbal medications are not FDA-approved.  They are not regulated. 

 And two years ago out in the State of New York, they went to Walgreens, Walmart, CVS and they got all these herbal medications.  They took them to a lab.  This is the state of New York.  They took them to a lab, and they tried to identify the ingredients.  They were all off.  They were not what they told that they were supposed to be in that ingredient on the label.   Avoid herbal medications, please.   Herbal medications and common side effects.  Some of us take garlic because we heard that was pretty good.  Yeah. 

 Nausea, burning sensation in your mouth, throat and stomach, bad breath.  Well, we kinda know that, right, with the garlic? But if you had that burning sensation in your mouth or the nausea and you're taking garlic and you didn't let the primary care physician know or your physician know, what's going to happen? You go in and you say I'm nauseous.   The medication cascade.  They're gonna start you on a medication for nausea because you're nauseous, but why were you nauseous? You're taking the garlic.  Stop taking the garlic.  My mother had terrible stomachache.  We thought, oh, she's got an ulcer or oh, she's got cancer.  She switched her multi-vitamin, which we don't use anymore.  She switched her multi-vitamin to a different brand, and what was in the filler in that pill, the cellulose, the coloring, was causing problems with her stomach so we took her off that multi-vitamin and her stomach pain went away.  So you've got to think what started, what was different when I started getting these symptoms. 

  This is what we tell our patients and this is what you wanna go in with.  When you go the emergency department, when you go to your primary care physician, you say I heard this talk and she said start low, go slow.  Start low, go slow.  So if we start a new medication, we're gonna start at the lowest dose possible and we're gonna slowly increase as we need it, but start low, go slow.  Low dose and titrate slowly.  Start only one new medication at a time.  Frequent medication reconciliation.  So when you go into the doctor, they always do that.  They want medications you're on.  They go through each one. 

  But we try to empower our patients is why...  What are you taking these meds for? We don't try to drill.  We just, do you know what you're taking these for.  If not, we'll make a list and say Lisinopril, blood pressure.  Not the white pill.  We wanna know...  you wanna know what pill you're taking and what you're taking it for.  That's empowering you and your health.  Risk factors, lifestyle, exercise, alcohol use, nutrition, hydration, fear of falling.  For those of us who exercise, it may just be walking up and down the hall five times a day. 

 That's great.  We don't expect everyone to be going to the gym, running laps around the Capitol.  We don't expect that.  We just expect you to get up and move.  Alcohol use.  Gotta be careful about that.  Some people like a glass of wine at dinner, but that's probably enough.  One drink... over the age of 65, it's usually one drink a day and that's it.  No more than that.  Nutrition. 

 Are you eating a balanced diet? And are you hydrating yourself? Hydration is not diet soda, it's not coffee, It's water.  And some of the water coming out now is flavored with lime or lemon.  That's absolutely fine.  We need you to drink water.  Water, water, water, water.  And fear of falling.  Once you have fallen, this is what happens.  This is what we see all the time.  You need to touch or hold onto things walking around or even hold onto a friend.  That's fine, but this is getting into the cycle of the fear of falling. 

  You walk very slowly.   You take small steps.   Limited movement and you express a fear of falling.  I don't wanna do that.  I'm gonna fall. I'm gonna fall.  We want to know that, though.  We need to know that so we can help you.  It's very normal.  Social factors.  We see this a lot. 

 Someone who has lost a spouse or a partner.  Depression or if you're caring for an ill partner.  Widowed, single or you just went into retirement.  How are you coping with that? How are you coping with a move from your big house into a small apartment?  Do you experience the fear, the cycle, the fear of falling? And your support systems.  Some of us have moved.  Some of the patients I see have moved from California to Madison because their kids teach here.  They're at the university.  They wanted to be near their children.  But they left all their friends.  That is hard and that can contribute to falls because it contributes to sadness, sometimes depression, sometimes not eating as much. 

  Extrinsic factors.  Here you go.   Pictures.  I love pictures.   You don't have to raise your hand, but that chair in the middle, I call it the propeller chair that propels you right out.  Not good.  Not good.  No. What happens is that sometimes...  I mean, look. Do you think he looks stable? Do you think his balance is okay? I'm fearful for him and he's just in a picture up there.   Bad chair. 

 This chair over here on the left hand side, it's low to the ground, which is probably too low.  It has good arms on it, which we all need to push out, but the cushion is too low.  So what can you do? And some of us have brought furniture from home, right? I'm not getting rid of that.  That is my favorite chair.  It is not leaving.  So what we did is for my father, it's a very similar chair.  We put two by fours underneath the feet and it lifted up the chair.  And then we put a board underneath the cushion so that lifted up the cushion.  So he was a little bit higher off the ground.  Because if you go into a room, I can see each... 

 all of us looking around and thinking which chair am I going to sit in.  I will not be able to get out of that chair.  I will not be able to get out of that chair.  So you selectively...  you don't...  unconsciously you select a chair that you know you can get in and out of quickly.  This chair.  Would anyone want to sit in this one down here? It looks comfortable, but think about getting out of that one.  Oh.  And then our beds. 

 A little bit too low.  We don't want our beds too high and too low.  So it all depends on you and what you need, but you got to think about that with the furnishings.  Oh boy.  Slick, irregular floor surfaces.  For those of us who always, like, "Oh, I love hardwood floors." Let's make it as bright as possible.  This floor in here, the carpeting.  Do you think there's too much? For some people it can be, depending on your vision.  You can look at the carpet and you're not quite sure where it stops and where it starts.  If the pattern's the same, it's okay. 

 This pattern over here, that is tough.  That is tough to follow if you have any vision issues.  The pattern up here, tough.  These are very shiny, slippery floor.  These are the things we want to avoid.  Loose carpeting and rugs.  We've heard this over and over again, right? Get rid of those rugs.   I got that rug when I traveled.  I'm not getting rid of that rug.  I can say that now about some of the rugs in my home. 

 Well how do I keep it down? There are plenty of things that you can use underneath the rug to keep it steady on that floor.  However, if the rug is like this one on the right, three inches, remember the old shag carpeting? Ah, no.  I'm sorry.  You may have to donate that rug somewhere.  That's probably not the best rug.  And that, you think, is just common sense.  That rug is too high to get your foot up and over.  Easy to trip on.   Clutter.  I'm sure none of you have clutter in your home. 

 (laughter) Right?  (laughter) What can happen with clutter?  Bad things can happen with clutter.  And it's so hard to get rid of some things that are so sentimental to us.  I got that from my granddaughter, I got that from my daughter.  I got that when I traveled to California.  Oh, that was when I went to an artist's colony in New Mexico.  Some of these things, great to have, but they have to be in a place that does not contribute to any of the falls.  If you're reaching for something like, oh, let me get this.  I wanna show you this, and it's way up here, probably not a good spot.  So clean up the clutter.   Lack of grab bars in the bathroom or handrails on the stairs. 

 So what we try to do is encourage people if they're still living in their big home on the west side or big home in Madison and don't have a nice secure apartment is to get handrails on both sides of the stairs.   And the handrails should go beyond the top step and beyond the bottom step.  And then for a lot of our people...  I did this for my father.  He had terrible vision with macular degeneration and glaucoma.  He could not see the steps, but once we put the yellow stripes on the edge of the step, was able to see each step and climb up the stairs.  Easy to do.  And then all the grab bars, which you are familiar with if you live, I think in some of your apartments here, you have the grab bars.  Poor illumination or glare.  Remember nightlights. 

 So some of us actually...  It can go both ways.  You can have limited light like the upper left.  Too much light here, too much glare.  And at night we really encourage people to use nightlights.  In the bathroom, in the hallway.  Find out where you're going.  In our home we leave the lights on in the bathroom so people can get back and forth.  They know where they're going.  We have a couple sleepwalkers, but that's okay. 

 We have the lights on. They wake up.  Footwear.   I like the footwear I'm seeing.  I like it.  You all have very nice footwear on.  You know it's just common sense.  The footwear on the left hand side, probably not the best footwear to wear and keep our balance.  Right? The pink slippers, the clogs.  And these shoes are very popular for awhile.  They have rocker shoes. 

 They worked on your legs a little bit.  Try to keep your balance.  Bad, bad shoes. Better shoes over here, and most of you in this room, I can see you have great shoes on.  So just think of your footwear.  Oh, another thing.   How many in here have bifocals?  Oh. Trifocals? Progressive? Oy. (laughter) Ah.  Well, they're great, but we have learned that a lot of our patients will fall with these because if you think about it, look at this guy in the middle.  Having trouble getting used to your new bifocals? He's like this.  I can't see the step.  So our patients that we have found, there are patients that fall going up and down steps, stairs, but also going up and over curbs. 

 It's because of the bifocals, the trifocals.  It's not that they tripped because they'll say I have no idea why I fell.  And so a couple things you can do.  When you go up and down steps, either you hold onto somebody or the railing and you look straight ahead and you count how many steps.  For people in their own home or here, we'll say how many steps do you have to go? They'll say seven.  Alright, keep that in your mind.  Seven steps.  You look straight ahead, seven steps.  Done.  But if you look up and down, that's when your vision... 

 It's completely off.  You can't see the step.  It's not where it's supposed to be.  That's when people fall.  So be very careful.  The other way we go about it is you just get single vision lens.  Use those most of the time.  When you read, you bring out the other ones.  We've gone to that with many of our patients and they stop falling.  Even though those trifocals and transition lens are quite expensive. 

  Alright, here's where the biggest bang for your buck.  This is all the research.  All the studies have been put together.  Looking at what is the best bang for your buck to keep you from falling.  Number one, balance.  Balance, balance, balance.  How are we going to get you to balance? Sometimes it's taking away those medications, right?, to keep your balance better, but a lot of times it's a class in balance and we'll talk about those in just a second.  Vitamin D.  For those people with low Vitamin D, Vitamin D is so important for your muscle function.  If your doctor has not checked your Vitamin D and you are not on Vitamin D, ask your physician or primary care, whomever you see, either to check your Vitamin D levels or you may go on just a general supplement, 1,000 to 2,000 International Units a day. 

 So we always check Vitamin D levels.  Occupational therapy interventions.  You may need some bars in the bathroom.  You may need a different walker.  You may need a different cane.  And then targeted interventions.  That's what we do in the Faint and Fall Clinic.  If you have cataracts, we like to take those cataracts out.  Restricted multi focal glasses.  This is where I talked about the trifocals, the bifocals, the transition lens. 

 They know.  These are studies that looking at why people fall.  Get rid of those.  Restrict how much you use them going up and down steps.  Podiatry.  Do you have corns, bunions? Are your nails trimmed? Get in and get your nails done.  Treat yourself.  Podiatry.  Or a massage therapist.  Or what am I thinking of? - Manicure? - Manicures. 

 Pedicures.  Pedicures.  Insertion of a pacemaker.  Believe it or not, one of my patients I talked about before needed a pacemaker.  We're gonna go over it.  (laughter) We're gonna go over which one of those...  Remember the three people I talked about at the beginning? One of those patients needed a pacemaker.  And then withdraw the high-risk medications.  Remember the map? All those high-risk medications? Well, we know that the people here in Dane County or in Wisconsin tend to use more medications than a lot of the other country.  Not as many high-risk medications, but we can peel away some of those medications. 

  This is what we ask patients to do.   It's a kind of a mental activity and focus training.  Think, think.  Do you ever hear your mother say that? Just think about what you're doing.  Right? Think before and after you stand, before you step, before you turn, before you reach.  We ask patients just to slow down just a little bit and think what am I going to do? How am I gonna reach up there and get this? Is this a good idea? Is this really a good idea? We tell everyone who comes in to the emergency department after falling off a ladder cleaning out the leaves in the gutter, did you think about it before you went up there? And, like, yeah, you know I should've maybe not done that.  So think about it before you do that.  Exercise.  Balance classes and there is a website if you are interested.  It's called Wisconsin Institute for Healthy Aging. 

  Do we have this available, these...  - I can send them.  - Okay.  There's a class that we promote quite a bit.  It's called Stepping On.  Stepping On is a fabulous class.  It's eight weeks.  Maybe an hour, hour and a half.  It's at all different community places here.  Dane County has the most... 

  The most frequent...   The number of Stepping On classes anywhere in the state of Wisconsin.  So if you go on...  If you actually just...  click Stepping On state of Wisconsin, you'll get that map and you'll get the number of classes.  But where you'll find them the most is at Wisconsin Institute for Healthy Aging website.   Wisconsin Institute for Healthy Aging website.  Stepping On.  By far, it's the best class I've ever recommended.   The other one is tai chi. 

 My patients with Parkinson's, I get them all...  If they're willing, I will get them all into tai chi classes.  It works.  Not just for Parkinson's.  For anyone with balance issues, tai chi will help.   And finally, yoga.   There are different.  Not the hot yoga, 98 degree type weather yoga.  Yoga appropriate for the age, for whatever ability that you can do that.  There are many different types of classes in yoga. 

 Number one is Stepping On, number two is tai chi and number three is yoga.  If you did all three, you'd have the best balance ever.  But if you can just do one, it will improve your balance.  I guarantee it.   Just a few words about devices.  This is what I've done for some of my patients.  Oh, remember we were talking about reaching up for that nice bowl that you had at the artist's colony or wherever in New Mexico? Well that person couldn't reach without getting dizzy because every time she put her head back, she like oh, I am so dizzy.  So we got a little reacher and she just looks up a little bit, reaches it and gets it and brings it down.  I had a patient that would fall every time he got out of bed.  He just didn't have the strength in his legs to get up and out of bed. 

 It was only getting out of bed that he fell.   He was not gonna get rid of that bed.  The bed was low to the ground.  We talked about how low that bed is to the ground so what we did and this is a...  an idea of the occupational therapist, was to get a pole.  And they have poles now from the floor to the ceiling with a handrail on it.  So he sits on the edge of that bed, marches his legs up a little bit, grabs the pole, and stands up.  Stopped his falling.  Pretty nice.  Pretty easy. 

 And the third one is a woman who had a stroke and to get up out of a chair, she needed something by the side and we stopped using the old table that she had by the side.  And one with a handle that we could get right by the side of her chair.  She gets up and out of that chair without any problem now.  But that's where she was falling.  The devil's in the details.  What were you doing? Where were you going? Were you carrying anything? Were you turning? What time of day was it? Devil's in the details.   Just a few facts about your canes if some of you have canes in the room.  Ten percent of us over the age of 65, we use canes.  Please carry your cane in the opposite to the weak leg.  So whatever leg is weak, carry it on the other side. 

 The size should come right to the middle of your wrist.  Sometimes the canes...  I see people walking with canes here.   Sorry.  Or I see canes up to here.  If you put the cane by your side,  the top of the cane should come right to the middle of your wrist.  Same with a walker.  When I line up a walker, I'll put it right...  Oh, that'll be the next picture.  I'll line up the walker. 

 It will go right to the center of your wrist, the top of the walker, where you're gonna hold onto it.  Okay? Look forward, not down.  Many people make the mistake of doing this.   No. We need you to straighten up a little bit and if you can, look forward about six feet ahead.  When you pivot on the stronger leg, this is the key when you go up the stairs, you go the good leg first.  Good leg first.  Coming down, bad leg first.   If you say well I can't carry my purse and carry my walker or my cane, that's when I get a shoulder bag for the patient or we encourage them to get a shoulder bag or even a backpack.  So you're free.  Your hands are free. 

 You can just put your shoulder bag over.  Okay.  Walkers.  They're not all the same.  Not at all.  And some of you in here have very different walkers and for different reasons.  And people can use...  Some people cannot...  They need to use the two-wheeled walker in the front with the prong on the back, usually when they're first starting to use the walker and then they can migrate to the larger wheeled four-wheel walkers with the brakes.   This is a walker that I put this picture in here, the one right above me. 

 That's actually from Sweden, a walker they use.  And she has Parkinson's disease.  She felt that this walker helped her out the most, but what we're going with with a lot of our patients in the States that have Parkinson's disease is called the USTEP walker.  It's a really cool walker.  It won't let you go backwards because a lot of Parkinson's patients, they kinda will go backwards quite easily.  It has a little...  A laser light that it will stop the walker.  So many, many different types of walkers.   I don't know them as well as an occupational therapist does or a physical therapist so we send all of our patients to the occupational or physical therapy to get the perfect walker for them and to get it fitted for them.  But walkers can make a big difference. 

 We have many patients...  which I understand, too, but they'll get a walker from a cousin, my dad's old walker, my uncle's old walker.  I got it at a garage sale.  That's fine.  I just need to fit it for you.  We need to get it fitted for you.  It's okay.  This is one thing we've gone to instead of canes.  I have several patients who use two canes to get around and we've tried to switch them to walking sticks.  Or some people call them trekking poles. 

 We were over in Beijing.  We were teaching there and we watched them doing exercises, balance exercises outside.  Everyone had walking poles.  And look at them balance there.  Just on the one foot.  Walking sticks are great.  They keep your balance a little bit more upright than just one cane, so I really encourage walking sticks.  And you can get those at Target,  Dick's Sporting Goods.  They're pretty inexpensive.  Oh, let's go back to our people. 

 We're almost done.  Here's Gloria.  Remember Gloria has hypertension, urinary incontinence, osteoarthritis.   That was it.  Gloria fell.  She got up out of bed.  She got dizzy and she fell.  That was one fall, and then the other fall, Gloria was rushing to the bathroom.  Right? So what did we do for Gloria? Remember we asked her all those questions.  Where were you? What were you doing? Were you carrying anything? Any recent illness? So what we found out with Gloria was that she had vertigo. 

 Has anyone ever heard of vertigo? The spinning sensation.   And luckily for Gloria, it was the type of spinning or the type of vertigo that we could use physical therapy to get it better, so we did that.  But that didn't account for her fall to the bathroom.  What happened was that she was losing urine.  She had urinary incontinence and she was trying to rush to the bathroom all the time.  She was also on a diuretic.  She was also on a pill that would help her lose urine easily and try to help control her blood pressure.  So we took her off that, put her on a different blood pressure pill.  Then we worked on what we call the Kegel exercise, the exercises so that she can try to strengthen the muscles near her bladder, and that helped.  She still will leak urine once in awhile, so what we decided to do is just put a pad. 

 Use a day pad and not rush to the bathroom.   No more falls.  Which is good.   Robert.  Robert has hypertension, macular degeneration, osteoarthritis, and diabetes.  Remember, Robert fell twice in the workout center.  He fell.  He was dizzy.  And then the other time, he just fell by kicking his foot.  Catching his foot on one of the pieces of equipment. 

 So what would make Robert dizzy? He had hypertension.  Robert was getting physically fit.  Robert was changing his diet, he was working out.  He didn't need as much blood pressure.  He came into the clinic.  We found his blood pressure was 90 over 60.  He was dizzy from his blood pressure medications.  So we peeled back on a lot of his blood pressure medications.  Blood pressure came up.  Much, much better. 

 The macular degeneration, I can't fix that.   He tripped on the equipment because he couldn't see it.  So what Robert has done was get a walking stick, a walking pole and every time...  like a trekking pole.  Every time he goes into the gym, it's almost like the white stick that people...  Folks with really poor vision will use the white walking stick and he makes sure that he's not gonna trip on any of the equipment.  Stop falling.  Change the blood pressure pills.  Making sure that he can find out where the equipment is.  No more falls. 

 Alfred.  Doesn't he look happy? (laughter) Alfred was not only falling, Alfred was passing out.  He was syncopizing.  He was going out.  And the reason why Alfred was going out, remember he had coronary artery disease, he had a stent, but he also had a valve replacement.  And once they go in to cut...  Once they go in and cause scar tissue around the heart, they can also cause scar tissue around the...  I call it the electricity from the top part of the heart to the bottom part of the heart to make it beat, and he...  It wasn't communicating.  The top part of the heart wasn't communicating with the bottom part of the heart. 

 He had called sick sinus syndrome and he needed a pacemaker.  No more passing out.  Alfred's doing well.  He has not fallen, either.   Last two slides here.   So intervention and prevention of falls.  Assessment and management of chronic conditions, your vision, and your hearing.  Make sure that's always checked.  If you have to go to a single vision lens and use bifocals...  or use the reading glasses, do that. 

 Check your hearing.  Exercise.  Look into Wisconsin Institute for Healthy Aging website.  Look for Stepping On class.  It is wonderful.   Osteoporosis screening, Vitamin D, medication review.  Go over your medications over and over and over again with your physician and say is there anything I can decrease.  Is there anything I can stop? Less medication the better.   Referrals for physical therapists and occupational therapists.  If you get a new walker, if you get a new cane, if you have hurt yourself or your back hurts, you're walking a little differently, take it in. 

 Make sure it's set up for you.  And the bottom line.  Here it is.  Falls are the result of complex multifactorial interactions between the intrinsic, all your medical conditions, your medications, et cetera, and the extrinsic, what chairs you have, are you reaching for things.  So it's a very, very complex interaction, and we have to tease that out.  A good history and focused physical exam can tease out many of these conditions.  Start low, go slow.  Remember, when you go into your physician and they say well let's start this one, this one, this one, start low, go slow, Doctor.  Start low, go slow.  The other thing you say I want to avoid that medication cascade. 

 Don't start this one and then I have to start this one and then I have to start this one.   Talk to your doctor if you've had any near falls or falls.  Balance, balance, balance.  That's the key to life.  That's the key to not falling.  It's your balance.  But what contributes to that is what we need to help you figure out.   A little tai chi class.  And thank you very much.  (applause) This is our Faint and Fall Clinic.