Gavrilles had difficulty taking her shoes off, and, after watching her struggle a bit, Bludau leaned in to help. When he got her socks off, he took her feet in his hands, one at a time. He inspected them inch by inch—the soles, the toes, the web spaces. Then he helped her get her socks and shoes back on and gave her and her daughter his assessment.
She was doing impressively well, he said. She was mentally sharp and physically strong. The danger for her was losing what she had. The single most serious threat she faced was not the lung nodule or the back pain. It was falling. Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without these risk factors have a 12 percent chance of falling in a year. Those with all three risk factors have almost a 100 percent chance. Jean Gavrilles had at least two. Her balance was poor. Though she didn’t need a walker, he had noticed her splay-footed gait as she came in. Her feet were swollen. The toenails were unclipped. There were sores between the toes. And the balls of her feet had thick, rounded calluses.
She was also on five medications. Each was undoubtedly useful, but together the usual side effects would include dizziness. In addition, one of the blood pressure medications was a diuretic, and she seemed to drink few liquids, risking dehydration and a worsening of the dizziness. Her tongue was bone-dry when Bludau examined it.
She did not have significant muscle weakness, and that was good. When she got out of her chair, he said, he noted that she had not used her arms to push herself up. She simply stood up—a sign of well-preserved muscle strength. From the details of the day she described, however, she did not seem to be eating nearly enough calories to maintain that strength. Bludau asked her whether her weight had changed recently. She admitted that she had lost about seven pounds in the previous six months.
The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world. Most doctors treat disease and figure that the rest will take care of itself. And if it doesn’t—if a patient is becoming infirm and heading toward a nursing home—well, that isn’t really a medical problem, is it?
To a geriatrician, though, it is a medical problem. People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable and to avert at least some of the worst effects. So Bludau referred Gavrilles to a podiatrist, whom he wanted her to visit once every four weeks, for better care of her feet. He didn’t see medications that he could eliminate, but he switched her diuretic to a blood pressure medicine that wouldn’t cause dehydration. He recommended that she eat a snack during the day, get all the low-calorie and low-cholesterol food out of the house, and see whether family or friends could join her for more meals. “Eating alone is not very stimulating,” he said. And he asked her to see him again in three months, so that he could make sure the plan was working.
Almost a year later, I checked in with Gavrilles and her daughter. She’d turned eighty-six. She was eating better and had even gained a pound or two. She still lived comfortably and independently in her own home. And she had not had a single fall.
*
ALICE BEGAN FALLING long before I met Juergen Bludau or Jean Gavrilles and grasped the possibilities that might have been. Neither I nor anyone else in the family understood that her falls were a loud alarm bell or that a few simple changes might have preserved, for at least some time longer, her independence and the life she wanted. Her doctors never understood this either. Matters just kept getting worse.
Next came not a fall but a car accident. Backing her Chevy Impala out of her driveway, she shot across the street, over the curb, and through a yard, and could not stop the car until it ended up in some bushes against her neighbor’s house. The family speculated that she’d stomped on the accelerator instead of the brake. Alice insisted the accelerator had got stuck. She thought of herself as a good driver and hated the idea that anyone would think that the problem was her age.