March 18, 2021

I’m growing concerned. Things had been going well in Covid land. The Biden administration, after promising 100 million doses of vaccine in its first 100 days of office, has managed to deliver that amount in 58 days. The numbers had at least plateaued locally and there was a hope that if we could hold steady we might have a relatively normal summer. Now numbers are surging in Europe, trends are upticking here in the US and in Alabama and we may be heading into another season of pain. We’re just about to hit 30 million total cases here in the US (nearly 10% of the population) and we continue to lose about 1,500 people a day.

We’re not going to know how the vaccine push has mitigated virus effects for another month or so. It takes about six weeks from initial injection to full immunity no matter which of the three formulations is used and we’ve only had mass vaccination available for the last few weeks so just how things will play out is unclear. The current uptick in cases represents social action from mid-February, when it started to become clear that cases were falling significantly and probably comes from people beginning to relax their social distancing and mask wearing due to the wide spread dissemination of that information. I’m not sure what’s driving the surge in Europe which is leading to new rounds of lockdown as I don’t have as good insight into social attitudes there. And I’m really unclear about the political backlash against the Astra Zeneca vaccine which had been a mainstay of their vaccination plan. Yes there have been a few issues of serious clotting disorders but it’s unclear if the vaccination is the cause and the rate is only a small percentage of the clotting issues known to be caused by most birth control pills and there doesn’t seem to be any great hue and cry to take them off the market. There seem to be some indications that the Astra Zeneca vaccine, as a British product, is caught up in EU/Brexit politics. At least we’re not the only advanced society putting political considerations before public health.
I’m still very worried about our various social institutions and that something major may still collapse under the strain. We’re still not out of the woods with Covid by a long shot and it might not take much of a change to bring down the health care system or the stock market. Systems failures aren’t usually caused by a massive blow, but rather through the cumilation of small problems which are overlooked or not thought to be serious enough to warrant the cost and energy of repair. Eventually the cumulative rot brings the whole thing down.

I use this sort of model a lot when teaching my patients and their families about falls. There’s not a lot of geriatric disease states that I can make much headway at. No cures for arthritis or chronic kidney disease. Fall prevention, however, brings a lot of bang for the buck. Young people don’t think much about falling over. Young bodies and nervous systems deal fine with it but the older you get, the more likely there’s going to be serious harm. One of the ways in which you know you’ve gotten old is the reaction of others when you fall in public. If they laugh, you’re young If they rush over in concern, you’re old.

Falls are a systems failure – the system that allows our bodies to be bipedal. Most mammals are not. Walking around on two feet is difficult and very hard to balance correctly. It takes most of us four or so years of all day every day practice to get it right. To do it, we must learn to coordinate our vision, what the balance mechanism of the inner ear tells us about gravity and up, what the outside world tells us (which when we stand and walk comes to us solely through the soles of our feet), and what a couple of hundred muscles in our legs and back are up to. All of that information ascends our nervous system, is processed by our brain, and then new signals are sent to the musculature to constantly adjust.

As we age, brain processing slows (it’s inevitable), the speed at which signals travel through the nervous system to the brain and back again slows, vision dims, muscles diminish in size and strength, and then there’s the disease processes which can interfere like neuropathy, arthritis, macular degeneration, and Parkinsons. The ability of the brain and body to work together to maintain balance becomes more and more tenuous. When a young person suddenly loses balance, such as a slip on the ice, a whole series of reflexes immediately go into play (the brain knows fall=bad on a very primitive level). There’s the dance as the feet scrabble to find purchase and the weight shifts quickly on the legs to try and maintain an upright posture. If the brain knows it’s going down, there’s a quick roll to get the arms and hands down to brace the body against impact. All of this is instinctual. You don’t think about it, you just do it. If the fall is serious, the most common fracture is the wrist as the hand and forearm takes the impact. In an older person, the neural slowing means that gravity takes over before those reflexes can fully be implemented and it’s not possible to get the hands out in time. Older people therefore break hips, vertebrae and their skulls, much more serious injuries. We start backing away from fall risks instinctively in middle age. At twenty, we leap from rock to rock across a mountain stream. At fifty, we look at the rocks, then walk downstream and across the bridge.

We can’t always fix the intrinsic causes of falls, but we can do something about the extrinsic ones by helping older patients eliminate fall risks at home and working with them on their gait and balance, teaching them some basic things like not carrying things up and down steps, making sure there is adequate light, and how to adjust posture more slowly to avoid dizzy spells. One of the things that becomes necessary is the use of an external device to improve balance, the dreaded cane. I have learned over the years, especially with the aging Baby Boom, never to refer to these things as canes. Canes are for old and frail people. Young and healthy people in their seventies need walking sticks, alpenstocks, trek poles, shepherds crooks, or some other such device that connotes health and exercise. In about fifteen years, I’m going to invest in a wizard’s staff and a pointy hat for myself.

This is not a new dilemma. We know this from Greek mythology and the legend of Oedipus. Long before he had difficulties with his parents, he was wandering in Egypt and ran across the sphinx. The sphinx, not the nicest of creatures, asked a riddle of travelers. If they answered correctly, they were allowed to pass; if not, they were torn limb from limb and tossed in the ditch. When Oedipus met the sphinx, the ditch was full of decaying bodies as the sphinx had not yet been defeated. Oedipus, being a cocky young man, said hit me with your riddle to which the sphinx replied ‘What walks on four legs in the morning, two legs at noon, and three legs in the evening?” Oedipus thought about it and replied “A human. First they crawl, then they walk, and then they need a staff”. This was, of course, the correct answer and he was allowed to pass. This story, which is three or four thousand years old, shows us that the need for assistance in ambulation as we grow older has always been there. We just like to pretend we’re not the same people our forebearers were.

Thus endeth the lesson in geriatric medicine for the day. Go forth in peace, but washeth thy hands, weareth thy mask, and keep thy distance.

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