Preventing falls in seniors: the surprising role of shoes [PODCAST]

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In this episode, Sheetal Gambhir, a geriatrician, discusses the importance of feet in preventing falls in elderly patients. She shares insights on what to look for in shoes, including surface area, heel height, and sole consistency. She also highlights the challenges in translating academic knowledge into practical advice, especially with the current shoe industry setup. Sheetal shares her dream of prescribing evidence-based shoes to prevent falls in seniors and the need for more randomized controlled trials on commercial shoes. Join us as we explore the role of shoes in falls prevention for seniors.

Sheetal Gambhir is a geriatrician.

She shares her story and discusses her KevinMD article, “Geriatric foot care 101: How shoes can help reduce the risk of falls.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today’s show is with Sheetal Gambhir. She is a geriatrician. Her KevinMD article is titled “Geriatric foot care 101: How shoes can help reduce the risk of falls.” Sheetal, welcome to the show.

Sheetal Gambhir: Thank you so much, Kevin. Truly, thank you for having me.

Kevin Pho: Sure. So we’ll get into your article a little bit, but first off, just briefly share your story and journey to where you are today.

Sheetal Gambhir: I was born and raised in India, essentially, and later on went into medicine, and I then followed it up with a fellowship in geriatrics. I finished that last year. I had a bit of a sabbatical and learned how to play pickleball instead of writing a book, and now I’m fresh, starting out as a PCP in Atlanta.

Kevin Pho: Excellent. So we were talking offline, and I understand you just started three to four weeks ago. So what have your first impressions been of being a new attending primary care physician?

Sheetal Gambhir: There’s a lot of billing and coding. I’m working in a value-based model, and that’s been pretty interesting, learning how that’s so different from the fee-for-service model. That’s been interesting.

Kevin Pho: Now, when you were training, did you get any classes or any training when it comes to billing and coding?

Sheetal Gambhir: No. You learn on the fly. They just kind of tell you to go ahead and do it.

Kevin Pho: Yeah. You are a geriatrician, and we read a lot of times that we do not have enough geriatric specialists. So tell us, what are some of the reasons why you chose geriatrics?

Sheetal Gambhir: So it kind of happened by chance. During the COVID pandemic, I was in the second year of my residency, and the way it worked out, our leadership decided that everyone just stays put wherever they are. I was working in the geriatric ward at that time, and I was there for, I think, two or three months, and that’s how I fell in love with it. It was pretty awesome, because that was the population that was pretty hard hit with COVID at that time, so we got to see how vulnerable they were.

And also, it was pretty amazing seeing how geriatricians worked, which is very different from the way, I think, family medicine doctors or internists work. So that was very interesting to see, and that’s how I knew: OK, this is what I really want to be doing.

Kevin Pho: Yeah. So you said that you saw geriatricians work for the first time during COVID, and you said it was a little bit different from how family physicians and internal medicine doctors work. So give us an example. How do geriatricians work a little bit differently?

Sheetal Gambhir: I think one of the things that I noticed geriatricians care about is mobility. They care about, and I never thought about this as a resident, how many times the patient is working with PT. So many times you’ll see PT notes, and they’re like, “Oh, we came, and the patient was busy with some procedure or something. We’ll see.” So the geriatricians get worked up about this. They’re like, “No, no. We’re going to make you walk. Even if there’s no physical therapist available, we’re going to find you one, or we’re going to do it ourselves.”

And that was the shift in mindset, that mobility is so important. We study about it, we talk about it, and then we just leave it to the nurses, or we leave it to physical therapists, and we think we’re done. Our job is to interpret results or think of medicines and think of how to get the patient out of the hospital, but we’re not thinking about mobility. We’re not thinking about incontinence and why that is important to the patient or the family. So thinking about those things was so different and refreshing.

Kevin Pho: So for those who don’t often work with the geriatric population, why is mobility so important?

Sheetal Gambhir: Mobility can really make or break your patients. The way we were taught was that even lying in bed for a day can lead to 1 to 3 percent muscle loss. That means more nursing home admissions, so that’s increasing health care costs. And then, when we don’t exercise and we’re not using our muscles, things go down. There’s more morbidity, there’s more mortality. So what we really want to focus on is keeping our patients functional as much as possible. Even though we know this, and in residency we were taught it, nobody really implements it, which is the sad part.

Kevin Pho: So as you know, I’m an internal medicine physician myself. I do primary care. Now, let’s say I’m in a room with a geriatric patient, and I want to ask them some questions to assess their mobility. What kind of questions should I be asking them?

Sheetal Gambhir: Well, that’s a good one. So what I do is ask them, “Describe to me your typical day.” That’s how I mostly see my patients once I’m trying to get to know them. I ask them to do that, and that’ll just give you everything you need. You will realize the level of function they have. When they’re waking up, are they taking care of others? Do they have stairs? Are they able to do certain things, or are they waiting on people to help them out? That will tell you so much about their level of mobility.

And the second thing is, more than asking, you make them do. So you ask them to just get up and walk, and in just that simple thing, you’ll see that so many patients will grab onto the handlebars and push themselves off. Just that little thing tells me that this person has weak quads and needs to be exercising. So there are these small, small clues that you can use to guide you on where, in the hierarchy of problems, this patient’s mobility should be.

Kevin Pho: All right, and speaking of mobility, we’re going to talk about foot care, which is essential to that. Your KevinMD article is titled “Geriatric foot care 101: How shoes can help reduce the risk of falls.” Now, how did your article come together?

Sheetal Gambhir: So I’m actually working on a book right now, and the book is for medical people as well as laypeople and patients themselves. Each chapter is a geriatric syndrome, which it kind of explains through anecdotes, but the idea is to help explain geriatric syndromes to people as well as clinicians, and what we can do about them. It focuses a lot on non-medicine ways of dealing with problems. So this article is a little excerpt from that book.

And why I care about this is that falls are the bane of every geriatrician’s existence. We hate falls, and the reason is they can kill, obviously. So head bleeds, or patients who have hip fractures; that’s very common. There’s a mortality of 40 percent associated with hip fractures within a year: 40 percent of those who have one, 40 out of 100 people, will die from one cause or another. So that’s why it’s important. And even if they survive the fall, there’s a lot of morbidity. There are so many patients who were functional and mobile, and then they had a nasty fall, and then they became bedridden or they became nursing home residents. So it’s important to talk about falls.

And the other thing I realized during my training was that when we were taught about falls, there was a lot of emphasis on, “OK, yeah, let’s get their medicine right,” or some of us would prescribe physical therapy, and that would be the end of it. You’d kind of be like, “I don’t know what else I can do. Falls are just a natural part of aging.” And I want to change that mindset, because no, it can be worked on. Not all falls can be prevented, but definitely a lot of falls can be prevented, and there are different ways of doing it.

And nobody during my residency taught me about shoes. It was only when I did my geriatric fellowship that we started talking about, “Oh, what kind of shoes is the patient wearing?” Even taking a look at the feet and the shoes of the patient became a very important part of my assessment as a geriatrician. As a result, I was like, “OK, I need to tell this to the world: Shoes are important, and you don’t need a doctor, for yourself or for your loved one.”

Kevin Pho: Yeah. So tell me more, because I certainly don’t always ask about footwear and shoes. So tell us, why are shoes so important?

Sheetal Gambhir: OK, so my article kind of outlines things we know about footwear and falls, and then what we don’t know. So what we do know is that there is an association. A lot of people walk barefoot; that’s very common in the elderly population. The reason is they might have crooked toes, hammer toes, corns, ulcers, things like that, that make it harder for them to wear shoes or slippers. And when they’re walking barefoot, they’re 11 times more likely to fall compared to when they’re wearing shoes. So that’s one thing we know.

The other thing we know is, I don’t know if you’ve had this happen in your clinic, but I have: In this southern part of the country, you see women being very proper. They’ll wear lipstick, and they’re quite chic, even at the age of 70. They’ll have small heels on when they’re going to church, because they want to look proper. But wearing heels that are more than 2.5 centimeters have been associated with falls.

And I don’t know how researchers gauged this part, which is the surface area of the shoe: If you do not have a broad-based shoe, and it’s narrow, then you’re more likely to fall. I have no idea, in real life, how one measures the surface area of a shoe and tells, “Oh, this looks fine, and this doesn’t look fine.”

So we know that. And then the other thing that different studies have noted is that people are not wearing the right kind of shoe. Physical therapists often notice, especially when patients are going for subacute rehab and things like that, that they are either wearing shoes that are too big for them or too narrow. That can cause a lot of problems, and it is also associated with falls. So we know that shoes and falls have a link, right?

And we also know, and this was something very interesting that I found out, and I hadn’t thought of it, it was kind of counterintuitive, that the more comfortable, soft-soled shoes are actually associated with a higher risk of falls. So when we were buying shoes for my mother-in-law, we wanted her to have the best shoes, where she would feel comfortable. But then she also falls a lot, and I was like, “Oh God, but this is going to make her fall more.” The firmer, harder-soled shoes are actually better. So it didn’t make sense, but that’s how it is.

Kevin Pho: Yeah, you’re right. That is so counterintuitive. I always see those advertisements, you know, like you’re walking on a yoga mat, you’re walking on clouds, those super soft shoes that I see often advertised. So you’re saying those actually are associated with an increased risk of falls?

Sheetal Gambhir: Yeah. And here is the problem that I find as a geriatrician. The fitting we can work on, and if they’re walking barefoot, we can tell them to wear proper shoes. But the other thing that the article kind of focuses on is that there’s a dearth of research. I want to be able to prescribe shoes; that’s my dream as a geriatrician. I want to write on a prescription pad, “One pair of Nike, whatever, XD 540 for falls,” and prescribe them, and they go to the Nike store and then maybe pay a copay and get the shoes that they need to prevent falls. That would be the dream.

And that’s only going to be possible if we have randomized controlled trials, good-quality data looking at commercial shoes that are already available. What is the risk of falls with those shoes? Are we reducing it? Are certain shoes worse off than others, that we should be telling our patients, “Please don’t buy these”? That is where I think this article could be helpful.

Kevin Pho: So when you’re advising the geriatric population to look for shoes, and they go to either some type of sports store or a shoe store, what kind of specific shoes are you asking them to look for? You did mention something about hard soles. So any specific type of shoe, like loafers versus running shoes versus different walking shoes? What should they be looking for at the store?

Sheetal Gambhir: I think that’s the hard part. I don’t know how to give that practical advice myself, because I can share with them what I shared. So some of the practical things that I think of: When I’m assessing my patients, I try and see if they can take their shoes off. If they are having a hard time even bending down and taking off their socks, I know they’re not going to wear shoes with laces, so I usually don’t recommend that. It’s fine to wear loafers or something that does not have laces, so it’s easier for them.

The second thing that I would kind of tell them is that the running shoes or the other shoes are usually made in a way that is specific to that. So I don’t ask them to get running shoes or tennis shoes; those are very differently made, for that purpose, for that movement. For a lifestyle of walking, walking shoes are fine. But I do tell them that they need to work on getting firmer soles. So if it feels too comfortable, then maybe not; try something a little firmer.

But this is the other pushback that I get: Arthritis is obviously very common in my population, and if there is a shoe that’s going to make their arches or ankles hurt, they’re not going to wear it. They’ll probably wear what they’re used to. And that’s where the challenge is. What is the right shoe? I don’t know, Kevin. That’s the short answer.

Kevin Pho: Now, when you recommend a type of shoe to your patients, do you often get some type of pushback? Do they sometimes say, “You know, I love my walking shoe. It’s super soft-soled, and I don’t want to switch”? So what kind of response do you get from patients when you make some of these recommendations to them?

Sheetal Gambhir: I think a lot of the time, with the shoe recommendation, the population that I’ll be working with doesn’t always have the means or the resources. The shoes can cost upwards of $100, so if they don’t feel the need, they’re not going to go ahead and specially buy them. But then you do have people who are very anxious about falls. You will have people who just stop walking or doing their regular activities because they almost fell or they have fallen. Those kinds of people are more open to the idea of, “Oh, if I wear the shoe, maybe I’ll feel a lot better.” So that population I can get to fairly easily.

Then the other thing is, it’s easier convincing people who are barefoot to wear shoes. So you kind of get a mixed bag. Some people are obviously going to be more motivated than others. But what I also found helpful is that it’s much easier to convince them to wear better shoes than to take a new tablet. So if you tell them, “Hey, you know, this is at least better than being on more medicine or having to worry about XYZ,” then sometimes that works.

Kevin Pho: Now, what’s the role of podiatry? When should you consider involving a podiatrist when it comes to choosing the right foot care for your patients?

Sheetal Gambhir: So if you examine your patient’s feet, that will give you a lot of information. I think something we commonly do is for diabetics, right? If they have bad neuropathy, or they have Charcot deformity and things like that, we do use our podiatrists. The other time when I use it is if I see, and this is very common, a hammer toe, right? You see that protrusion. And then if it starts bothering them, if it’s hurting, or it has started to limit their activities, that is when I will think about involving podiatry.

And the other thing, no matter what, I think the important thing is also to know whether insurance is going to pay for podiatry or not. So a lot of the time, the framework is limited not by medical knowledge or the indication, but actually by the insurance, which is a challenge.

Kevin Pho: We’re talking to Sheetal Gambhir. She is a geriatrician. Her KevinMD article is titled “Geriatric foot care 101: How shoes can help reduce the risk of falls.” Sheetal, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Sheetal Gambhir: Falls can leave patients disabled, and they cost a lot, so preventing falls is important. There’s a link between footwear and falls. Certain footwear is associated with a higher risk of falls: badly fitting footwear, either too big or too loose; high heels; and soft, cushiony footwear. They’re all associated with a higher risk of falls. And the third thing is that there is a dearth of research in this field, and if we just get enough research, and without spending a lot of money, I think we can make a meaningful change in the risk of falls for our patients.

Kevin Pho: Well, thank you so much for sharing your time and insight. Thanks again for being on the show.

Sheetal Gambhir: Thank you so much.

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