SAN FRANCISCO – Falls are the main cause of hip fractures, and proven prevention strategies should be in every clinician’s toolbox.
Physicians should ask patients aged 75 years or older if they’ve had any falls in the prior year or if they have balance or gait difficulties and observe them walking and getting into and out of a chair, said Dr. Edgar Pierluissi, medical director of the Acute Care for Elders Unit at San Francisco General Hospital.
A fall in the previous year increases the risk for a future fall three- to fourfold.
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Group tai chi exercise has proven to be an effective strategy for reducing falls in the elderly.
Studies suggest that approximately 30% of U.S. adults over 65 years of age who are living in the community and half of adults over age 80 years will fall in the next year. Falls in adults aged 65 years or older cause injury in approximately 31%. Among those injured, 56% go to an emergency department and 38% visit a medical clinic, he said at a conference on osteoporosis sponsored by the University of California, San Francisco.
An exercise program with balance and strength training might be appropriate for older patients who’ve had only one or no falls and who don’t have balance or gait difficulties, various guidelines suggest. If a patient reports two or more falls or has balance or gait difficulties, do a "falls evaluation," an assessment of predisposing or precipitating factors that can point to appropriate preventive interventions, he said.
"We can perhaps make a difference" in many of the most common risk factors for falls that have been identified in 16 studies, Dr. Pierluissi said.
Muscle weakness quadruples the risk for a fall. A gait deficit, balance deficit, or use of an assistive device nearly triples the risk for falling. A visual deficit, arthritis, depression, or impaired activities of daily living more than doubles the risk for a fall. Cognitive impairment, use of some types of medications, or age older than 80 years each nearly doubles the risk for falling.
To conduct a falls evaluation, get a good history of the patient’s falls and their circumstances. Do a cardiovascular examination, medication review, neurological examination, and assessment for cognitive impairment. Assess gait, balance and mobility, muscle weakness, visual impairment, home hazards that might precipitate a fall, and the patient’s perceived functional ability and fear related to falling (because many people who fear falling restrict their activity, which can lead to deconditioning and increased risk of falling).
How to Reduce the Risk of Falling
A Cochrane Review of 111 randomized, controlled trials with 55,303 participants identified effective interventions to reduce the risk of falling (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD007146.pub2]).
A number of forms of exercise reduced both the number of people who fell and the number of falls. Group tai chi exercise or individually prescribed exercise programs at home were effective. Multiple-component group exercise was effective if it targeted at least two of the following: strength, balance, flexibility, and endurance.
Conducting a multifactorial falls evaluation reduces the number of falls. In patients with visual impairment and a high risk of falling, assessing and modifying home hazards was effective.
Withdrawing psychotropic medications and educating primary care physicians about the risk of falls association with drug therapy reduced the number of falls, but not the number who fell. In patients with cardioinhibitory carotid sinus hypersensitivity, cardiac pacing reduced the number of falls.
Vitamin D supplementation may reduce falls in people with low vitamin D levels, but it’s unclear whether this helps people with adequate vitamin D levels. Other preventive strategies of unknown effectiveness include correction of visual deficiency, hormone replacement therapy, or modifying home hazards for people who have not fallen.
The Cochrane Review suggested that wearing hip protectors may provide some marginally significant benefit to frail, older adults in institutional care but not for older people who remain ambulant in the community, Dr. Pierluissi said.
One randomized, controlled trial of 1,042 residents in 37 nursing homes found a high rate of adherence to wearing hip protectors (74%) but these did not reduce the risk for hip fracture during the 20-month study. Residents served as their own controls by wearing hip protectors with padding on one hip but not the other. Investigators stopped the study early due to lack of efficacy, with hip fractures on 3.1% of the protected hips and 2.5% of unprotected hips, a statistically nonsignificant difference (JAMA 2007;298:413-22).
Dr. Pierluissi said he has no relevant conflicts of interest.