Each year, hip fractures land 350,000 people in the hospital and 60,000 in nursing homes, according to the American Academy of Orthopaedic Surgeons. And the prognosis is bleak for hip fracture patients:
Be on the lookout
The best course of action a family physician can take is to help patients prevent osteoporosis and reduce their risk of falling, says James Mold, M.D., professor of family and preventive medicine and adjunct professor of geriatric medicine at the University of Oklahoma Health Sciences Center in Oklahoma City.
"Family physicians need to think about osteoporosis as early as possible and throughout a person's whole life," Mold says, offering these suggestions: Hound teens to get plenty of calcium to ensure they build as much bone mass as possible. Make sure elderly patients get enough vitamin D; many don't drink milk, and their skin no longer produces vitamin D in the necessary quantities. Counsel all patients against smoking, excessive consumption of alcohol and a sedentary lifestyle.
James Mold, M.D.: |
Identifying patients at risk of falling can prevent future disability. "For us to maintain our proper balance and posture, a number of different systems must function well," says Mold. "You have to be able to tell where you are in space, which depends upon senses in your feet, your vision and your inner ear. You also need muscle strength and reaction speed.
"All of us start to fall periodically, but we catch ourselves. People between 65 and 74 years of age are often still able to react quickly enough to catch themselves with an outstretched hand and are, therefore, more likely to break their wrist. Those 75 and older are more likely to land squarely on the ground and break a hip."
Conditions beyond frailty
Specific medical conditions also put patients at a high risk of falling. These include Alzheimer's disease, which affects visual-spatial orientation; Parkinson's disease, which causes postural instability; stroke; and peripheral neuropathy. Diabetes in the absence of neuropathy is not a strong risk factor for falling, says Mold.
Certain medications, including neuroleptic/antipsychotic drugs and benzodiazepines/anti-anxiety drugs, can increase a patient's risk of falling by slowing reaction speed.
Similarly, alcohol use is a risk factor, Mold points out. "Ten percent of falls at home may be related to drinking alcohol," he says. "Although alcoholism is not that common in the elderly, even one drink of alcohol reduces your reaction speed, and its effect can last for six or eight hours in an older person."
Genetic factors come into play for both osteoporosis and falls. Patients have an increased risk of falling and breaking bones if they have relatives who have done the same, says Mold.
At risk? Already down?
Once you determine that a patient is at risk of falling, what should you do? "List all the risk factors the person has and try to address as many as possible," Mold says. "It has to be an individualized, multipronged approach."
He also suggests getting patients into a Tai Chi class. A major study on fall prevention found that Tai Chi -- an exercise combining muscle strengthening with balance training -- reduced the risk of falling by between 30 percent and 40 percent.
Bone density testing in high-risk patients is warranted. And a new approach to fracture prevention is the use of hockey hip pads on nursing home patients to protect their hips if they do fall, he says.
If, despite your efforts, a patient takes a spill, don't disregard it. "Falls can be a clue to the onset of something new, like the first symptom of an infection or a new illness that hasn't been diagnosed yet," Mold says.
Physicians must explore the reason for the fall as thoroughly as they address the injuries that result. "In a younger person, we tend to address the injury and say, 'Don't let it happen again,'" he says. "With an elderly person, you have to think about why the fall occurred."
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