Causes of a sudden fall in an elderly person. Prevention of falls in the elderly. All causes of falls in old age can be divided into two groups
Falls in older adults can occur for a variety of reasons, but there are a number of simple preventive measures that can be taken to significantly reduce the risk of serious injury. In most cases, loss of support and slipping are to blame. These recommendations will help reduce the risk of a sudden fall in an older person.
Creating a safe indoor environment
The ideal, fall-free home environment has non-slip walking surfaces.
The room should always be in order, especially on the floor. Furniture and other objects should not interfere with walking. This means no electrical cords, small rugs, etc.
Keep floor surfaces clean and dry.
Make sure all rugs and rugs have anti-slip protection or are firmly secured to the floor, including carpeting on stairs.
Stairwells should be well lit and have strong handrails on both sides. Consider placing fluorescent tape around the edges of each step to help prevent falls.
Install grab bars on bathroom walls near bathtubs, showers and toilets. For those seniors who are unsteady on their feet, consider using a shower chair.
Use non-slip mats on shower and bathtub floors.
Place light switches near the entrance to each room to prevent falls in the dark. Another option is to install voice or sound lamps.
Reorganize closets and chests of drawers to minimize the need to bend or reach to retrieve items the older person frequently uses.
Older people often have a favorite pair of shoes or slippers, but if they are worn out, ill-fitting or impractical, they can become a serious hazard. Closed, low-heeled shoes with non-slip soles are ideal. At home, it is better to avoid walking in socks, stockings or barefoot.
Use of assigned mobility aids
Older adults are often reluctant to use walking sticks, walkers, or handrails, even though these devices play a key role in continuing to live a safe and active life. It is important to convince them to use this mobile assistance correctly.
Regular examinations with an ophthalmologist
Even small changes in visual field can increase the risk of falling in older and older adults. Encourage your loved ones to wear glasses so they can see their surroundings clearly. Regular examinations by an ophthalmologist will allow you to recognize and treat eye diseases at an early stage, as well as choose the right glasses to correct poor vision.
Ask older adults to be careful while they get used to their new glasses. For example, bifocal and trifocal lenses can cause altered depth perception while walking. This makes it easy to lose your balance and fall. To prevent this from happening, people who wear these glasses should practice looking straight ahead and keeping their head down.
From this article you will learn:
What are the causes of frequent falls in older people?
What symptoms indicate an imminent fall in an elderly person?
Where are older people most likely to fall?
What are the consequences of frequent falls in older people?
How to secure an elderly person's home to reduce the risk of falls
Each of us has heard the phrase more than once: “The elderly man fell!” Every year, about 40% of older people lose their balance. The consequences of a careless fall can be fatal and rank seventh among the causes of death in the population over 65 years of age.
In 75% of cases, death occurs due to loss of balance in 12.5% of people in this age category. Most old people conceal information about the fall that occurred because they do not want to admit their frailty, because, in their opinion, this could lead to restrictions on free movement and activities or their placement in closed institutions. But the fact that an elderly person has fallen must be reported, as it is very dangerous.
Causes of falls in old age
Predictors of falls among older adults include previous falls. But it should be noted that in old people, the reasons that provoked loss of balance rarely have a common cause. A fall in an elderly person can occur as a result of a complex interaction of various factors, namely:internal (age-related disorders in the body, side effects from medications);
external (threat from the environment);
situational (include actions that the old man performs, for example, quickly moving around the apartment).
- Internal factors.
- External factors.
- Situational factors.
Where are older people most likely to fall?
In most cases, older people fall at home, most often in the bathroom or toilet. Also, one of the common places for older people to lose balance is in medical institutions where they have to undergo treatment. In this regard, relatives should definitely inform the medical staff of the hospital where the elderly person is admitted about the possibility of him falling. In cases where facility staff are aware of the patient's predispositions, injuries resulting from loss of balance can be avoided. Most patients (about 80%) fall without witnesses, which deprives them of prompt help. On the street, loss of balance in older people most often occurs when walking on slippery sidewalks, wet asphalt, or when getting out of a vehicle. If an elderly person falls in a public place without witnesses, this situation leads not only to injury, but also to hypothermia, which results in pneumonia, infectious diseases of the urinary system and other inflammatory diseases.Symptoms that occur in older people before a fall
If an older person falls, they likely exhibited certain symptoms before the incident. In cases where the cause of loss of balance is external factors or a dangerous situation, there is practically nothing to indicate this. But when a fall occurs due to the poor physical condition of an old person, some symptoms can be observed.It may manifest itself in the following:
dizziness;
pre-fainting states;
fast, irregular heartbeat.
In most cases, a fall for an elderly person does not go unnoticed and leads to injury. The consequences are mainly minor contusions, bruises and sprains. In some cases, loss of balance leads to serious injuries such as broken bones, torn ligaments, deep cuts and internal organ damage. After an elderly person falls, a fracture of the femur is diagnosed in 2% of cases, and other fractures (shoulder, wrist, pelvis) in 5% of cases. Sometimes falls lead to loss of consciousness and head injuries.
If an elderly person falls and cannot get up but is conscious, this can cause a lot of difficulties. In such a situation, feelings of panic and helplessness may develop.
Staying on the floor after a fall for some time can lead to the development of problems such as:
Loss of fluid from the body;
Decreased body temperature;
Pneumonia;
Rhabdomyolysis (destruction of muscle tissue cells, leading to the development of kidney failure);
Bedsores (death of soft tissues due to poor circulation in them).
Diagnosis of an elderly person after a fall
To determine what caused an older person to fall, the doctor needs to determine what symptoms the patient was exhibiting before the loss of balance, what the circumstances were at the time (for example, chest pain, dizziness, and shortness of breath), and what kind of activity provoked the incident. The doctor interviews possible witnesses to the fall about what they saw. The doctor also needs to provide information about the medications that the old man is taking, about the use of alcoholic beverages, as well as about everything that could lead to the incident. In addition, the physician should know whether the person lost consciousness and whether he got up on his own. First, the doctor performs a physical examination to determine whether there are any injuries and to find out what caused the old man to fall.Diagnostic measures will be as follows:
Blood pressure measurement. In cases where the pressure decreases when moving from a horizontal to a vertical position, the cause of the drop may be orthostatic hypotension.
Listening to heart sounds. A doctor uses a stethoscope to listen to an old man's heartbeat to look for signs of slow heart rate, arrhythmia, heart failure and heart valve disease.
Determining the volume of muscle strength and range of motion. The doctor examines the patient's back and legs to identify problems with the feet.
Study of the organs of vision and nervous system. The doctor diagnoses the functions of the nervous system, evaluates the functioning of the vestibular apparatus and muscle strength.
Complications after a fall in the elderly
If an older person falls, and this is not an isolated incident, the risk of injury, hospitalization and even mortality increases. This especially applies to older people who have concomitant diseases and deficits in activities of daily life. The possibility of reducing injury lies in the limitation of motor functions of elderly patients, fear of falls and institutionalization. According to statistics, 40% of older people fall in nursing homes.
Mild to moderate injuries occur in 50% of cases when an elderly person falls. In 5% of cases, people over 65 years of age require hospitalization. If an old man stumbled and fell on his hands, then 5% of such incidents result in fractures of the humerus, wrist and pelvis. About 2% of balance losses result in hip fractures. In 10% of cases, elderly people are diagnosed with serious injuries after a fall (for example, injuries to the head, internal organs or cuts). In some situations, loss of balance can be fatal. Most older people are prone to falls and cannot get up on their own. If an elderly person falls and cannot get up, being on the floor for more than two hours can lead to dehydration, bedsores, rhabdomyolysis and hypothermia. There is also a risk of developing pneumonia. After a fall, older people's vital signs deteriorate sharply. About 50% of older patients who were seen as outpatients before a fall and hip fracture are unable to regain their previous level of mobility. Due to loss of balance, older people may develop a fear of repeating a similar situation, since the level of mobility often decreases and a sense of stability is lost. After a fall, an older person should avoid certain activities (such as shopping or cleaning the house). As activity decreases, stiffness and weakness increase, which further leads to decreased mobility. Fall prevention in old age
External hazards that can be eliminated or corrected:
Improving lighting by increasing the number of lighting fixtures or lamps.
Move the switches so that they are easy to reach. Lighting fixtures that turn on when touched or respond to movement are also great.
Cords that lie on the walkway must be removed under floor coverings or secured under the doorway. You can also add additional outlets to avoid the need for extension cords.
Provide good lighting on the stairs inside and outside the house, as well as in the local area that the elderly person uses at night. Steps must be equipped with a non-slip surface and durable handrails. You can cover them with bright stripes.
Remove unnecessary items that are lying haphazardly on the floor or stairs.
In the bathroom and toilet rooms, you can attach additional handrails in those places where you need to hold on to climb. It is necessary to securely fix them so that they do not come off the wall.
Most old people have disturbed sleep at night, so they often wake up, can read, take medicine, etc. In this regard, essential items (glasses, medicine, book, drinking water, watch) should be nearby, at the head of the bed. This will eliminate the need for nighttime walking around the room and reduce the likelihood that the elderly person will fall.
When choosing house shoes for the elderly, you need to pay attention to the fact that they fit well on the foot, do not slip on the floor, have a soft heel and a low heel. If it is difficult for an elderly person to lace shoes, it is better to purchase shoes with Velcro, elastic or fastener. It is not recommended to buy slippers without backs, as they increase the risk of falling, the foot is not fixed and often slips out.
Understanding how to avoid putting an older person at risk is more important than addressing external risk factors. In some cases, it is necessary to pay attention to potential causes of loss of balance and consider how you can carry out daily activities calmly. For example, replace a wired telephone with wireless devices, placing them in different parts of the house so that an elderly person does not have to rush to the phone.
Good afternoon. I will try to describe as fully as possible what is happening to my grandmother.
Woman 1935 gr. I have been to the hospital several times throughout my life. Both times were associated with suspected cancer. The first time, back in the 80s, there was an operation on the thyroid gland (after which he takes medications for this very thyroid gland (I don’t know the name), the second time - already in the early 2000s, they removed a nodule on the chest. Then the nodule was taken for examination - but it was oncology not found.
Until 2007, the woman was very lively. I also played football with my grandson. She didn’t exactly run, but she hit the ball quite well. It’s clear that she completely took care of herself + was in service in one social organization caring for retired WWII veterans. She cooked, cleaned and washed. Everything is fine! But since the end of 2007. there was a gradual decline. Around 2009 She already began to walk with a cane and literally after a few months she began to feel unsteady. Those. began to fall. He says that for no reason he will feel dizzy and bang... already on the ground. Gradually, day after day, she continued to fail. I went to the doctor. He said that he had some kind of disorder in his head and prescribed pills, which she took. (I can’t say the diagnosis because I don’t have a map at hand). And then at the end of 2012. (November) Granny fell at home. Again, she says she's dizzy and BANG... she's on the floor. Only this time, unlike many others, the grandmother was no longer able to get up. He says his back hurts a lot and he can’t move. This was the last day she walked on her own.
They took her to the hospital. So the diagnosis was first made: a spinal fracture. We are terrified! But then, during a more detailed analysis, the doctor said that the grandmother had a simple injury. They hired her a nurse who constantly sat with her and systematically bothered her. Because Since the hospital did not have a neurology department, it was decided to transfer her to another hospital.
At the hospital, the grandmother is diagnosed with stage 3 dyscircular encephalopathy. against the background of hypertension, atherosclerosis, ischemic heart disease, cardiosclerosis, akinetic-regid syndrome, pyramidal syndrome, frontal dysbasia. Severe cognitive impairment.
After discharge (11/30/12)
Table: Trental 0.1 3r. per day – 1 month
Table: Lixidol 125ml – 3 rubles. per day - 1 month
Table: nootropil 0.4 - 2 rub. per day (morning-afternoon) - 2 months.
Table Madopar 250 mg. 1 tablet * 3 rubles per day - constantly.
BUT!!! Every day my grandmother is getting worse. She has not been able to take care of herself since her fall in November 2012. But if before she could at least somehow move, now we actually carry her on us. She can’t sit on the toilet by herself – if you just put pressure on her, they ask: “When will you be able to walk on your own, grandma?!” And the answer: - I'm coming! At the same time, she is sitting on the sofa. He recognizes names and faces, but he cannot add 5+2, despite the fact that he has a higher education in economics and has always added prices in his head, and confuses the day of the week and the month. He can continue counting 1, 2,3,4,5 – only up to the number 5, then he stumbles. Etc.
In general, every day she gets worse and worse. And remembering that, according to the doctor, since 2009 my grandmother was treated for the wrong thing (they said she took the wrong pills), doubts crept in that this treatment was also incorrect. Well, he can’t give up on a person so quickly. She passed in just a couple of weeks, and continues to pass every day.
Maybe there is some possibility of admitting her to a hospital in Moscow or Moscow Region, or maybe you can tell me how to replace the medications she takes?! It’s just that at one time, when she accidentally missed taking Madopar (day-evening), she seemed to be better, but then she got sharply worse.
The local clinic actually spat on me. They actually brought the neuropathologist by the hand. She walked for almost 5 months, very busy. As a result, she admitted that my grandmother was sick and gave a referral to receive a 2nd group of disability.
For quotation: Schwartz G.Ya. Osteoporosis, falls and fractures in old age: the role of the D-endocrine system // Breast Cancer. 2008. No. 10. P. 660
Demographic changes that occurred in the last decades of the twentieth century. and continuing in the 21st century, including a noticeable increase in life expectancy, have led to a significant increase in the proportion of older people in the population. According to the World Population 2007 report prepared by the United Nations Population Fund and presented in June 2007, out of the current 6.6 billion world population, the number of people over the age of 60 is more than 705 million with a clear upward trend in industrialized countries. In Russia, the proportion of elderly (60-75 years old) and senile (75-85 years old) people is close to the indicators for Western Europe and the USA and in total is about 30 million, which exceeds 20% of the country’s total population. A study of the elderly population shows that this group is extremely heterogeneous in terms of somatic, psychological and mental status. According to the WHO age period classification (1973), women aged 55-74 years and men aged 60-74 years are considered elderly, 75-89 years old - senile age, 90 years or more - long-livers. As a person ages, the morbidity structure changes significantly as a result of a decrease in the number of acute diseases and an increase in the prevalence and incidence of diseases associated with the progression of chronic pathological processes. The health status of elderly and senile people is characterized by a high level of accumulation of pathology against the background of pronounced age-related changes in various organs and systems (primarily the kidneys, heart, gastrointestinal tract, endocrine glands, etc.). The elderly population is characterized by a high incidence of morbidity in general, among which the leading diseases are cardiovascular and oncological diseases, as well as diseases of the musculoskeletal system, including osteoporosis (OP). Due to the high medical and social significance, in the last 10-15 years, the entire range of issues related to AP (epidemiology, pathogenesis, clinical picture, diagnosis, treatment, medical, social and economic aspects, etc.) has received significant attention. Each of these questions is important, and without them the OP's problem cannot be discussed. A feature of this systemic skeletal disease, characterized by a progressive decrease in bone mass per unit volume and disruption of the microarchitecture of bone tissue, is scanty clinical symptoms, which leads to insufficient attention to the possible presence of AP by both patients and medical workers. The outcomes of AP - increased bone fragility and fractures - are often the basis for post-facto diagnosis of the disease and initiation of therapy.
Main features of OP, falls
and fractures in old age
The distribution curve of fractures in the population is bimodal with peaks in childhood and old age (Fig. 1). It is believed that fractures forming an early peak are not associated with AP. They are represented by fractures of the skull bones in infants, traumatic fractures of the bones of the extremities (mainly the diaphysis of long tubular bones, hands and fingers) in adolescents (5-14 years old) and young adults (mainly males) due to high physical activity (games) , sports, etc.). The late peak in the incidence of fractures, beginning in women aged 55-64 years and in men aged 65-74 years, is represented mainly by fractures of the vertebral bodies, as well as so-called peripheral fractures - the proximal femur, distal forearm (Collis fracture), somewhat less frequently - the proximal humerus and pelvic bones and some other localizations. Until recently, this peak in the incidence of fractures was associated with AP. From an epidemiological point of view, these fractures are characterized by: 1) frequency rates, which increase significantly with age; 2) gender differences - they are observed much more often in women (2 or more times more often), and only at the age of 85-90 years the frequency of fractures in both sexes approaches; 3) dependence on minor/moderate trauma to those areas of the skeleton that contain sufficiently large volumes of trabecular bone.
As a rule, OP develops at the age of 60-70 years, and more than 80% of all cases of the disease occur in women. Thus, the main group of patients with this disease are: a) elderly and senile people; b) predominantly female, which reflects its functional connection with both age and gender. In clinical practice, AP occurs in a number of types and forms. Taking into account the etiology and pathogenesis, primary and secondary AP are distinguished. Primary AP combines the two most common forms of the disease - postmenopausal AP and senile AP, accounting for up to 85% of all its cases. In addition, relatively rare cases of idiopathic AP (OP in men, AP of unknown etiology in adults), as well as juvenile AP, are classified as primary. The etiology of primary AP remains unclear to date and is the subject of intensive, including genetic, research. As for secondary AP, the causes of its occurrence and the main links of pathogenesis are clearer, because its variants and forms are largely associated with specific diseases, in particular those of endocrine origin, pathology of the gastrointestinal tract, kidneys, blood system, iatrogenic effects (use of glucocorticoid hormones, antiepileptic drugs, etc.).
Features of elderly patients, including patients with AP, include a decrease in the background of endocrine-immune dysfunction of total muscle mass (sarcopenia) and the presence of weakness of voluntary muscles (weakness syndrome), decreased vision (decreased acuity and narrowing of visual fields) and adequate functioning of the vestibular system. device, which is accompanied by an increased risk of falls and resulting injuries and fractures (Table 1, Scheme 1). It is known that more than 50% of patients with AP have sarcopenia, approximately 25% of them suffer from postural hypotension, and the vast majority have impaired vision and partially impaired mobility.
The role of falls associated with internal causes, including dysfunction of the musculoskeletal system (muscles, bones, sense of balance, proprioceptive reflexes, etc.), is especially important. Gait changes appear in 50% of elderly and 100% of old people. They are manifested by a shortening of the step and height of the foot (the angle of the foot in old people is close to 10°, in contrast to 30° in young and middle-aged people). Swaying when walking increases and the depth of perception of the surface decreases (decreased tactile and deep muscle sensitivity of the feet). Walking speed and coordination of movements decrease, reaction time increases, a noticeable decrease in muscle strength and endurance is observed (fatigue syndrome), and a feeling of fatigue prevails (Diagram 2).
Sarcopenia, joint pain and decreased mobility play a leading role in these disorders. An age-related decrease in physical performance and endurance, and any dysfunction of the lower extremities lead to a violation of the motor stereotype. The gait of old people becomes shuffling, unsteady, they have difficulty overcoming even small obstacles, which indicates the presence of spatial-motor maladjustment. Many who have had falls develop a fear of repeating them. For this reason, they further limit physical activity (including exercise, walking, etc.), which, in turn, increases the risk of repeated falls.
When considering the relationship between falls and fractures in the elderly, it is also important to take into account the direction of the fall. If young people fall predominantly forward, then older people and old people usually fall to the side. This direction of fall is accompanied by the maximum application of the impact force on the surface to the pelvis/hip joint/femoral neck/femur area. Against the background of weight loss, redistribution of subcutaneous fat from the hips to other areas, often observed in the elderly population, as well as sarcopenia, the natural mechanical protection of the femoral region is significantly reduced, which increases the risk of hip fracture.
Falls in elderly and senile people may be due to internal causes (age-related changes in systems that maintain body balance, weakness syndrome, a number of diseases - neurological and somatic, taking certain medications) and external causes (insufficient lighting, steep stairs, etc.) . Unlike young people, only 14-15% of falls in older people are caused solely by external causes, for example, falling on an icy sidewalk. In other cases, falls are associated with internal factors and occur at home or in a hospital ward. The risk of falls and their complications is significantly higher in patients who have been on bed rest for a long time. Prolonged immobilization is accompanied by AP, muscle weakness, often a certain amount of social isolation and the development of depression.
Changes in gait in older people predispose to falls. With age, walking becomes slower, the stride shortens, the duration of the period of pushing off from the support decreases, and the period of support on both legs increases. Falls are more common in older women than in older men, which may be due to gender differences in gait changes with aging. As women age, they tend to waddle and walk with their legs close together; in men, a flexor posture is more common, a tendency to walk in small steps, with legs widely spaced. At the same time, a fairly large proportion of older people (up to 20%) do not have clinically obvious walking disorders. It is assumed that imbalances in elderly and senile people are associated not so much with aging, but with various diseases, including those that are not clinically evident (myelopathy of various origins, the initial stages of Parkinson’s disease, normal pressure hydrocephalus, etc.). It should be noted that the occurrence of walking disorders is an unfavorable prognostic sign of the subsequent development of dementia (especially vascular dementia).
Maintaining posture and balance depends on the functioning of a complex of systems: sensory, motor, musculoskeletal. Aging and disease in the elderly may involve any of the above components, and the combination of factors involved is often additive. However, in most cases, a leading pathological factor can be identified, and treatment should be aimed at eliminating it.
Sensory information comes through the proprioceptive, visual and vestibular pathways. These systems are very plastic, and when one of them is pathological, the other two take on the function of the damaged one. However, in the event of suffering (damage) to two systems, the functioning one bears the entire burden of providing afferentation, and in case of its insufficiency, imbalances occur and the likelihood of falls increases. With age, there is a decrease in the number of deep sensitivity receptors, which is especially pronounced in patients with rheumatoid arthritis and cervical spondylosis. This leads to a decrease in afferentation from the spinal cord to the overlying parts of the central nervous system. It is assumed that in some patients such a decrease in proprioception leads to the clinical picture of the so-called vertebrobasilar insufficiency, although in fact dysgemic disorders in the vertebrobasilar system do not play a significant role in the genesis of such disorders. The cause of pathological muscle fatigue may be myasthenia gravis, the incidence of which in elderly and senile people is often underestimated. Falls are often caused by alcoholism or alcohol abuse at home, especially in people who are depressed or live in relative social isolation. The risk of falls with even small doses of alcohol increases significantly as tolerance to alcohol decreases with age.
The likelihood of falls increases with the number of risk factors: in people without factors, falls occur in 8% of cases, and in people with 4 risk factors or more - in 78%. Only in a small percentage of cases falls occur under the influence of one factor; most elderly patients have several factors predisposing them to falls, which together enhance the adverse effects of each of them. It should be emphasized that the risk of falls increases significantly with the acute development or exacerbation of chronic somatic diseases.
External factors leading to falls include poor lighting in rooms, uneven or slippery floor surfaces, uncomfortable shoes, etc. Falls most often occur when going down stairs, as well as when getting up from a chair/chair or from bed. Insufficiently attentive care for patients, especially those with mnestic-intellectual disorders, contributes to falls. The risk of falls increases in the first days after hospitalization or immediately after stopping bed rest.
Among the causes of falls in the elderly, various cardiovascular disorders accompanied by syncope (fainting) also occupy a significant place. In particular, the rapid development of loss of consciousness followed by recovery is characteristic of arrhythmias, while in epilepsy the rapid development of loss of consciousness is followed by slow recovery. Vasopressor syncope is characterized by a rapid onset with prodromal phenomena (often against the background of emotional stress) followed by rapid recovery. A thorough examination reveals orthostatic hypotension in almost 30% of elderly and senile people. However, a significant proportion of these patients do not experience dizziness or any visual disturbances when standing up. Predisposing factors that may be accompanied by the development of syncope may include coughing, sneezing, and a sudden change in body position (standing up).
Factors predisposing to impairment of coordination and motor functions that increase the risk of falls and fractures in elderly patients with AP are also some of the medications prescribed to them simultaneously (polypharmacy or polypharmacy) (Table 2), primarily from the groups of hypnotics, antidepressants, antihypertensives, etc., which can increase the risk of falls by more than 40%. In this regard, the presence of iatrogenic problems, i.e. associated with medical influences, is a feature quite characteristic of old age. Polypharmacy in old age is a very common and difficult to manage phenomenon, associated not only with the use of therapy prescribed by a doctor, but also with self-medication, with the availability of over-the-counter medications (so-called OTC medications).
Epidemiology and medical and social characteristics of falls in the elderly
In Russia, accidental knocks and injuries have occupied the overall structure of causes of mortality since the late 80s. last century, second place after cardiovascular diseases. Unfortunately, official statistics do not reveal the place of falls in the structure of morbidity, injury, disability and mortality. At the same time, such statistics and analysis are being conducted abroad. In particular, the US Department of Health has the Center for Disease Control and Prevention, which pays serious attention to the problem of falls. Thus, in particular, according to this Center, among the US population, more than 1/3 of people aged 65 years and older experience a fall at least once a year, and falls themselves are the leading cause of traumatic deaths and non-fatal injuries requiring hospitalization. In 2005, 15,800 elderly people died due to injuries sustained from unintentional falls; 1.8 million people aged 65 years and older visited emergency departments due to falls; 433,000 were hospitalized in trauma departments. The analysis concluded that fall-related mortality among older people has increased significantly over the past decade. Up to 30% of people who fall have severe traumatic injuries, including subdural hematomas, femoral neck fractures, and head injuries. It has been shown that the majority of fractures of any location are associated with falls. Men have a 49% higher risk of fatal falls than women. In 2000, in the United States, total medical costs associated with the treatment of fatal falls amounted to $179 million, and more than $19 billion for the treatment of non-fatal falls. According to WHO (2004), up to 30% of people over the age of 65 years and 50% of those aged 80 years and older experience a fall at least once a year, 30% of which are accompanied by serious injuries (fractures, head and spinal injuries, concussions, soft tissue injuries, etc.). Moreover, approximately half of them experience falls more than once a year. Among the most common causes of falls are: accidents associated with external causes (slippery, uneven road with obstacles) - 31% of cases, with internal causes: muscle weakness and balance disorders - in 27%, dizziness - in 13% of cases, arthrosis joints of the lower extremities - in 11%, depression - in 3%, visual impairment - in 2%, etc. The risk of fractures due to falls is especially significant in patients who have impaired motor functions (paresis, ataxia) after a stroke. In persons who have fallen, peripheral fractures are observed in 5% of cases and fractures of the femoral neck are observed in 1% of cases. According to available data, more than 90% of femoral neck fractures are associated with falls.
The role of D-deficiency in the pathogenesis of falls
In the last two decades, modern ideas about vitamin D3 (cholecalciferol) have been formed not as, in fact, a vitamin in the classical sense of the term, but as a steroidal biologically inactive prehormone, which is converted in the body into an active metabolite - D-hormone, which, along with a powerful regulatory effect on calcium metabolism and a number of other important biological functions.
In the body, vitamin D3 is formed from a precursor found in the skin (provitamin D3), 7-dehydrocholesterol, under the influence of short-wave ultraviolet irradiation. Vitamin D3, which comes in small quantities from food or is formed in the body in the process of endogenous synthesis, as a result of two successive hydroxylation reactions in the liver and kidneys, is converted into the active hormonal form - 1a,25-dihydroxyvitamin D3 (also called D-hormone, calcitriol or 1a .25(OH)2 D3).
D-hormone, together with parathyroid hormone and calcitonin, is traditionally combined into a group of calcium-regulating hormones, the function of which is to maintain the physiological level of calcium in the blood plasma due to both direct and indirect effects on target organs. In addition to maintaining calcium homeostasis, 1a,25-dihydroxyvitamin D3 also affects a number of body systems, such as the immune and hematopoietic, regulates cell growth and differentiation, etc.
The molecular mechanism of action of 1a,25-dihydroxyvitamin D3 is similar to other steroid hormones and consists of interaction in tissues with specific receptors called vitamin D receptors (VDR, or in English transcription - VDR). These receptors are widely present in the body and are found in at least 35 organs and tissues, not only in the classic target organs for vitamin D (intestines, kidneys and bones), but also in the brain, heart, skeletal muscles, pancreas, parathyroid and prostate glands, intestines, organs of the excretory and reproductive systems, as well as other organs and tissues, which is further evidence that 1a,25-di-hydroxyvitamin D3 is a typical hormone that performs many regulatory functions .
One of the main and most thoroughly studied functions of vitamin D and D-hormone is participation in maintaining calcium homeostasis: through interaction with RBD in the cells of target organs, D-hormone causes the synthesis of calcium-binding proteins that carry out the absorption of calcium in the gastrointestinal tract and its reabsorption in kidneys, fixation in the skeleton.
D-hormone, in addition to participating in the maintenance of calcium homeostasis, skeletal development and bone remodeling processes, also affects the functions of skeletal (syn. voluntary or striated) muscles, which have specific RBD.
Back in the mid-70s of the 20th century, it was found that vitamin D and its metabolites have a stimulating effect on the metabolism of skeletal muscles. RBD were subsequently discovered in the muscles of animals and humans. Genetic studies have established that the removal of the gene encoding the expression of RBD proteins in animals (“knockout” animals for this gene) is accompanied by the development of pathologically altered (shortened and different in size) muscle fibers while maintaining generally normal myocyte differentiation. At the same time, significant metabolic disorders in the muscles were found in the “knocked out” animals: hypocalcemia, hypophosphatemia, accompanied by unusually high and persistent production of pathologically altered muscle proteins, such as myf5, myogenin, E2A, isoforms of myosin light chains, etc. The data were especially important obtained from the orthopedic clinic of the University of Basel (Switzerland), that in muscle tissue in elderly and senile ages there is a progressive decrease in the number of RBD (Fig. 2).
According to modern concepts, the D-hormone stimulates the uptake (influx) of Ca2+ into voluntary muscles due to the nuclear mechanism, the 2-phase formation of diacylglycerol (DAG), and the second phase of this process is independent of the hydrolysis of phosphoinositide under the influence of phospholipase C. It stimulates the hydrolysis of phosphoatidylcholine in mammalian tissues due to a mechanism catalyzed by phosphalipase D, which involves Ca2+ ions, as well as protein kinase C and G proteins.
In recent years, the molecular mechanisms of action of 1,25(OH)D3 in skeletal muscle have been significantly detailed. D-hormone has been shown to modulate calcium homeostasis in skeletal muscle cells both through classical genomic action, which is the control of gene expression, and through a non-genomic mechanism, including direct membrane effects of the hormone mediating various signaling systems. This steroid rapidly modulates Ca2+ influx due to G-protein-mediated activation of phospholipase C and adenylate cyclase, leading to activation of phosphokinases C and A, release of Ca2+ from intracellular stores (cisterns) and activation of voltage-dependent L-type Ca2+ channels.
It has also been established that a rapid change in the entry of labeled 45Ca2+, caused by 1,25(OH)D3 in muscles and in cultured myoblasts, is accompanied by a parallel increase in the level of calmodulin (CM) protein associated with membranes with a simultaneous decrease in the concentration of CM in the cytosol without changes in its total quantity in the cell. D-hormone rapidly alters calcium homeostasis in skeletal muscle cells by shifting the signal transduction mechanism, which promotes the release of Ca2+ from stores and entry from outside into the cell through voltage-gated L channels and store-operated Ca2+ channels.
Another characteristic biological effect of D-hormone is its effect on cell proliferation and differentiation. It also manifests itself in skeletal muscle cells and is associated with an effect on the Raf-1 protein. This protein, discovered as the first member of the cytoplasmic serine/threonine kinase family, plays a leading role in the activation of the classical cytoplasmic signaling cascade, which is involved in the regulation of cell proliferation, differentiation and apoptosis. Activation of Raf-1, as a consequence of activation of protein tyrosine kinase receptors, is mediated by Ras-GTP-binding proteins, which are necessary to stimulate Raf-1 kinase activity. Raf-1 then phosphorylates and activates a mitogen-activated protein kinase (MAPK) kinase known as MEK, triggering a protein kinase cascade that leads to phosphorylation and activation of extracellular signal-regulated protein (MAP). ) - kinase (MAPK), existing in 2 isoforms: ERK1 and ERK2. Due to activation of MAP kinase (MAPK), it moves from the cytoplasm to the nucleus, where it phosphorylates transcription factors and thus triggers the processes of proliferation or differentiation of different cell types. It was found that 1β,25(OH)2D3 in target cells - myoblasts (chicken embryonic muscle cells) causes activation of Raf-1 through Ras and phosphokinase Ca-dependent serine phosphorylation and that this mechanism plays a central role in hormone stimulation MAPK signaling pathways that trigger muscle cell proliferation.
Thus, D-hormone plays an important role both in the differentiation and proliferation of skeletal muscle cells and in the implementation of Ca2+-dependent mechanisms, which are one of the central ones in the process of muscle contraction.
Disturbances in the formation of hormones and their deficiency are important causes of many human diseases. Deficiency of one of them - D-hormone (more often referred to as vitamin D deficiency) also has negative consequences and underlies a number of types of pathological conditions and diseases. Below we discuss both the characteristics of vitamin D deficiency and its role in the occurrence and development of common diseases.
Under physiological conditions, the need for vitamin D varies from 200 IU (in adults) to 400 IU (in children) per day. It is believed that short-term (10-30 min) sun exposure to the face and open arms is equivalent to taking approximately 200 IU of vitamin D, while repeated exposure to the sun in the nude with the appearance of moderate skin erythema causes an increase in 25OHD levels above that observed with repeated administration. at a dose of 10,000 IU (250 mcg) per day.
D-hormone deficiency is most often represented by D-hypovitaminosis or D-vitamin deficiency. In contrast, for example, to the dramatic decrease in estrogen levels in postmenopause, this term usually refers to a decrease in the level of formation of 25OHD and 1a,25(OH)2 D3 in the body and disturbances in its reception. D-deficiency plays a significant role in the pathogenesis of not only primary osteoporosis (involutional types of osteoporosis (OP) - postmenopausal and senile, juvenile osteoporosis), and secondary forms of this disease (steroid-induced osteoporosis, etc.), as well as some other types of skeletal and extraskeletal pathology.
There are two main types of D-hormone deficiency, sometimes also called “D-deficiency syndrome.” The first of them is caused by deficiency/insufficiency of vitamin D3 - a natural prohormonal form from which the active metabolite(s) (1a,25(OH)2 D3) is formed. This type of vitamin D deficiency is associated with insufficient sun exposure and dietary intake, as well as constant wearing of clothing that covers the body, which reduces the formation of natural vitamin in the skin and leads to a decrease in the level of 25OHD in the blood serum. A similar situation was previously observed mainly in children and was essentially synonymous with rickets. Currently, in most industrialized countries of the world, due to the artificial fortification of baby food with vitamin D, deficiency/insufficiency of the latter is relatively rarely observed in children. However, due to the demographic situation that changed in the second half of the twentieth century, such a deficiency often occurs in older people, especially those living in countries and territories with low natural insolation, having an inadequate or unbalanced diet and insufficient physical activity. People aged 65 years and older have been shown to have a 4-fold decrease in the ability to form vitamin D in the skin. Due to the fact that 25OHD is a substrate for the enzyme 1a-hydroxylase, and the rate of its conversion into the active metabolite is proportional to the level of substrate in the blood serum, a decrease in this indicator below 30 ng/ml interferes with the formation of adequate amounts of 1a,25(OH)2 D3. It was this level of decrease in 25OHD in the blood serum that was detected in 36% of elderly men and 47% of elderly women as a result of a study (Euronut Seneca Program) conducted in 11 countries of Western Europe. Although the lower limit of serum 25OHD concentration required to maintain a normal level of 1a,25(OH)2 D3 formation is not known, its threshold values appear to range from 12 to 15 ng/ml (30-35 nmol/l) .
25OHD deficiency is considered in close connection with impaired renal function and age, including the number of years lived after menopause. At the same time, both geographical and age differences in the level of this indicator were noted, as well as its dependence on the time of year, i.e. on the level of solar insolation/number of sunny days, which must be taken into account when conducting relevant studies and analyzing the data obtained.
25OHD deficiency has also been identified in malabsorption syndrome, Crohn's disease, conditions after subtotal gastrectomy or bypass operations on the intestine, insufficient secretion of pancreatic juice, liver cirrhosis, congenital atresia of the bile duct, long-term use of anticonvulsants (anti-epileptic) drugs, nephrosis.
Another type of vitamin D deficiency is not always determined by a decrease in the production of D-hormone in the kidneys (with this type of deficiency, both normal and even slightly increased levels of the D-hormone itself in the blood serum can be observed), but is characterized by a decrease in its reception in tissues (resistance to hormone), which is seen as a function of age. Nevertheless, a decrease in the level of 1a,25(OH)2 D3 in plasma during aging, especially in the age group over 65 years, has been noted by many authors. A decrease in renal production of 1a,25(OH)2 D3 is often observed in AP, kidney diseases (renal failure, etc.), in elderly people (>65 years), with deficiency of sex hormones, hypophosphatemic osteomalacia of tumor origin, PTH-deficient hypoparathyroidism , PTH-resistant hypoparathyroidism, diabetes mellitus, under the influence of glucocorticosteroids, etc. The development of resistance to 1a,25(OH)2 D3 is believed to be due to a decrease in the amount of RBD in target tissues (primarily in the intestines and kidneys). In addition, a decrease in the expression of RBD in voluntary muscles in the elderly was found. Both variants of vitamin D deficiency are essential links in the pathogenesis of the main types and forms of AP.
The most significant role is played by disturbances in the formation and reception of D-hormone in the main involutional form of AP - senile AP. This type of AP in elderly patients of both sexes is characterized by the dissociation of initially closely related remodeling processes (decreased new bone formation against the background of increased bone resorption). Among the pathogenetic mechanisms of this condition, along with a decrease in the production of sex hormones (estrogens and testosterone), the so-called somatopause (deficiency in the production of growth hormone and insulin-like growth factor, IGF), primary and secondary deficiencies of D-hormone, due to a number of reasons, are important . Among them are a decrease in the motor activity of older people and their exposure to the sun, a decrease in the formation of D-hormone in the kidneys and bones due to a decrease in the activity of 1a-hydroxylase (at the age of 70 years this decrease reaches 50%), a decrease in organs -targets of the number of RBDs and their affinity for the ligand. These changes lead to a decrease in the absorption of Ca2+ in the intestine and an increase in its leaching from the bones to maintain the stability of the concentration in the blood plasma, which is realized through the development of secondary hyperparathyroidism, increased synthesis of PTH and the resulting activation of the resorption process and OP. In addition, deficiency of D-hormone leads to a limitation in the synthesis of bone matrix proteins due to a decrease in the formation, differentiation and activity of osteoblasts, the synthesis of cytokines by these cells involved in conjugation and the intensity of remodeling processes, which has an adverse effect on bone mass and quality. It should also be noted that a decrease in the production of D-hormone leads to disruption of the normal functioning of the neuromuscular system, because the conduction of nerve impulses from motor nerves to striated muscles and the contractility of the latter are Ca-dependent processes. In this regard, vitamin D deficiency/insufficiency contributes to impaired motor activity in elderly patients, impaired coordination of movements and, as a result, increases the risk of falls, which are associated with the majority of cases of fractures in senile AP.
Problem with falls
and vitamin D deficiency
According to modern concepts, one of the important and common causes of sarcopenia in the geriatric population is vitamin D deficiency, accompanied by muscle weakness. The development of vitamin D deficiency in old age is mainly due to the following reasons:
- unbalanced diet and use of foods with insufficient vitamin D content,
- rare and short exposure to the sun,
- thinning of the skin (reduction in the thickness of the dermal layer - the site of vitamin D formation),
- disruption of the processes of hydroxylation of prehormonal forms of vitamin D in the liver and kidneys,
- impaired reception of 1,25(OH)2D3 in tissues.
The widespread prevalence of D-deficiency in the elderly is evidenced, in particular, by the results of a study of 824 people aged 70 years and older, conducted in 11 countries of Western Europe: in 36% of men and 47% of women in the winter season, the concentration of 25(OH)D3 in blood serum was<30 нмол/л. Важно отметить и то, что количество рецепторов к витамину D (РВD) в ядрах мышечных клеток с возрастом резко снижается. В частности, при иммуногистологическом исследовании биопсийных образцов m. gluteus medius, полученных от женщин (n=20, ср. возраст 71,6 года) при проведении хи-рур-гических операций тотальной артропластики шейки бедренной кости, и биоптатов m. transversospinalis от 12 женщин (ср. возраст 55,2 лет) при проведении операций на позвоночнике было выявлено прогрессирующее в возрастом снижение числа РВD в обеих исследованных мышцах (r=0,5, p=0,004, рис. 2). При этом не было обнаружено сильной корреляционной связи между экспрессией РВD и уровнями 25ОНD и 1,25(ОН)2D3 в сыворотке крови. В то же время мультивариантный анализ результатов исследования позволил авторам сделать вывод о том, что пожилой возраст является важным предсказательным фактором корреляции между снижением числа РВD и уровнем 25(ОН)D3.
Data on the high correlation between the level of D-hormone in the blood serum and creatinine clearance are of undoubted practical interest. Muscle weakness associated with vitamin D deficiency usually occurs predominantly in the proximal muscle groups and is accompanied by a feeling of heaviness or pain in the legs, fatigue, difficulty climbing stairs or getting out of a chair. In this case, the changes mainly affect the muscle groups of the lower extremities responsible for the vertical position of the body and walking. These disorders, reaching the level of distinct myopathy, can be partially eliminated by normalizing nutrition, staying in the sun and taking vitamin D supplements.
Along with genomic and non-genomic mechanisms that regulate the supply of Ca2+ ions into skeletal muscle and are necessary for the implementation of its contractions, genetic mechanisms dependent on the RBD genotype make a significant contribution to the implementation of the effects of 1,25(OH)2D3. Specifically, in a study of elderly female twins of the 2 homozygous types, differences of 23% in quadriceps strength and 7% in handgrip strength were found. There are other studies indicating a connection between RBD polymorphism and the state of voluntary muscles.
Accordingly, with vitamin D deficiency, there is a decrease in muscle strength, the ability to extend the lower extremities at the knee joint, the distance traveled and walking speed.
Despite numerous studies on this problem, carried out in different depths and with the participation of significantly different groups of elderly people, there is no final clarity regarding drug prevention and treatment of muscle disorders caused by vitamin D deficiency. In some cases, positive results have been obtained with the use of native vitamin D preparations, manifested in a decrease in the incidence of falls and associated fractures. There are also observations that the use of native vitamin D preparations is not accompanied by a significant effect on the state of the muscular system and does not prevent falls in the elderly. At the same time, in a placebo-controlled study involving 378 elderly men and women, it was found that daily intake of a D-hormone analogue, the drug alfacalcidol, at a dose of 1 mcg/day. over 36 weeks leads to a significant reduction in both the number of falls and the number of patients in whom they were observed. Apparently, such heterogeneous results reflect differences in research methods, the number of patients included in them, the influence of time of year, etc. More uniform positive results were obtained in studies using drugs of active metabolites of vitamin D. However, even among them there is information about insufficient effectiveness therapy.
Nevertheless, among these studies there are some that can be considered as very serious, providing the maximum possible objectification of the results at present. These primarily include the STOP/IT (Sites Testing Osteoporosis Prevention and Intervention Treatments) study, conducted at Creighton Medical University (Omaha, USA), which involved 489 women with postmenopausal AP. This double-blind, randomized, placebo-controlled study compared three pharmacotherapies: (1) hormone replacement therapy with conjugated estrogens in combination with medroxyprogesterone acetate, (2) the active metabolite of vitamin D, the D-hormone (calcitriol), and (3) a combination of both. pharmacotherapy.
During the first phase of the study, which lasted 5 years, 8000 women aged 67-77 years (average 71 years) were examined, of whom 489 were randomized into three groups. In accordance with the inclusion criteria, the patients did not have severe concomitant diseases. The treatment period was 3 years. To assess the duration of the effect, in the second phase of the study, patients were re-examined 2 years after cessation of pharmacotherapy. The study protocol included assessing the incidence of new fractures using the X-ray method. During the study, patients received 700 mg of calcium per day from food; no additional calcium supplements were prescribed.
During treatment, an increase in BMD was noted in both groups of patients receiving HRT. In the group receiving calcitriol, an increase in this indicator was also observed, which was, however, less pronounced than in the combination therapy group (HRT + calcitriol). In the placebo group, there was a decrease in BMD compared to baseline.
As a result of the studies, it was found that in the group of patients receiving calcitriol, the incidence of new fractures was 2 times lower than in the HRT and placebo groups. The effect of combination pharmacotherapy on the incidence of fractures did not exceed the similar effect of calcitriol monotherapy. The use of HRT did not lead to a decrease in the incidence of new fractures, despite a significant increase in BMD compared to the calcitriol group. From these results, the authors made two very important and interrelated conclusions: 1) the use of calcitriol significantly reduces the incidence of new fractures; 2) for the prevention of fractures, improving the quality of bone tissue is more important than increasing BMD.
Another aspect of the STOP/IT study that is important in the context of this section is the effect of different types of pharmacotherapy on the incidence of falls, which are associated with the majority of fractures in old age. Falls were found to be common at baseline in all patient groups: at least 50% of included patients fell at least once over 3 years. When analyzing the data, it was found that in the groups receiving HRT and placebo, the incidence of falls was the same, while in the group receiving calcitriol, this indicator was statistically significantly lower. Compared with the placebo group, the incidence of falls in patients receiving calcitriol was 15% lower, and per person - 30% lower. This result was unexpected, primarily because the patients were not severely deficient in vitamin D: serum 25OHD levels averaged about 30 ng/ml (75 nmol/l).
In summary, this study showed that the reduction in fracture incidence is a consequence of the use of calcitriol, which not only has a positive effect on bone quality, but also reduces the incidence of fractures. At the same time, the study authors concluded that this drug of the active metabolite of vitamin D in elderly patients with postmenopausal AP increases muscle strength, improves neuromuscular coordination and the balance of flexor-extensor functioning, apparently affecting well, not only directly on the skeletal muscles, but also, probably, on the central mechanisms of motor functions, because RVD was detected in the central nervous system. In addition, a fundamental conclusion was made, which is currently shared by leading experts in AP, that pharmacotherapy aimed only at increasing BMD does not adequately reduce the risk of peripheral fractures, since it does not reduce the incidence of falls.
Convincing data on the positive effect of another drug from the group of the active metabolite of vitamin D - alfacalcidol on the condition of voluntary muscles and the frequency of falls were obtained in a double-blind, placebo-controlled study in patients of both sexes (age 65 years and older) with reduced creatinine clearance. It was shown that the use of the drug in a daily dose of 1 mcg for 36 weeks is accompanied by a reduction in the risk of falls by 71% compared with the placebo group (p = 0.019) (Fig. 3). At the same time, not only the frequency of falls, but also the number of patients in whom they were observed before the start of the study significantly decreased. The data obtained on the prevention of falls when using alfacalcidol, a drug that has been widely used in our country for more than 15 years (Alpha-D3-Teva®) for the treatment of all types and forms of osteoporosis and some other calcium-dependent diseases, significantly complements its characteristics and creates the prerequisites to expand indications for use.
Fall prevention is a new aspect in the treatment strategy for AP, aimed at preventing peripheral fractures. The US National Institutes of Health has expressed high interest in studying the problem of falls in general, uncovering their mechanisms and developing preventive measures.
In discussing the connection between this issue and vitamin D, there are a few points to reiterate in closing. Firstly, it became obvious that even a moderate deficiency of vitamin D is accompanied by negative consequences not only in the skeletal system, but also in the functioning of voluntary muscles. Secondly, in older people, this deficiency is both a factor/link in the pathogenesis of AP and predisposes to impaired motor function and increases the risk of falls - the direct cause of fractures. Thirdly, in connection with the already noted above decrease in the amount of RVD and the reception of 1,25(OH)2D3 in old age, the use of drugs with active metabolites of vitamin D (calcitriol, alfacalcidol) is necessary for the treatment of AP and the prevention of fractures.
It is known that the administration of biologically inactive native vitamin D does not reduce the frequency of falls, since in old age the body’s ability to form D-hormone (1,25(OH)2D3) in the kidneys decreases. In studies by Chapuy et al. (1997), Pfeiffer et al. (2002), Bischoff et al. (2003) showed that the administration of native vitamin D preparations to patients with serum 25OHD levels below 10 ng/ml can significantly increase this indicator, but not the level of 1,25(OH)2D3. In particular, the work of Bischoff et al. (2003) the use of cholecalciferol in a daily dose of 800 IU for 12 weeks was accompanied by an increase in the average values of 25OHD in the blood serum by 71%, while the concentration of 1,25(OH)2D3 increased by only 8%. Analysis of these data indicates the need to use preparations of the active metabolite of vitamin D (Alpha D3-Teva) for the prevention of falls, which do not require (unlike preparations of native vitamin D) biotransformation in the kidneys to form a biologically active form - D-hormone.
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13.04.2016
Fall Prevention
Often, people start thinking about prevention only after an accident occurs - for example, a fall, etc. Meanwhile, it is always easier to prevent a disaster than to eliminate its consequences, treat a fracture and care for the victim for a long time and help him recover.
Even if this has already happened, it is worth thinking about prevention in the future so as not to end up in a similar situation again.
In Germany, nursing science has developed a so-called expert standard for fall prevention. There are a number of such standards - for example, “pain”, “dystrophy”, “bedsores”, they relate to the most important aspects of the patient’s health and quality of life. Fall prevention is one such aspect. The standard describes everything that needs to be done to ensure that an elderly and/or disabled person does not fall, and, accordingly, to prevent such an accident as a hip fracture from occurring. It identifies the causes of falls, groups of people at increased risk of falls, consequences of falls, interventions in the event of a fall, and finally, a variety of measures to prevent falls.
If you have elderly or disabled people in your home, it may be worth assessing their fall risk and taking appropriate measures.
The causes of falls are divided into two groups: internal and external.
Internal diseases include various diseases of the musculoskeletal system, nervous system or cardiovascular system. To keep things simple, I’ll simply note: if a person is limping, suffers from back or joint pain, or is unsteady when walking, naturally the risk of falls is increased. It is also increased in Parkinson's syndrome or multiple sclerosis, when muscle tone and coordination of movements are impaired. In any case, if a person has difficulty moving, this is a risk. The risk of falls is also increased if a person suffers from dizziness, heart failure, low blood pressure, or heart rhythm disturbances; Also, hypoglycemia in diabetes is a risk of dizziness/weakness and falls.
All people with dementia, even mild dementia, are at increased risk of falls because they lack sufficient cognitive awareness of the environment.
The risk of falls is also increased by taking certain medications, for example, many psychotropic drugs, sedatives, and antiarrhythmics.
Internal factors also include fear of falling. If your relative has already fallen or been injured, the fear of falling will arise in the future, and this does not reduce, but on the contrary, increases the risk.
As for external risk factors, everything is simpler here: uncomfortable clothes and bad shoes (we’ll talk about this later), wires on the floor and lying objects, poor lighting, narrow passages, slippery floors (or ice on the face), lack of objects or handrails, that you can hold on to.
And now about prevention itself. It has two goals: to prevent a fall in general and to minimize its consequences.
Prevention of falls in residential areas. What measures can be taken to achieve this?
· - Remove carpets on the floor, wires, and unnecessary objects from the room where the patient at risk of falls lives.
· - The floor covering must be non-slip: carpet, rough linoleum, etc.
· - It is desirable to have no steps or thresholds.
· - Rubber mats should be placed in the shower and bathtub.
· - Bright enough lighting, but not blinding.
· - Arrange furniture so that it does not interfere with walking.
· - If possible, install handrails on the walls for holding – this is especially important in the toilet/bathroom and in the corridor.
· - A special high toilet seat, preferably with handrails.
· - In an elderly person’s room, things should not be stored on mezzanines and high cabinets; stepladders and similar climbing devices should not be used.
· - To prevent the patient from bending over, special devices are desirable, for example, a grabber for lifting objects.
You should definitely consider how someone in need of care can call for help. In Germany, this can be done by installing a home alarm system, where the patient wears a special bracelet and can call the mobile care service directly from the bracelet. It seems that in Russia there are no such opportunities yet, so if an elderly or disabled person lives or is left alone for a long time, it is worth teaching him or her to use a mobile phone (perhaps you need a phone with large buttons) and carry it with you at all times. Otherwise, there is a risk that the person will fall and lie on the floor for hours, unable to call for help.
It is important, of course, to treat underlying diseases, say, in case of diabetes, avoid hypoglycemia, and wear glasses in case of poor vision.
At night, you can install a toilet chair near the bed so that the patient does not have to walk across the entire apartment to the toilet.
Clothing should be comfortable, and great attention should be paid to shoes. How many older people fall just because they wear “not a step back” flip-flops or cozy woolen slippers at home! This is, of course, convenient - but it is fraught with danger. The soles of shoes must be anti-slip and shoes must have heels. Sometimes it is worth taking care of orthopedic shoes.
Prevention of falls includes physical therapy and physical exercise - the stronger the muscles and ligaments, the more confident a person is on his feet, the less likely he is to fall. Physical education also helps overcome the fear of falling.
Finally, various aids can be used to prevent falls. These are rollators, walking sticks, crutches (the latter are usually used temporarily, after an injury).
But there are also protectors for the head and hips. This is especially true for patients with dementia. It is often completely impossible to prevent a dementia patient from falling - after all, he or she overestimates their capabilities, cannot call for help, gets up and moves as they please, without thinking about the danger. Therefore, it is necessary to at least minimize the consequences of falls. And the most dangerous injuries from falls are concussions and hip fractures.
Thigh protectors are worn under pants and soften the impact of a fall.
Contrary to popular belief, restraining the patient (tying him in a bed, to a chair, etc.) is not a method of preventing falls.
I still remember the times when almost all dementia patients in hospital care sat or lay, secured with belts. But, in addition to ethical considerations, statistics have shown that bracing does not reduce, but increases the number of falls! This is logical: someday a person will still have to be untied, and having lost the habit of free movement, he falls almost immediately. Patients have become entangled in belts, and even deaths have been reported. The raised bed rail caused the patient to climb over it and fall to the floor from a height.
We currently use very little restraint in our residential care setting. There were, of course, difficult patients who did not want to lie down at night, but were not able to walk on their own - they got up and fell. In such cases, we placed a mattress next to the bed. One patient even slept on the floor on a mattress so as not to fall out of bed at night. Now we use special mats for dementia patients; when stepped on, a bell rings at the duty nurse's station. These mats significantly reduce the risk of falls - when the call is made, the nurse or caregiver immediately runs to the patient's room and helps him get to the toilet or get back into bed.
At home, this is, of course, hardly possible. But as you can see, there are many very simple, basic measures that, when applied, can reduce the risk of falls - and ensure that your relative will no longer break his hip.
Basically, you just need to think about it and don't lose sight of the simple things.
Yana Zavatskaya
Tags: Prevention of falls in older people
Description for the announcement:
Start of activity (date): 04/13/2016 10:15:00
Created by (ID): 6
Key words: Prevention of falls, hip fracture, treatment of fracture, pain, dystrophy, bedsores, quality of life of the patient, a person limps, suffers from back pain, is unsteady when walking, Parkinson's syndrome, multiple sclerosis, coordination of movements, a person suffers from dizziness, heart failure , low blood pressure, heart rhythm disturbances, hypoglycemia in diabetes, dementia, cognitive assessment of the environment, fear of falls, Preventing falls in the home, large button telephone, toilet chair, rollators, walking sticks, crutches, head protectors and for hips, concussions, femoral neck fractures, Hip protectors, patient restraint, tying up in bed, dementia patients, getting to the toilet, getting into bed
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