Secondary prevention of falls and osteoporotic fractures in older people
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7509.123 (Published 14 July 2005) Cite this as: BMJ 2005;331:123All rapid responses
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The remarkable association between fractures in the elderly and the
locale of accident, has for too long been neglected. In a random survey
among the older age groups, we found most accidental falls occured 'in the
bathroom'. The overwhelming statistical significance between frequency of
fracture and the constancy of the locale wherein it was acquired in,
requires analysis and assessment.
Our preliminary inferences embolden us to postulate that the sudden
change of posture, from astride or asquat the toilet seat, to an erect
one,is of some bearing on the causes of accidental falls.
The sudden downward shift in the garvitational 'G' forces within
cranially directed arterial columns, due to a rapid change of positiopn
from sitting to standing, can engender transient alteration and imbalance
in blood pressure.The situation is akin to the physiological stress
suffered by the astronaut during the upward thrust during space launch.
The odds of this transient "black-out" increases with vascular and
circulatory physiological compromizes, concurrant and common with advances
in age.
It would worth delving a bit deeper into this nebulous areas of
science. The biophysics of gravity, and its effects on posture, stance,
balance, sex and age, may well provide a key to better undertanding of the
problem of fracture-falls in the elderly, and hopefully also provide clues
to preventive measures.
Competing interests:
None declared
Competing interests: No competing interests
Effective Falls Prevention into Practice
The Editorial by Oliver et al. (1) brings to our attention that falls
and fracture assessment and prevention is often not done in tandem,
despite there being a fairly strong evidence base for both and a strong
causal association between falls and fractures. Services in the UK,
although backed by high grade evidence based guidelines (2,3,4), are still
often lacking individualized, tailored, falls prevention specific exercise
in their provision. A recent British Geriatric Society Survey on Falls
Services was disappointing with only 69% suggesting a formal exercise
programme was part of their service and with 41% of exercise programmes
reporting no strength or balance training (the two key components of a
successful exercise programme for fallers)(5).
The problem, as we are all aware, is that any Falls Service will be
swamped if professionals referred all people at risk of falling. For
many, tailored, specific exercise will provide important benefits to both
balance and bone health. Correctly tailored and progressed exercise can
significantly reduce risk of falls even in those with a history of
frequent falls (6). Weight resisted exercise is effective for bone health
as well as strengthening muscles and stabilizing joints for efficient
movement. Even older patients with established osteoporosis can reduce
their falls risk (7).
Yet, money is still invested in single interventions (eg. sloppy
slipper exchanges) rather than exercise services which are evidence based.
Health services must acknowledge that physical activity and group exercise
has many additional benefits to older people, including reducing fear and
isolation, improving independence, reducing depression and improving other
health outcomes (8). With all this evidence, why is it that even those
services in the UK which claim to be “comprehensive and integrated” often
have no exercise provision within their falls care pathways? Where there
is some provision, it is often only for a very brief duration, with no
formal mechanism for monitoring and supporting exercise adherence and
progression, or for ongoing referral into a community based programme.
Yet, a community, evidence based, interdisciplinary falls exercise
service, of appropriate duration and intensity is known to be effective in
engaging older people with a high risk of falls (9).
It is time for Commissioners and Health Service Managers to invest in
an intervention that is known to both prevent and manage falls in the same
way they have effectively invested in Phase IV cardiac rehabilitation.
References
1. Oliver D, McMurdo MET, Patel S. Secondary prevention of falls and
osteoporotic fractures in older people. BMJ 2005; 331:123-124
2. NICE Guidelines. Falls: the assessment and prevention of falls in
older people. 2004. National Institute of Clinical Evidence, London.
3. American Geriatrics Society, British Geriatrics Society and American
Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guidelines for
the prevention of falls in older persons. J Am Geriat Soc 2001; 49: 664-
672.
4. All Party Parliamentary Osteoporosis Group (APPOG) 2004. Falling
short; Delivering Integrated Falls and Osteoporosis Services in England.
5. Ali A, Morris RO, Skelton DA, Masud T. Falls Services in the UK – A
Survey of UK Geriatricians. 5th National Conference on Falls and Postural
Stability. Manchester, 2004.
6. Skelton DA, Dinan SM, Campbell M, Rutherford OM. FaME (Falls
Management Exercise): An RCT on the Effects of a 9-month Group Exercise
Programme in Frequently Falling Community Dwelling Women age 65 and over .
Journal of Aging and Physical Activity 12 (3); 457-458 (In Press, Age and
Ageing)
7. Liu-Ambrose T, Khan KM, Eng JJ, Janssen PA, Lord SR, McKay HA.
Resistance and agility training reduce fall risk in women aged 75 to 85
with low bone mass: a 6-month randomized, controlled trial. J Am Geriatr
Soc. 2004; 52: 657-65.
8. Department of Health. National Service Framework for Older People:
Modern Standards and Service Models. 2001: London, Her Majesty’s
Stationary Office. Standards 3,5,6 and 8.
9. Dinan S, et al. Camden & Islington PCT Falls Exercise Service
(FES). Poster accepted for the 6th National Conference on Falls and
Postural Stability, Manchester, Sept, 2005.
Competing interests:
None declared
Competing interests: No competing interests