Falls and Fractures

The majority of fractures in the aging populations are caused by low impact violence such as a fall caused by slipping indoors. Many falls happen when getting out of bed, walking indoors or falling to the floor from a chair. The surroundings are often indoors and it happens in their own apartment or house. Both somatic and environmental causes of falls and following fractures must be examined and their possible association with current pharmacotherapy. 

What associations can there be between falls in old age and drugs During the last decades, a number of scientific studies have been performed to examine if there are associations or not (Blalock et al. 2005, Leipzig et al. 1999a,b). Several of these studies have shown that many different kinds of drugs increase the numbers of falls and especially in people 65 years or older. These falls can lead to both physical injuries and mental health problems in elderly with consequences for a long time afterwards. 

There are many different reasons why elderly people fall more easily than young people do. Chronic diseases often give rise to general weakness, less muscle strength and impaired balance which all can make falling more dangerous (Box 5.9). 

Joint disease (osteoarthritis, rheumatoid arthritis, gout) Depression 

Orthostatic hypotension Cognitive dysfunction Impaired eye sight 

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Goals in patients who have already suffered osteoporotic fractures include reducing future falls and fractures, improving functional capacity, reducing pain and deformity, and improving quality of life. 

Weight-bearing aerobic and strengthening exercises can decrease the risk of falls and fractures by improving muscle strength, coordination, balance, and mobility. 

Finally hold in mind that falls are frequent in old age and can lead to severe consequences, including sufferings both for the individual and the next of kin. Also the cost for the society of falls and fractures are considerable. Falls increase with the use of fall-risk-increasing drugs and polypharmacy and can be prevented by a multifactor approach including reassessing the medications used by older people. 

Flurazepam (Dalmane) This benzodiazepine hypnotic has an extremely long half-life in elderly patients (often days), producing prolonged sedation and increasing the incidence of falls and fracture. Medium- or short-acting benzodiazepines are preferable. High... 

Approximately a third of stroke survivors are functionally dependent at one year and stroke is the commonest cause of neurological disability in the developed world (Murray and Lopez 1996 MacDonald et al. 2000). Stroke also causes secondary medical problems, including dementia, depression, epilepsy, falls and fractures. In the UK, the costs of stroke are estimated to be nearly twice those of coronary heart disease (British Heart Foundation Statistics Database 1998 Rothwell 2001), accounting for about 6% of total National Health Service (NHS) and Social Services expenditure (Rothwell 2001). As the population ages over the coming two decades, the total stroke rate will probably increase unless there are substantial decreases in age- and sex-specific incidence (Rothwell et al. 2004a). Stroke deaths are projected to increase from 4.5 million worldwide in 1990 to 7.7 million in 2020, when stroke will account for 6.2% of the total burden of illness (Bonita 1992 Sudlow and Warlow 1997 Menken et al. 2000). 

Spasticity, muscle contractures, painful shoulder and other joints of a paralyzed limb, malalignment or subluxation of the shoulder, falls and fractures can all potentially be avoided by good nursing and physiotherapy. Osteoporosis in a paralyzed Umb presumably increases the risk of fractures but may be unavoidable (Sato et al. 1998). 

Gumming, R.G. Epidemiology of medication-related falls and fractures in the elderly. Drugs Aging 1998,12 (1), 43-53. 

Especially orthostatic hypotension, which can cause dizziness and imbalance, in the elderly, especially can result in falls and fractures. 

The goal from birth to around 20 to 30 years of age is to achieve the highest peak bone mass as possible. Beyond this age, the goals are to maintain BMD and minimize age-related and postmenopausal bone loss. In women and men with osteopenia, prevention of osteoporosis is the goal. For a variety of reasons, osteoporosis prevention is not always possible. For those at significant risk of developing an osteoporosis-related fracture, the aims are to increase bone mineral density, prevent further bone loss, and to prevent falls and fractures and their associated sequelae. For those who experience an osteoporosis-related fracture, the goals are to achieve adequate pain control, maximize rehahihtation... 

In contrast, a systematic review of double-blind randomized controlled trials, eight dealing with falls (n = 2426) and 12 with non-vertebral fractures (n = 42 279), there was a significant dose-response relation between the dose of 25-hydroxycole-calciferol and prevention of falls and fractures and no association between serum 25-hydroxycolecalciferol concentrations of 75-110 nmol/1 and serum calcium concentrations [42 ]. The authors suggested that the ideal oral dose of 25-hydroxycole-calciferol is in the range of 1800-4000 lU/ day. 

Falls SSRIs and serotonin and noradrenalin reuptake inhibitors (SNRIs) have long been linked with an increased risk of osteopenia/osteoporosis potentiating falls and fractures, especially in tiie elderly. A biological mechanism for these risks associated with SSRIs has been idenhfied. Studies have demonstrated a reduction in osteoblast proliferation and activity following treatment with SSRIs, the magnitude of such effects being linked to affinity to the serotonin transporter. In addition, recent research examining serotonin receptor expression in human osteoblasts and osteoclasts has found that SSRIs differentially inhibit bone cells via apoptosis [10 ]. 

Other trials have shown an increased risk of falls and fractures with annual oral administration of high doses of vitamin D. Therefore, supplementation with more frequent, lower doses is preferred. Yet the optimal dosing schedule is unknown and needs further investigation. In order to treat age-associated secondary hyperparathyroidism and to prevent osteoporotic fractures, a daily dose of 1000-1200 mg calcium and 800 lU vitamin D is recommended in elderly or individuals on chronic glucocorticoid therapy. 

As the number of people older than 65 years is expected to double in the USA over the next 15 years [6], sarcopenia is becoming a serious public health issue, with loss of mobility and increased risk of falls and fractures in the elderly population, and hence the importance of better understanding the pathogenesis and reducing the severity of sarcopenia. 

It has been reported by [8, 9] that neuropathic patients experience problems with gait and posture. They also suffer more falls and fractures. Gait analysis techniques are being used to explore both the role of the foot as a sensory organ and the contributions of proprioception to the control of movement. Others [10] have indicated the importance of footwear in the prevention of foot lesions in patients with Non-Insulin Dependent Diabetes Mellitus (NIDDM). 

With increased mobility there is a risk of falls and fractures. The effects of levodopa with benzerazide in 132 patients over a 6-year period have been studied and the side effects reported include 14 cases of fracture (71 ). In toxicity studies with benzerazide skeletal changes were observed in rats (72 ). 

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