Fall Prevention and Osteoporosis

Osteoporosis (or porous bone) is a disease in which bones become less dense, resulting in weak bones that are more likely to break. Without prevention or treatment, osteoporosis can progress without pain or symptoms until a bone breaks (fractures). Fractures associated with osteoporosis can take a long time to heal and can cause permanent disability.

Osteoporosis is not just an "old woman's disease." Although it is more common in white or Asian women older than 50 years of age, osteoporosis can occur in almost any person at any age. In fact, many American men have osteoporosis. In women, bone loss can begin as early as 25 years of age. Anyone with osteoporosis, male or female, young or old, is at risk for broken bones from falls. However, most falls do occur among elderly women.

Because osteoporosis has no symptoms, people may not be aware that they have decreased bone density (osteopenia) or osteoporosis. Falls are especially dangerous for people who do not know they have weak or less solid bones. If a bone does break from a fall, a person's activities may be limited while the bone is healing. Surgery or a heavy cast may be necessary, and physical therapy may be required to resume normal activities.

Three factors are related to whether or not a bone breaks from a fall: the fall itself, the force and direction of the fall, and how fragile the bones are. Prevention of falls is very important for people with osteoporosis because of their fragile bones. According to the National Institutes of Health (NIH)

• of all broken hips, a majority are associated with osteoporosis;
• falling is the cause of 95 percent of hip fractures in the U.S.;
• a hip fracture makes an elderly person more likely to die in the first year after this injury than other elderly people;
• of elderly people living without assistance before a hip fracture, a significant percentage will need care in long-term care institutions (nursing home, assisted living) a year after their fracture;
• most falls happen to women in their own homes in the afternoon.

Factors that increase the risk for falling

• Muscle weakness around the hip joint
• Increased unsteadiness when on the feet
• Intake of more than three medications
• Using a cane when its rubber tip is worn through
• Old age

Causes of falling

• Loss of footing: Loss of footing means a loss of contact between a foot and the ground. Footing can be easily lost if people use things for purposes other than what is intended, for example, using a kitchen chair as a ladder or stool.
• Loss of traction: Loss of traction occurs when the surface is wet or slick and a person slips or when the ground is uneven and a person trips.
• Vision problems: Usually, wearing glasses can correct vision problems that develop with age. However, these glasses are often bifocals, which have one level of vision correction at the top of the glasses' lens (for looking far away) and another level at the bottom of the lens (for looking close up). This means that the vision is distorted when looking down at the feet through the bottom of the glasses' lens, making it easy to lose balance and fall. Also, for many older people, glasses cannot fix their vision changes, so they cannot see clearly and their chance of falling is increased.
• Loss of balance or balance problems can cause falls.
• Diseases that impair mental or physical functions: Certain diseases affect circulation, sensation, mobility, or mental alertness. These diseases can increase the risk of falling.
• Certain medications (such as sedatives): Older people often have medical conditions that require taking several medications. People who take certain medications (such as blood pressure pills, heart medicines, diuretics or water pills, or muscle relaxers or tranquilizers) or multiple medications are more likely to fall as a result of drug-related side effects such as dizziness, confusion, disorientation, or slow reflexes.
• Change in reflexes: Reflexes are automatic responses to something in the environment. For example, stumbling to catch one's balance or reaching out an arm to catch the body as one trips are reflexes. Reflexes become slower as one ages, making it harder to regain balance after a sudden body movement.
• Changes in muscle and fat: The strength and amount of muscle (muscle mass) changes as a person ages. Muscle mass usually decreases because people exercise less and become less active as they age, meaning muscles are weaker. With age, the loss of body fat that cushions and protects bony areas, such as the hips, occurs. This also affects the soles of the feet, which changes the ability to balance.

The force and angle of a fall

The force of a fall (how hard a person lands) is a significant factor in whether a person will have a broken bone or not. For example, falling a longer distance increases the risk of fracture, so a taller person has a greater risk of a broken bone from falling than a shorter person does. The angle of a fall is also important. Falling sideways or straight down is more likely to cause a broken bone than falling backward. Any bone will break if the force from the fall is strong enough and if the fall occurs at a certain angle, but reducing the force of the fall or falling at a less dangerous angle may prevent fracture.

Protecting oneself during a fall

Using one's reflexes and changing one's body position during a fall can protect a person from breaking a bone, especially the hip. Putting one's hands out to catch oneself is a reflex during a fall. If a person lands on his or her hands or grabs onto something while falling, he or she is less likely to break a hip, but the fall could break the wrist or arm. Of note, even though a broken arm or wrist is painful, it is less likely to cause long-term disability or death compared to a broken hip.

Landing on a softer surface could reduce the risk of a fracture. That is why hip (trochanteric) pads are recommended by some physicians. For people in nursing homes or people who have already had a broken hip, hip protectors are worn to reduce the impact of trauma and may protect the bone when a fall occurs from a standing position. However, studies have not conclusively demonstrated that these hip protectors can protect people at risk of a broken hip, and their use remains controversial.

Certain factors, such as female gender, family history of osteoporosis, use of medicines that increase bone loss, small body size, and an inactive lifestyle, are associated with increased risk of developing osteoporosis (see Prevention of Osteoporosis and Bone Mineral Density Tests for details on risk factors or take a 1-minute osteoporosis risk test from the International Osteoporosis Foundation).

People with osteoporosis have thinner, weaker bones compared to the average healthy population, but people with osteoporosis often do not know they have it. This is because osteoporosis has no symptoms, so many people do not know they have weak bones until they have an unexpected fracture. For example, a simple everyday movement such as picking up a grocery bag causes a broken bone, or a slip and fall in a parking lot causes a broken hip, and that is the first "symptom."

Preventing osteoporosis and treating it to prevent further bone loss is essential to protect against broken bones. The bottom line is to preserve the bone mass and density a person has to decrease the risk of broken bones (osteoporotic fractures) and disability. The many treatments available today have been shown to work quickly (within one year), and they reduce the risk of fracture by up to 50%. The choice of treatment should fit a person's specific medical needs and lifestyle, so talk to a doctor (see Treatment of Osteoporosis and Prevention of Osteoporosis).

The following steps may prevent osteoporosis (porous bone) and osteopenia (weak bones):

• Get enough calcium and vitamin D from the diet to keep bones strong.
• Exercise regularly (especially weight-bearing and resistance exercises).
• Talk to the doctor about bone density tests (for example, dual energy X-ray absorptiometry [DXA or DEXA] scanning) for early detection of osteoporosis.
• If osteoporosis or osteopenia has occurred, talk to the doctor about medications to reduce bone loss.

The best way to avoid a broken bone is to avoid a fall. Certain safety tips are recommended by the National Institutes of Health:

Outdoor safety tips

• When the ground is slippery or wet, such as in rainy or snowy weather, use a walker or cane for added stability and wear shoes with rubber soles for added traction.
• When it is cold or snowy, wear warm boots (so the feet do not go numb) with rubber soles for added traction.
• Pay attention to the floor in public buildings because many floors are made of highly polished marble or tile that can be very slippery, especially if the floor is wet.
• Find and use delivery services, such as 24-hour pharmacies or grocery stores that take orders over the phone and deliver, especially in bad weather.
• When going out, keep the hands free by using a shoulder bag, fanny pack, or backpack instead of a clutch purse or a bag or wallet held in the hands.
• Always stop at curbs and check the height before stepping up or down. Be careful using walkways for wheelchairs, grocery carts, bicycles, etc., because the incline up or down may lead to a fall.

Indoor safety tips

• Floor safety
  • Keep all rooms neat and tidy and especially keep things off the floors.
  • Floor surfaces should be smooth and level but not slippery. Always pay attention to changes in floor levels, especially at thresholds and in doorways.
  • Wear supportive shoes without high heels even at home. Avoid walking around in socks, stockings, or floppy slippers to avoid tripping or slipping.
  • Make sure all carpets and rugs are stuck to the floor or have skid-proof backing so they cannot slide around when someone steps on them.
  • Keep electrical cords and telephone lines out of the way.
• Stair and bathroom safety
  • Make sure stairs have plenty of light and that there are handrails on both sides. Placing fluorescent or colored tape on the edges of the top and bottom steps may help make them more visible.
  • For safety in the bathroom, install bars to grab onto on bathroom walls beside tubs, showers, and toilets. Consider using a plastic chair with a back in the shower.
  • Always use a rubber bath mat in the shower or tub so the chance of slipping is reduced.
• Lighting
  • Keep a flashlight with fresh batteries beside the bed in case of a power failure.
  • Make sure the lights in a room can be turned on from the doorway. A ceiling light with a light switch by the door or lamps that can be turned on by a switch are possible solutions. Another option is to install voice- or sound-activated lamps (such as the Clapper).
  • Use at least 100-watt bulbs in the home so that lamps are brighter.
• Telephones and contact
  • A portable phone or cell phone that can be taken from room to room is another option to improve safety in the home. This helps prevent a fall caused by rushing to answer the phone, and it can be used to call for help if an accident occurs.
  • Arrange for daily contact with a family member or friend. This increases the chance of receiving immediate help in case of an accident.
  • Monitoring companies are also available if living alone. They will respond to a call 24 hours a day.
• Other safety issues
  • If using a step stool, use a sturdy one with a handrail and wide steps. It is better to reorganize closets, cabinets, and shelves so climbing on a stool or bending over is not necessary.
  • Always keep enough prescription medications to last at least one week at home. Also, talk to a doctor or pharmacist about these medications. Determine whether any medication or combination of medications may increase the risk of falling.

Another safety tip that I recommend is to regularly examine the rubber tip of your canes to be certain that there is not too much wear. A tip that has worn through makes the cane dangerous and can lead to a serious slip and fall. Most rubber tips now have treads on the bottom. If these show substantial wear, it is time to replace the tip. Rubber tips are inexpensive and commonly available in the local pharmacy or medical supply shop.

A person can evaluate balance by looking in a mirror. The body may lean or sway back and forth or side to side while walking or standing still. This may be an indication of the ability to balance because lots of body sway often indicates decreased ability to balance, making a person more likely to fall.

Practicing balancing exercises every day is helpful. Elderly people or those with medical problems should check with their doctor before performing exercises to help with balance.

• Hold onto the back of a chair or the counter top and practice standing on one leg at a time for a minute. Gradually increase the time spent balancing on one leg. Try balancing with eyes closed. Finally, try balancing without holding onto anything.
• Hold onto the back of a chair or the counter top and practice standing on the toes for a count of 10. Then rock back to balance on the heels for a count of 10. Repeat.
• Hold the back of a chair or a counter top with both hands and make a big circle to the left with the hips but do not move the shoulders or feet. Then do this to the right. Repeat five times.

Reducing the impact of a fall

Remember that the force of a fall (how hard a person lands) is a significant factor in whether a person will have a broken bone or not. Take the following steps to lessen the chances of breaking a bone if a fall occurs.

• Try not to fall sideways or straight down because a hip fracture is more likely to occur than if the fall is in other directions. If possible, try to fall forward or to land on the buttocks.
• Even though a broken arm or wrist may result, try to land on the hands because a broken arm has fewer complications than a broken hip.
• Break a fall by grabbing onto counters or other surfaces around.
• Walk carefully, especially on hard or slippery surfaces.
• When possible, wear protective clothing for padding or wear hip (trochanteric) pads. Talk to a doctor about hip padding.

Determining the risk

Early detection of low bone mass (osteopenia) or osteoporosis is the most important step to protect against broken bones from falls. If a person has osteopenia or osteoporosis, he or she can take action to stop the progression of bone loss. Remember effective treatment or prevention cannot take place if the person does not know he or she has or is at risk for osteoporosis.

Certain factors, such as female sex, family history of osteoporosis, use of medicines that increase bone loss, small body size, and an inactive lifestyle, are associated with increased risk of developing osteoporosis (see Prevention of Osteoporosis and Bone Mineral Density Tests for details on risk factors).

If any of these risk factors or other signs of osteoporosis are present, a doctor may recommend that the bone mass is measured. Even though risk factors can indicate the possibility of low bone density, only a bone mineral density (BMD) test can be used to measure current bone density, diagnose osteoporosis, and determine the risk of fracture. Bone mineral density tests measure the solidness and mass (bone density) in the spine, wrist, and/or hip, which are the most common sites of fractures due to osteoporosis. Other tests measure bone density in the heel or hand. These tests are performed like X-ray films. They are painless, noninvasive, and safe (see Bone Mineral Density Tests for more information).

Doctors examine bone mineral density test results to do the following:

• Detect low bone density (osteopenia) before a fracture occurs
• Confirm a diagnosis of osteoporosis if broken bones (fractures) have already occurred
• Predict the chance of having a fracture in the future
• Determine the rate of bone loss and monitor the effects of treatment (tests done to monitor treatment are usually conducted every year or so)

Decreasing bone weakness

Preserve existing bone mass and density (strength) to decrease the risk of broken bones and disability from falling. The many treatments available today have been shown to work quickly (within one year), and they reduce the risk of fracture by up to 50%. Protect the health of bones by following osteoporosis treatment and prevention strategies (see Treatment of Osteoporosis and Prevention of Osteoporosis).

• A calcium-rich diet is essential to strong bones. A diet high in calcium should provide 1,200 mg of calcium from a combination of foods and supplements.
• The body needs vitamin D to absorb the calcium from the diet. Obtain 800-1,000 international units (IU) of vitamin D each day from diet or supplements.
• Participate in weight-bearing exercise (exercise that works against gravity) and resistance exercise three times a week. Weight-bearing exercises include walking, hiking, jogging, climbing stairs, tennis, and dancing. Resistance exercises include using free weights and weight machines found at gyms and health clubs.
• Talk to a doctor about having a bone density test (a special X-ray that measures the strength of the bones and indicates the risk for fracture).
• Talk with a doctor about medications for osteoporosis to stop bone loss, improve bone density, and reduce fracture risk.

A person needs to know if he or she has weakened bones or osteoporosis. Using painless tests to measure bone density, the doctor can determine the risk of broken bones from a fall. Remember, osteoporosis can occur in any person at any age and falls can cause broken bones in any person at any age. Protect against falls and minimize the damage and disability that falls can cause, especially as a person gets older or if osteoporosis has already occurred. Falls are serious, but simple inexpensive steps can be taken to reduce the risk for falling and reduce the risk of breaking a bone if a fall does happen.

National Osteoporosis Foundation
1232 22nd Street NW
Washington, DC 20037-1292
202-223-2226

International Osteoporosis Foundation
[email protected]