tag:theconversation.com,2011:/us/topics/patient-falls-5152/articlesPatient falls – The Conversation2023-05-19T12:41:05Ztag:theconversation.com,2011:article/2041742023-05-19T12:41:05Z2023-05-19T12:41:05ZBalance declines with age, but exercise can help stave off some of the risk of falling<figure><img src="https://images.theconversation.com/files/525481/original/file-20230510-25-jmyca.jpg?ixlib=rb-1.1.0&rect=0%2C53%2C5991%2C3817&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">About 1 in 4 adults ages 65 and up experience a fall every year.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/caregiver-help-asian-or-elderly-old-woman-walk-with-royalty-free-image/1383512710?phrase=seniors+fall&adppopup=true">sasirin pamai/iStock via Getty Images Plus</a></span></figcaption></figure><p>My wife and I were in the grocery store recently when we noticed an older woman reaching above her head for some produce. As she stretched out her hand, she lost her balance and began falling forward. Fortunately, she leaned into her grocery cart, which prevented her from falling to the ground. </p>
<p>Each year, about <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm">1 in every 4 older adults experience a fall</a>. In fact, falls are the leading cause of injuries in adults ages 65 and older. Falls are the <a href="https://doi.org/10.1007/bf00298717">most common cause of hip fractures</a> and <a href="https://doi.org/10.1111/j.1553-2712.2000.tb00515.x">traumatic brain injuries</a>. </p>
<p>Injuries like those are also <a href="https://doi.org/10.1056/NEJM199710303371806">risk factors for placement in a nursing home</a>, where the fall risk is <a href="https://doi.org/10.7326/0003-4819-121-6-199409150-00009">nearly three times higher than for people living in the community</a>.</p>
<p>A number of physical changes with aging often go unseen preceding falls, including muscle weakness, decreased balance and changes in vision. </p>
<p>I am a <a href="https://facultyprofiles.tufts.edu/evan-papa">physical therapist</a> and <a href="https://scholar.google.com/citations?user=T9B_dHQAAAAJ&hl=en">clinical scientist focused on fall prevention</a> in older adults, commonly ages 65 and older. I’ve spent most of my career investigating why older adults fall and working with patients and their families to prevent falls. </p>
<h2>Why aging leads to increased risk of falls</h2>
<p>Aging is a process that affects the systems and tissues of every person. The rate and magnitude of aging may be different for each person, but overall physical decline is an inevitable part of life. Most people think aging starts in their 60s, but in fact we spend most of our life span <a href="https://doi.org/10.1093%2Fgeront%2Fgnv130">undergoing the process of decline</a>, typically beginning in our 30s. </p>
<p>Older adults are more prone to falling for various reasons, including age-related changes in their bodies and vision changes that leave them vulnerable to environmental factors such as curbs, stairs and carpet folds.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ztPbKP68P2Q?wmode=transparent&start=24" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Some straightforward measures to improve the safety of the home environment for older adults can significantly lower the risk of falls.</span></figcaption>
</figure>
<p>Based on my experience, here are some common reasons older adults may experience falls:</p>
<p>First, <a href="https://my.clevelandclinic.org/health/diseases/23167-sarcopenia#">aging leads to a natural loss of muscle strength</a> and flexibility, making it more challenging to maintain balance and stability. The loss of strength and poor balance are two of the most common causes of falls.</p>
<p>Second, older adults often have chronic conditions such as arthritis, Parkinson’s disease or diabetes that can affect their mobility, coordination and overall stability. </p>
<p>In addition, certain medications commonly taken by older adults, <a href="https://doi.org/10.4088/jcp.18f12340">such as sedatives</a> or <a href="https://doi.org/10.1001/jamainternmed.2013.14764">blood pressure drugs</a>, can cause dizziness, drowsiness or a drop in blood pressure, leading to an increased risk of falls.</p>
<p>Age-related vision changes, such as reduced depth perception and peripheral vision and difficulty in differentiating colors or contrasts, can make it harder to navigate and identify potential hazards. Hazards in the environment, such as uneven surfaces, slippery floors, inadequate lighting, loose rugs or carpets or cluttered pathways, can <a href="https://doi.org/10.1186/s12877-021-02499-x">significantly contribute to falls among older adults</a>.</p>
<p>Older adults who lead a sedentary lifestyle or have limited physical activity may also experience reduced strength, flexibility and balance.</p>
<p>And finally, such conditions as dementia or Alzheimer’s disease can affect judgment, attention and spatial awareness, leading to increased fall risk.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of an iceberg underwater and just partially showing above water, annotated with a few of the age-related changes that can increase fall risk." src="https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=827&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=827&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=827&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1039&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1039&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524725/original/file-20230506-40482-sxlgnl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1039&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Falls reflect age-related changes happening under the surface.</span>
<span class="attribution"><a class="source" href="https://www.istockphoto.com/photo/iceberg-with-underwater-view-gm486634864-73438575">Annotated by Evan Papa via iStock/Getty Images</a></span>
</figcaption>
</figure>
<h2>Theories of aging</h2>
<p>There are numerous theories about why we age but there is no one unifying notion that explains all the changes in our bodies. A large portion of aging-related decline is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295054/">caused by our genes</a>, which determine the structure and function of bones, muscle growth and repair and visual depth perception, among other things. But there are also numerous lifestyle-related factors that influence our rate of aging including diet, exercise, stress and exposure to environmental toxins. </p>
<p>A recent advance in scientific understanding of aging is that there is a difference between your <a href="https://theconversation.com/are-you-a-rapid-ager-biological-age-is-a-better-health-indicator-than-the-number-of-years-youve-lived-but-its-tricky-to-measure-198849">chronological age and your biological age</a>. Chronological age is simply the number of years you’ve been on the Earth. Biological age, however, refers to how old your cells and tissues are. It is based on physiological evidence from a blood test and is related to your physical and functional ability. Thus, if you’re healthy and fit, your biological age may be lower than your chronological age. However, the reverse can also be true. </p>
<p>I encourage patients to focus on their biological age because it empowers them to take control over the aging process. We obviously have no control over when we are born. By focusing on the age of our cells, we can avoid long-held beliefs that our bodies are destined to develop cancer, diabetes or other conditions that <a href="https://doi.org/10.1016/j.cub.2012.07.024">have historically been tied to how long we live</a>. </p>
<p>And by taking control of diet, exercise, sleep and other lifestyle factors you can actually <a href="https://doi.org/10.1111%2Facel.13538">decrease your biological age</a> and improve your quality of life. As one example, our team’s research has shown that moderate amounts of aerobic exercise <a href="https://doi.org/10.1371/journal.pone.0188538">can slow down motor decline</a> even when a person begins exercise in the latter half of the life span.</p>
<h2>Fall prevention</h2>
<p>Adopting lifestyle changes such as regular, long-term exercise can <a href="https://doi.org/10.1001/jamainternmed.2018.5406">reduce the consequences of aging</a>, including falls and injuries. Following a healthy diet, managing chronic conditions, reviewing medications with health care professionals, maintaining a safe home environment and getting regular vision checkups can also help reduce the risk of falls in older adults. </p>
<p>There are several exercises that physical therapists use to improve balance for patients. It is important to note however, that before starting any exercise program, everyone should consult with a health care professional or a qualified physical therapist to determine the most appropriate exercises for their specific needs. Here are five forms of exercise I commonly recommend to my patients to improve balance:</p>
<ol>
<li><p>Balance training can help improve coordination and <a href="https://www.sciencedirect.com/topics/neuroscience/proprioception#">proprioception</a>, which is the body’s ability to sense where it is in space. By practicing movements that challenge the body’s balance, such as standing on one leg or walking heel-to-toe, the nervous system becomes better at coordinating movement and maintaining balance. A large research study analyzing nearly 8,000 older adults found that balance and functional exercises <a href="https://doi.org/10.1002/14651858.cd012424.pub2">reduce the rate of falls by 24%</a>. </p></li>
<li><p>Strength training exercises involve lifting weights or using resistance bands to increase muscle strength and power. By strengthening the muscles in the legs, hips and core, older adults can improve their ability to maintain balance and stability. Our research has shown that strength training can also lead to <a href="https://doi.org/10.2147/cia.s104674">improvements in walking speed and a reduction in fall risk</a>.</p></li>
<li><p>Tai chi is a gentle martial art that focuses on slow, controlled movements and shifting body weight. Research shows that it can improve balance, strength and flexibility in older adults. Several combined studies in tai chi have demonstrated a 20% reduction in the <a href="https://doi.org/10.1002/14651858.cd012424.pub2">number of people who experience falls</a>. </p></li>
<li><p>Certain yoga poses can enhance balance and stability. Tree pose, warrior pose and mountain pose are examples of poses that can help improve balance. It’s best to <a href="https://theconversation.com/yoga-modern-research-shows-a-variety-of-benefits-to-both-body-and-mind-from-the-ancient-practice-197662">practice yoga</a> under the guidance of a qualified instructor who can adapt the poses to individual abilities.</p></li>
<li><p>Flexibility training involves stretching the muscles and joints, which can improve range of motion and reduce stiffness. By improving range of motion, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990889/">older adults can improve their ability to move safely</a> and avoid falls caused by limitations in mobility. </p></li>
<li><p>Use of assistive devices can be helpful when strength or balance impairments are present. Research studies involving the evaluation of canes and walkers used by older adults confirm that <a href="https://doi.org/10.1016/j.apmr.2004.04.023">these devices can improve balance and mobility</a>. Training from a physical or occupational therapist in the proper use of assistive devices is an important part of improving safety.</p></li>
</ol>
<p>When I think back about the woman who nearly fell in the grocery store, I wish I could share everything we have learned about healthy aging with her. There’s no way to know if she was already putting these tips into practice, but I’m comforted by the thought that she may have avoided the fall by being in the right place at the right time. After all, she was standing in the produce aisle.</p><img src="https://counter.theconversation.com/content/204174/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Evan Papa receives funding from the National Institutes of Health / National Institute of General Medical Sciences under the Mountain West Center for Translational Research Infrastructure grant #U54GM104944, and the Idaho Elks Rehab Society. </span></em></p>Lifestyle factors like physical activity, diet and sleep can lower the ‘biological age’ of your cells and tissues and reduce age-related physical decline.Evan Papa, Associate Professor of Physical Therapy and Rehabilitation Science, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/755462017-06-06T03:20:28Z2017-06-06T03:20:28ZExplainer: what is traumatic brain injury?<figure><img src="https://images.theconversation.com/files/172358/original/file-20170606-16856-gqwp6g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with traumatic brain injuries, say after a car accident or an assault, can have behavioural problems long after their physical injuries have healed.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=syyx_gDuQnNZId7IeIgaYg-1-3">from www.shutterstock.com</a></span></figcaption></figure><p>Adam was fortunate to survive a major car accident three years ago. He was in hospital for several months but had no ongoing physical injuries. He looked like he made a full recovery. But he was argumentative, childish, vulgar and his family said he “was not the same person”. Adam had a severe traumatic brain injury. </p>
<h2>What is traumatic brain injury?</h2>
<p>A <a href="http://www.sciencedirect.com/science/article/pii/S0003999310006507">traumatic brain injury</a> is when the brain is damaged by an external mechanical force, like the type you may have in a car accident, if you fall, play sport or if you are assaulted.</p>
<p>These injuries are usually in the news when <a href="https://www.thechronicle.com.au/news/toowoomba-man-liam-cullen-is-suing-queensland-rugb/2960018/">sports players</a> have a <a href="http://www.abc.net.au/news/2017-03-20/nrl-players-brains-more-damaged-than-non-players:-study/8369226">concussion</a>; or in relation to drug and alcohol fuelled assaults where a blow to the head results in a damaging, <a href="http://www.smh.com.au/nsw/killer-punch-fall-caused-thomas-brain-damage-20120715-224q9.html">sometimes fatal</a>, <a href="http://www.dailytelegraph.com.au/news/nsw/newcastle-surfer-suffers-fractured-skull-in-coward-punch-attack/news-story/3576f0a5b3d1c8751ec78347fc210a4f">fall to the ground</a> (<a href="https://en.wikipedia.org/wiki/Sucker_punch">the coward’s punch or king hit</a>).</p>
<p>Mostly, it’s young adults, particularly men, who are affected. But many elderly people may get a traumatic brain injury when they fall.</p>
<p>Australia has a growing population of survivors of traumatic brain injury. This is due to the young age of most victims and decreased death rates <a href="https://www.psychology.org.au/publications/inpsych/2012/april/ponsford">due to better treatment</a>. Traumatic brain injury is expected to be a <a href="https://www.ncbi.nlm.nih.gov/pubmed/18162698">major cause of disability by 2020</a>.</p>
<h2>How does it affect people?</h2>
<p>Few traumatic brain injuries are the same and the outcomes of two similar injuries can be different in different people. Injuries can affect the way people think, feel, behave and relate to everyday situations.</p>
<p>People with moderate to severe injuries can have problems communicating, paying attention, processing thoughts quickly, learning, remembering, planning, problem-solving, meeting goals, and thinking abstractly or flexibly.</p>
<p>Damage to the part of the brain called the <a href="https://www.researchgate.net/profile/Catherine_Gow2/publication/232210406_Frontal_Dysfunction_After_Traumatic_Brain_Injury/links/57ea9c6908aed3a3e08aaeb6.pdf">frontal lobes</a> affects people’s ability to regulate their thoughts, emotions and behaviour. It can cause people to be impulsive, irritable, aggressive, have reduced drive, be apathetic, to have excessive emotions or a flattened mood. </p>
<p>Difficulties understanding the emotions and intentions of others (known as <a href="https://en.wikipedia.org/wiki/Social_cognition">social cognition</a>) may cause reduced empathy and socially inappropriate behaviour. Reduced self-awareness can also result in lack of insight into their abilities and the changes others perceive.</p>
<p>Traumatic brain injury can change an individual’s personality to the point where they “may no longer be the same person” that they were before. Given that many of these difficulties can occur without physical problems, they fall under the umbrella of an “<a href="http://www.changedlivesnewjourneys.com/hidden-disability-after-brain-injury/">invisible disability</a>”.</p>
<h2>How does traumatic brain injury affect the brain?</h2>
<p>Injuries can be due to the immediate effect of the impact (known as primary injuries) or ones that follow these (secondary complications).</p>
<p>Primary injuries include: <a href="https://en.wikipedia.org/wiki/Cerebral_laceration">lacerations</a>, when the brain tissue is cut or torn; <a href="https://en.wikipedia.org/wiki/Cerebral_contusion">contusions</a>, when the brain is bruised; rupturing of blood vessels; and <a href="https://en.wikipedia.org/wiki/Diffuse_axonal_injury">axonal injury</a>, where neurons are stretched and torn.</p>
<p>These can occur where the object hits the head (a <a href="https://en.wikipedia.org/wiki/Focal_and_diffuse_brain_injury">focal injury</a>) or throughout the brain (<a href="https://en.wikipedia.org/wiki/Focal_and_diffuse_brain_injury">diffuse injury</a>). Parts of the brain known as the frontal and temporal lobes are most susceptible to both of these types of injuries. This is because of their large size and as they are close to the hard and uneven surfaces of the skull that can cause damage.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/168349/original/file-20170508-20725-56q10b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The frontal and temporal lobes of the brain, shown here, are particularly susceptible to injury.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/102046603?src=Fe-S7aDefYB73SjZdXDbug-1-0&size=huge_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>Secondary complications include brain <a href="http://www.webmd.com/brain/brain-lesions-causes-symptomstreatments#1">lesions</a> (damaged brain tissue); <a href="https://en.wikipedia.org/wiki/Edema">brain swelling</a>, increased <a href="https://en.wikipedia.org/wiki/Intracranial_pressure">intracranial pressure</a> (pressure inside the skull), <a href="https://en.wikipedia.org/wiki/Brain_herniation">herniation</a> (movement of brain tissue), <a href="https://en.wikipedia.org/wiki/Ischemia">tissue death</a>, <a href="https://en.wikipedia.org/wiki/Hypoxia_(medical)">hypoxia</a> (oxygen deprivation) and infection. </p>
<p>How long someone loses consciousness initially and how long they’re confused for (known as post-traumatic amnesia) are used to <a href="http://emedicine.medscape.com/article/326643-overview">classify</a> traumatic brain injury as mild, moderate or severe. Most (<a href="http://online.liebertpub.com/doi/abs/10.1089/089771501750357609">about 80%</a>) hospitalisations are for mild injuries.</p>
<h2>How is it managed?</h2>
<p>People with a traumatic brain injury can be treated while staying in hospital (as an in-patient) or after they’re discharged into the community (as an out-patient).</p>
<p>In-patient rehabilitation focuses on immediate medical and functional issues, with a range of health professionals involved, like physiotherapists, speech pathologists, neuropsychologists (psychologists who specialise in assessing, diagnosing and treating disorders of the brain) and occupational therapists. Typically, a personalised rehabilitation plan is drawn up to help the patient to move back into the community. </p>
<p>Out-patient rehabilitation focuses more on the <a href="https://www.ncbi.nlm.nih.gov/pubmed/20134333">context of daily living</a>. Here, there is a shift to helping patients establish life roles and successfully complete everyday tasks, like making meals, showering and travelling. </p>
<h2>What are the challenges ahead?</h2>
<p>Recovery from a traumatic brain injury varies from person to person. Some people can easily resume their lives while others can struggle <a href="http://journals.lww.com/jnnonline/Abstract/2005/02000/The_Meaning_of_Living_with_Traumatic_Brain_Injury.7.aspx">adjusting</a> to their limitations, new lifestyle and new self. Some can have trouble living independently, fulfilling life goals and finding a meaningful place in society. </p>
<p>Behavioural and emotional difficulties are significant barriers to <a href="http://journals.sagepub.com/doi/pdf/10.1177/026921559601000215">long-term recovery</a>. These challenges may not become obvious until the person is in the community, discharged from rehabilitation services and completely dependent on their carers and/or <a href="http://www.tandfonline.com/doi/full/10.3109/02699052.2015.1005134">families</a>. </p>
<p>Behavioural and personality issues also make traumatic brain injury difficult <a href="http://online.liebertpub.com/doi/pdf/10.1089/neu.2013.2997">to manage</a>, placing burden on carers and result in difficulties finding and keeping a job.</p>
<p>Family members and friends can pull away, leading to further <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1315633/">social isolation</a> and loneliness, making survivors more susceptible to <a href="https://www.ncbi.nlm.nih.gov/pubmed/10533556">mental health problems</a> and institutionalisation. Sadly, these problems <a href="http://journal.frontiersin.org/article/10.3389/fnhum.2013.00031/full">worsen</a> as years pass, despite improvements made during early recovery.</p>
<hr>
<p><em>If you or someone you know is a survivor of traumatic brain injury, contact <a href="http://www.braininjuryaustralia.org.au/">Brain Injury Australia</a>, <a href="http://synapse.org.au/">Synapse</a> or the <a href="http://moving-ahead.com.au/">Centre for Research Excellence in Brain Recovery</a> for more information and support.</em></p><img src="https://counter.theconversation.com/content/75546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Survivors of traumatic brain injuries might have behavioural issues or have problems holding down a job for years after a blow to the head or a bad fall.Travis Wearne, Postdoctoral Research Fellow, UNSW SydneyEmily Trimmer, Postdoctoral Research Fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/681452017-01-24T19:17:56Z2017-01-24T19:17:56ZWhy older people get osteoporosis and have falls<figure><img src="https://images.theconversation.com/files/148820/original/image-20161206-25721-hgzja7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Older people are more likely to have falls as their balance and muscle strength usually isn't what it was. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>This article is part of our series on <a href="https://theconversation.com/au/topics/older-peoples-health-33308">older people’s health</a>. It looks at the changes and processes that occur in our body as we age, the conditions we’re more likely to suffer from and what we can do to prevent them.</em></p>
<hr>
<p>As the world’s population lives longer, the significance of osteoporosis and fractures increases.</p>
<p>In Australia, it is estimated that <a href="http://www.osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf">4.74 million Australians aged over 50</a> have osteoporosis, osteopenia (less severe than osteoporosis) or poor bone health. By 2022, <a href="http://www.osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf">it’s estimated this will increase</a> to 6.2 million, with one fracture occurring every 2.9 minutes.</p>
<p>In 2012, the <a href="http://www.osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf">total cost of poor bone health</a> in adults aged over 50 was A$2.75 billion, and 64% of this cost was directly associated with treating and managing fractures.</p>
<h2>What is osteoporosis?</h2>
<p>Osteoporosis is a condition in which bones become fragile and brittle, leading to higher risk of breakage. This occurs when bones lose minerals such as calcium more quickly than the body can replace them.</p>
<p>In Australia, osteoporosis
affects <a href="http://www.osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf">one in three women and one in five men</a> over the age of 50.</p>
<p>Referred to as a “silent” disease, osteoporosis generally has no symptoms and is rarely diagnosed until bones break or fracture. Osteoporosis is the disease and fractures are the outcome we are trying to prevent.</p>
<h2>Why do we get osteoporosis as we age?</h2>
<p>Our bones are living tissue and are in a continual state of renewal. As we age, more bone is broken down (resorbed) than is replaced by new bone. Thus our bones get thinner and more fragile as we age. This is particularly true during menopause for women and in men with lower levels of sex steroid hormones such as testosterone.</p>
<p>“Primary osteoporosis” is bone loss that can be attributed to ageing or the known hormonal consequences of ageing, such as the decline in oestrogen and testosterone. These hormones help regulate bone renewal that occurs naturally as we age. </p>
<p>As the level of these hormones decline from about the age of 50 in women and around 60 in men, the rate of bone breakdown is faster than the growth of new bone to replace it. Over time this leads to weaker, thinner bones. In women, the risk abruptly increases from the time of menopause, coinciding with a significant drop in circulating levels of oestrogen.</p>
<p>“Secondary osteoporosis” occurs as a consequence of another disease (such as coeliac disease with associated calcium malabsorption), or as an adverse consequence of therapy for another disease where medication might bring it on.</p>
<p>Thin bones of a poorer quality structure are more likely to break. The vast majority of fractures occur as a result of a fall from standing height. Vertebral or spinal fractures are the exception, frequently occurring without a fall or significant “trigger event”.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=542&fit=crop&dpr=1 754w, https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=542&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/148822/original/image-20161206-25730-9h561e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=542&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">We’re more likely to have a hip fracture if our parents did.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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</figure>
<h2>Why do we fall over when we get older?</h2>
<p>There are many reasons older adults are susceptible to falls. These include side effects of some medications, vision impairments and less ability to prevent tripping over as balance, muscle mass and strength decline with age.</p>
<p>The risk of fracture due to poor bones increases with age, and this is further enhanced by osteoporosis. </p>
<p>Genetics also plays a role in an individual’s risk of fracture. Those of us with parents who had a hip fracture have an increased risk of fracture. The most common sites of fracture in older adults are the hip, vertebrae or spine, wrist or the humerus (upper arm or shoulder).</p>
<p>About <a href="https://www.ncbi.nlm.nih.gov/pubmed/10083688">30% of older adults</a> fall at least once a year. The less often you fall, the less likely you are to break a bone.</p>
<p>People aged 70 and over <a href="http://www.osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf">accounted for 70% of the total</a> acute hospital inpatient costs in 2012. Hip fractures <a href="http://www.osteoporosis.org.au/sites/default/files/files/Burden%20of%20Disease%20Analysis%202012-2022.pdf">impose the highest burden</a> both in terms of cost and decline in health-related quality of life.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/25792491">Results from a recent study</a> show most fracture patients have not fully recovered their previous level of quality of life by 18 months after the fracture.</p>
<h2>Preventing osteoporosis and falls</h2>
<p>Preventing falls in older people is an important way to prevent fractures. Adults who have good balance and muscle strength are often able to “save themselves” when they trip. Exercises that improve balance (such as Tai Chi) and help maintain muscle mass (weight-bearing and resistance exercises) are beneficial.</p>
<p>Preventing osteoporosis involves regular weight-bearing and resistance exercise, adequate calcium in the diet (at least three serves of dairy or equivalent per day) and an adequate level of vitamin D in the bloodstream.</p>
<p>Sunlight exposure on the skin is the primary source of vitamin D, but we need to practise safe sun exposure to reduce the risk of skin cancer. The recommendations vary by <a href="https://www.mja.com.au/open/2013/2/1/building-healthy-bones-throughout-life-evidence-informed-strategy-prevent-osteoporosis">skin type, latitude and season</a>. For people with moderately fair skin, six to seven minutes before 11am or after 3pm during summertime is considered sufficient. </p>
<p>During wintertime, the daily recommended sun exposure increases to between seven and 40 minutes <a href="https://www.mja.com.au/open/2013/2/1/building-healthy-bones-throughout-life-evidence-informed-strategy-prevent-osteoporosis">depending on where you live in Australia</a>.</p>
<p>While lifestyle factors such as nutrition and exercise can make an important difference to bone health over time, if an older adult has several risk factors for fracture their doctor may discuss the benefits of “bone active” medication. These medications slow the rate bone breaks down as we age. In general these medications halve the risk of fracture and are much more effective than lifestyle measures alone.</p>
<hr>
<p><em>Read other articles in the series <a href="https://theconversation.com/au/topics/older-peoples-health-33308">here</a>.</em></p><img src="https://counter.theconversation.com/content/68145/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kerrie Sanders has previously received an Honarorium from Sanofi Pty Ltd for presenting on the Burden of Osteoporosis. She has previously received several project grants from the National Health and Medical Council. One of these projects on the burden of disease study on osteoporosis received supplementary funding from Merck Pty Ltd. Prof Saanders is a member of the scientific advisory committees for both Osteoporosis Australia andfd the International Osteoporosis Foundation. </span></em></p>In 2012 the total cost of poor bone health in adults aged over 50 years was A$2.75 billion, and 64% of this cost was the direct cost associated with treating and managing fractures.Kerrie Sanders, Professor -Musculoskeletal Science, Nutrition and Health economics, IHA, Australian Catholic UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/527252016-01-06T18:01:06Z2016-01-06T18:01:06ZThe sun goes down on vitamin D: why I changed my mind about this celebrated supplement<figure><img src="https://images.theconversation.com/files/107268/original/image-20160105-28974-1jtlugf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Supplementary benefits?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-142484191/stock-photo-cod-liver-oil-omega-gel-capsules-isolated-on-pastel-background-vitamin-capsuls.html?src=pd-same_artist-142484185-ZTeHxwWkVIsy2kwauC88Ig-1">Vitamin D by Shutterstock</a></span></figcaption></figure><p>Everyone loves D, the sunshine vitamin. Doctors, patients and the media have been enamoured with vitamin D supplements for decades. As well as their clear benefit in curing severe vitamin D deficiencies, endless headlines hail their magical ability to reduce a vast range of conditions from dementia to cancer. </p>
<p>Medical specialists such as myself have been promoting supplements to our patients with osteoporosis and other bone problems for decades. Many food products contain artificially added vitamin D with the aim of preventing fractures and falls and improving muscle strength although the vitamin also has been claimed to boost the immune system and reduce ageing. I used to sometimes take vitamin D myself and recommended it to my family to survive sun-starved winters. </p>
<p>However, <a href="http://archinte.jamanetwork.com/article.aspx?articleid=2478893">a new paper</a> on the risks that vitamin D may pose finally has convinced me that I was wrong. My view on vitamin supplements and the multi-billion dollar industry behind them altered radically after I began researching my book, The Diet Myth, in 2013. The industry and its PR is supported by <a href="http://www.dailymail.co.uk/femail/article-2572858/INVESTIGATION-The-toxic-truth-vitamin-jabs-Rihanna-Cara-Delevingne-Rita-Ora-Madonna-use-stay-game.html">celebrities</a> who reportedly have high-dose vitamins drip fed <a href="http://www.theguardian.com/lifeandstyle/shortcuts/2012/jun/04/rihanna-vitamin-drip-celebrity-health-fad">into their veins</a>, and around 50% of Americans and Britons take them regularly. But surprisingly, <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/vitamin-pills-are-a-waste-of-money-offer-no-health-benefits-and-could-be-harmful-study-9010303.html">there is a lack of evidence</a> to support the health benefit claims of virtually all vitamin supplements on the market. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/107275/original/image-20160105-28997-schbqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/107275/original/image-20160105-28997-schbqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/107275/original/image-20160105-28997-schbqk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/107275/original/image-20160105-28997-schbqk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/107275/original/image-20160105-28997-schbqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/107275/original/image-20160105-28997-schbqk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/107275/original/image-20160105-28997-schbqk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Heart health.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-124706830/stock-vector-hand-drawn-painted-red-heart-vector-element-for-your-design.html?src=LkZVPtXzcsawoawZjTNzfQ-1-8">Shutterstock</a></span>
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<p><a href="https://www.fredhutch.org/en/news/center-news/2014/02/vitamin-e-selenium-prostate-cancer-risk.html">One study</a> based on <a href="http://www.cancer.gov/types/prostate/research/select-trial-results-qa#2">the large SELECT trial</a> suggested that supplements such as vitamin E and selenium actually <a href="http://www.ncbi.nlm.nih.gov/pubmed/19066370">increased prostate cancer in some men</a>. And last year massive analyses combining 27 studies on half a million people <a href="http://jama.jamanetwork.com/article.aspx?articleid=1820428">concluded</a> that taking vitamin and mineral supplements regularly failed to prevent cancer or heart disease. Not only are they a waste of money for the majority of us – but if taken in excessive quantities they can actually hasten an early death, <a href="http://www.medicalnewstoday.com/articles/260147.php">increasing your risk of heart disease</a> and <a href="http://www.theguardian.com/society/2015/apr/21/vitamin-supplements-increase-risk-cancer-heart-disease-research">cancer</a>.</p>
<p>Virtually no vitamins or supplements have actually been shown to have any benefit in proper randomised trials in normal people without severe deficiencies. Rare exceptions have been lutein nutrients for macular degeneration, a <a href="http://jama.jamanetwork.com/article.aspx?articleid=1684847">common cause of blindness</a> – and vitamin D, the golden boy of vitamins. </p>
<p>Since the 1980s, researchers (including myself) have written thousands of papers, associating a lack of our favourite vitamin with over 137 diseases. <a href="http://www.bmj.com/content/348/bmj.g2035">A 2014 BMJ report</a>, however, found these links mainly to be spurious. </p>
<h2>Won’t do you any harm?</h2>
<p>Our genetic makeup <a href="http://www.ncbi.nlm.nih.gov/pubmed/23746901">influences vitamin D levels</a>. We can use this information to tell if naturally low vitamin D levels might actually increase the risk of disease (rather than be a consequence of it). The evidence so far suggests (with the possible exception of multiple sclerosis and some cancers) that low vitamin D levels are either irrelevant or merely a marker of the disease. </p>
<p>Until now we haven’t worried about giving people extra vitamin D because we thought “it might help anyway and of course (as it’s a vitamin) doesn’t do you any harm”. With our increasing knowledge, we should now know better. Recent studies in the last five years have suggested that even calcium supplements as well as being ineffective in preventing fracture can <a href="http://www.ncbi.nlm.nih.gov/pubmed/26420387">increase the risk of heart disease</a>. </p>
<p>While several studies in normal people failed to find any protective effects from vitamin D, others have been more worrying. One <a href="http://media.jamanetwork.com/news-item/neither-vitamin-d-nor-exercise-affected-fall-rates-among-older-women-in-finland">2015 randomised study</a> of 409 elderly people in Finland suggested that vitamin D failed to offer any benefits compared to placebo or exercise – and that fracture rates were, in fact, slightly higher.</p>
<p>The usual prescribed dose in most countries is 800 to 1,000 units per day (so 24,000-30,000 units per month). However, two randomised trials found that at around 40,000 to 60,000 units per month Vitamin D effectively became a dangerous substance. </p>
<p><a href="http://jama.jamanetwork.com/article.aspx?articleid=185854">One study</a> involving over 2,000 elderly Australians, which was largely ignored at the time, and <a href="http://www.ncbi.nlm.nih.gov/pubmed/20460620">the one just published</a> found that patients given high doses of vitamin D or those on lower doses that increased vitamin D blood levels within the optimal range (as defined by bone specialists) had a 20-30% increased rate of fractures and falls compared to those on low doses or who failed to reach “optimal blood levels”.</p>
<p>Explaining exactly why vitamin D supplements are often harmful is harder. Some people who don’t take supplements have naturally high blood levels which may be due to them spending large amounts of time outdoors in the sun or eating oily fish regularly – and there is no evidence that this is harmful. Higher than average levels can also be due to genes which on average influence about 50% of the differences between people. So our obsession with trying to bring everyone up to a standard normal target blood level is seriously flawed, in a similar way to our one-size-fits-all approach to diet.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/107266/original/image-20160105-28966-26rqzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/107266/original/image-20160105-28966-26rqzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/107266/original/image-20160105-28966-26rqzy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/107266/original/image-20160105-28966-26rqzy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/107266/original/image-20160105-28966-26rqzy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/107266/original/image-20160105-28966-26rqzy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/107266/original/image-20160105-28966-26rqzy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Eggs are a source of vitamin D.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/healthgauge/7474848656/in/photolist-cowy5Y-7wSvav-7Aj8BS-7xtdu1-c2SmNW-4VhzX-7wSuEV-7zh7Xo-7z2R6i-5tbRFm-4Brsm9-bahrpR-7jD99p-fozFpy-7Afn5F-jdmpAK-7Afnzn-7ywgAF-7wWiAE-7ywgP4-7wWio5-7Aj8EJ-7ywgGT-7yA4Xj-dif7Vs-7zh7TW-9rsTDj-7ywgmT-4yQZox-4yVcuu-4yQZVH-4yVcBq-4yVcm9-4yQZZR-4yQYFe-4yVh9y-4yQYeT-4yR1KH-4yVexj-4yQWVR-4yVgbb-4yQYv6-4yVf7s-4yVf2E-4yVdU5-4yVgvJ-4yVfbE-4yR1RX-4yVdNb-4yR1nT">Health Guage</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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</figure>
<p>Until now we have believed that taking vitamin supplements is “natural” and my patients would often take these while refusing conventional “non-natural” drugs. Our body may not view supplements in the same misguided way. Vitamin D mainly comes from UV sunlight converted slowly in our skin to increase blood levels or is slowly metabolised from our food. In contrast, taking a large amount of the chemical by mouth or as an injection could cause a very different and unpredictable metabolic reaction. For example, our gut microbes are responsible for producing around a quarter of <a href="http://www.ncbi.nlm.nih.gov/pubmed/9167138">our vitamins</a> and a third of our blood metabolites and also respond to changes in vitamin levels picked up by receptors in our gut lining. Any artificial addition of large amounts of chemicals will upset <a href="http://www.ncbi.nlm.nih.gov/pubmed/24684957">some sensitive immune processes</a>.</p>
<p>The news that even my favourite vitamin can be dangerous is a wake-up call. We should be taking our worldwide abuse of these chemicals much more seriously rather than routinely adding them to foods. The billions we waste on these products, assisted by the poorly regulated but rich and powerful vitamin industry should be spent on proper healthcare – and people should be educated to go in the sunshine and eat <a href="http://www.marieclaire.co.uk/blogs/suzannah-ramsdale/548714/vitamin-d-foods-8-foods-to-that-ll-help-you-get-your-daily-dose.html">a diverse range of real food</a> instead. For 99% of people, this will provide all the healthy vitamins they will ever need.</p><img src="https://counter.theconversation.com/content/52725/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tim Spector is Director of the British Gut microbiome project. He is author of The Diet Myth, a book on gut microbes.</span></em></p>Vitamin D is often seen as a harmless supplement to take – the more the better. But the evidence suggests a different picture.Tim Spector, Professor of Genetic Epidemiology, King's College LondonLicensed as Creative Commons – attribution, no derivatives.