How do you unintentionally accelerate aging
Fall in old age and its consequences
A fall can be a decisive event, especially for an elderly person, which initiates the beginning of a downward spiral, at the end of which there is a risk to independent living. A fall can not only break your bones, but also lose confidence in your own motor skills. This leads to avoidance behavior with a progressive loss of further skills. In order to be able to effectively prevent this downward spiral, the identification of endangered patients and target-oriented prevention are crucial in order to contain existing risk factors.
The general practitioner is very often confronted with falls in geriatric patients in daily practice. By definition, geriatric patients are characterized by multimorbidity and older age (mostly over 70 years of age). The calendar age should not necessarily be seen as having priority over multimorbidity. In the case of those over 80 years of age, it is assumed per se that they are more vulnerable to complications and are more likely to become chronic with the risk of loss of autonomy.
In Germany, around 4 - 5 million senior citizens fall each year. Around a third of people over 65 who live independently fall once a year, among those over 80 the proportion rises to over 50% [24, 25, 28]. A large proportion of patients even fall several times. In institutionalized patients, the number of patients who fall is even higher . In about half of all cases, a fall is without physical injury. In 30 - 40% there are minor injuries such as hematomas [25, 28]. Serious injuries occur in 5 - 10% of those who have fallen. Older women have a higher risk of falling injuries than men of the same age .
5% of seniors suffer fractures after a fall [25, 28]. The "worst-case scenario" in old age is the common femoral neck fracture, 90% of which are due to falls. For Germany that is around 120,000 fractures per year . The consequences of injuries, such as pain or immobilization (for example with a cast), lead to a reduction in the functionality of the patient. 40% of the patients who had to go to an emergency room because of a fall still complain of restricted activity after two months .
Half of the elderly who develop a femoral neck fracture after a fall can no longer cope with five steps after one year, can no longer sit or stand up independently on the toilet or take shorter walks . For 20% of those affected, this has the consequence that they cannot stay in their own four walls and have to move to a retirement home with permanent care . A problem for the general practitioner to recognize a patient at risk of falling is the word "fall" in German-speaking countries. Everyone understands a different event by this word .
Fear of falling
The importance of the psychosocial consequences of a fall is increasingly being considered . A reduction in physical activity can be a direct consequence of falls, e.g. B. be caused by pain when walking, but also by fear of falling (English: Fear of Falling) . The data on the incidence of fear of falling vary in the literature between 20 and 50% [3, 20, 21]. Interestingly, a fall does not necessarily have to trigger the fear of falling. Older people without a history of falling also develop fear of falling .
Fear of falling often leads to a downward spiral of avoidance, loss of self-confidence, a reduction in everyday activity and further muscle degradation. Ultimately, this also increases the risk of falling. It is not uncommon for this development to end with social withdrawal and loss of independence [7, 26]. It has been shown that people who suffer from fear of falling are more likely to develop depression .
Although many falls are multifactorial, large epidemiological studies have identified risk factors that relate either to the individual himself (intrinsic risk factors), the environment (extrinsic risk factors) or to the task or situation (behavior and risk). It is hardly surprising that weakness in the lower extremities (leg strength) is associated with a four-fold increased risk of falling . A fall in the last twelve months increases the risk of falling three times , walking aids per se by two and a half times. Patients with cognitive impairments fall almost twice as often. As an example of extrinsic tripping hazards, sliding carpets or bed rugs are mentioned, which are involved in 20 to 45% of all falls . Behavior in certain situations or complex tasks can also significantly increase the risk of falling. It could be shown that the gait pattern changes after a fall. Fear of further falls also seems to be an independent risk factor for further falls . The risk of falling also accumulates with the number of risk factors. While the risk of falling is 27% with none or one risk factor, it increases to 72% with four or more risk factors .
Screening and Assessment
The guideline of the American and British Geriatrics Societies suggests a very simple, easy-to-implement algorithm in which every patient over 65 years of age should undergo a simple screening consisting of three questions (Fig. 1) . Only when a question is answered with "yes" should the patient be classified as a "high-risk patient" and an assessment should be carried out using a standardized test. Otherwise the screening should be repeated annually.
The Federal Initiative for Fall Prevention recommends the Short Physical Performance Battery (SPPB), as this test battery can also map slight changes well and can be carried out quickly . The SPPB measures strength as well as balance and gait speed . It includes these three areas:
- the habitual walking pace over 4 m (normal: 0.6 - 0.8 m / sec)
- the chair rise test (normal: 11-15 sec)
- the ability to balance in the closed and semi-tandem position (normal: 10 sec or <10 sec).
In addition to the assessment, a detailed medical history and physical examination should be carried out. In doing so, a targeted search is made for factors that favor falls and possible resources are also recorded .
With an increased risk of falling, the multidimensionality must be taken into account and cognitive areas as well as fear of falling and environmental influences must be recorded (see above). In particular, the influence of cognitive abilities on motor control in maintaining balance - also known as the dual-task paradigm - can be easily assessed in the general practitioner's practice by talking to the patient while accompanying him from the waiting room to the examination room . The dual-task paradigm can also be captured with other assessment methods (walking and listing animal names). It is particularly sensitive when it comes to the early detection of motor restrictions that cannot be detected in "motor only" assessment .
If appropriate risk factors have been identified, they should be addressed in a targeted manner. A multifactorial approach is recommended in the guideline (Fig. 2). The exhaustion of resources, e.g. B. social support, patient information, etc. With regard to local offers for age-appropriate training programs, fall prevention strategies and an increase in sensitivity to fall triggers in the home environment, as well as the targeted improvement of motor skills, form the basis for avoiding future falls.
Strength and balance can be improved in both group and individual therapies and has proven to be very effective . It should be noted that the training should be progressive and challenging and take place at least twice a week. There are numerous programs for this, such as B. the OTAGO program. Corresponding courses are z. B. offered by the German Gymnastics Federation in cooperation with the Federal Initiative for Fall Prevention (BIS).
In addition, pharmacotherapy should be optimized with a view to avoiding or reducing drugs that promote falls, such as benzodiazepines and neuroleptics [15, 17]. The combination of antihypertensive drugs with diuretics and accompanying desiccosis can cause postural hypotension. In addition to adjusting the pharmaceuticals, care should be taken to ensure adequate hydration, and support stockings should be prescribed if necessary. In particularly pronounced cases, drug therapy must also be considered. A meta-analysis showed no positive effect in terms of reducing the risk of falls or the fall rate for general administration of vitamin D to senior citizens living independently . However, a supplementation of vitamin D (800 IU / day) if a deficit is suspected and if there is an increased risk of falling is generally recommended before initiating an intervention.
The installation of handholds as well as the removal of tripping hazards in the home environment and an optimization of the lighting can reduce the risk of falling, especially for people at high risk of falling . Changing footwear to stable shoes with non-slip soles is also effective. In the case of falls due to underlying cardiovascular diseases such as brady or tachyarrhythmias, a hypersensitive carotid sinus or a vasovagal syndrome, the patient should be referred to a cardiologist or to the clinic for further diagnosis and therapy. The implantation of a pacemaker can help avoid future falls if there is an existing indication. Whether the detection of a visual impairment through an assessment and an individual intervention leads to a reduction in the risk of falling is still a matter of controversy. However, cataract surgery can make sense. be.
Conflicts of Interest: The authors have not declared any.
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