Young People Get Osteoporosis Too 

Falls and Related Fractures: The Risk of Undiagnosed Osteoporosis

Falls are serious at any age, and breaking a bone after a fall becomes more likely as a person ages. Everyone knows someone who has fallen and broken or fractured a bone. While healing, the fracture limited activities and sometimes required surgery, and, often, the person wore a heavy cast to support the broken bone and needed physical therapy to resume normal activities. People are unaware that there is often a link between the broken bone and osteoporosis, a silent disease in which there is a gradual loss of bone tissue or bone density that makes bones so fragile they break under the slightest strain. Because osteoporosis progresses without symptoms, falls are especially dangerous for people who are unaware that they have low bone density. If the patient and the physician fail to connect the broken bone to osteoporosis, the chance to make a diagnosis with a bone density test and begin a prevention or treatment program is lost. Bone loss continues until another bone breaks.

Even though bones do not break after every fall, the person who has fallen and broken a bone almost always becomes fearful of falling again. As a result, she or he may limit activities for the sake of "safety." Among Americans age 65 and older, fall-related injuries are the leading cause of death due to unintentional injuries^.

There are 5 main factors which affect the risk of fracture in patients with osteoporosis: life expectancy, age, bone density, previous fracture history, and the underlying condition responsible for the osteoporosis (if known).

The Fracture Triangle

The Fracture Triangle includes the following three factors that play a role in the breaking of a bone:

Did You Know?

• More than 90% of hip fractures are associated with osteoporosis?
• Nine out of ten hip fractures in older Americans are the result of a fall?
• Individuals who have a hip fracture are 5-20% more likely to die in the first year following that injury than others in this age group?
• For those living independently before a hip fracture, 15-25% will still be in long-term care institutions a year after their fracture?
• Most falls happen to women in their homes in the afternoon?

If one of these factors is modified, the chances of breaking a bone are greatly reduced. 

The Fall Itself

There are several factors that can lead to a fall. Loss of footing or loss of traction are common causes of falls. Loss of footing occurs when there is less than total contact between the person's foot and the ground or floor. Loss of traction occurs when the ground upon which the person is stepping is wet or slippery, and the person's feet fly out from under her or him. Other examples of loss of traction include tripping, especially over uneven surfaces such as sidewalks, curbs or floor elevations that result from carpeting, risers or scatter rugs. Loss of footing also happens from using household items for unintended purposes, such as trying to gain height climbing on kitchen chairs or balancing on boxes or books.

A fall may occur because a person's reflexes have changed. As people age, reflexes slow down. Reflexes are automatic responses to stimuli in the environment. Examples of reflexes include quickly slamming on the car brakes when a child runs into the street, or quickly moving out of the way when something accidentally falls. Aging slows a person's reaction time and makes it harder to regain one's balance following a sudden movement or shift of body weight.

Changes in muscle mass and body fat also can play a role in falls. As people get older, they lose muscle mass because they have become less active over time. Loss of muscle mass, especially in the legs, reduces a person's strength to the point where she or he is often unable to get up from a chair without assistance. In addition, as people age, they lose body fat that has cushioned and protected bony areas, such as the hips. This loss of cushioning also affects the soles of the feet, which upsets the person's ability to balance. The gradual loss of muscle strength, which is common in older people but not inevitable, also plays a role in falling. Muscle strengthening exercises, however, can help people regain their balance, level of activity and alertness no matter what their age.

Changes in vision also increase risk of falling. Diminished vision can be corrected with glasses, but often, these glasses are bifocal or trifocal so that when the person looks down through the lower half of her/his glasses, depth perception is altered. This makes it easy to lose one's balance and fall. To prevent this from happening, people who wear bifocals or trifocals must practice looking straight ahead and lowering their head. For many other older people, vision changes cannot be corrected completely, making even the home environment hazardous
 

As people get older, they also are more likely to suffer from a variety of chronic medical conditions that often require taking several medications. People with chronic illnesses that affect their circulation, sensation, mobility or mental alertness or those taking medications (see chart) are more likely to fall as a result of drug-related side effects such as dizziness, confusion, disorientation or slowed reflexes.

Drinking alcoholic beverages also increases the risk of falling. Alcohol slows reflexes and response time, causes dizziness, sleepiness or lightheadedness, alters balance and encourages risky behaviors that can lead to falls.

The Force and Direction of a Fall

The force of a fall (how hard a person lands) plays a major role in determining whether a person will fracture or not. For example, the greater the distance of the hip bone to the floor, the greater the risk of fracturing a hip so tall people seem to have an increased risk of fractures when they fall. The angle at which a person falls also is important. Falling sideways or straight down is more risky than falling backwards, for example.

Protective responses, such as reflexes and changes in posture that break the fall, can reduce the risk of fracturing a bone as a result of a fall. Individuals who land on their hands or grab an object on their descent are less likely to fracture their hip, but they may fracture their wrist or arm. While these fractures are painful and interfere with daily activities, they do not carry the same risks that are associated with a fractured hip. The type of surface on which one lands can also affect whether a bone breaks or not. Landing on a soft surface is less likely to cause a broken bone than landing on a hard surface.

Preliminary research has suggested that trochanteric (hip) padding can decrease the chances of fracturing a hip after a fall. The energy created by the fall is distributed throughout the pad, lessening the impact to the hip. Further research is needed to fully evaluate the role of these devices in decreasing the risk of a hip fracture following a fall.

Bone Fragility

While most serious falls happen when people are older, steps to prevent and/or treat bone loss and falls can never begin too early. Many people begin adulthood with less than optimal bone mass, so the fact that bone mass or density is lost slowly over time puts them at increased risk for fractures. Bones that once were strong become so fragile and thin that they easily break. Activities that once were done without a second thought are now avoided for fear they will lead to breaking another bone.

Prevention of Falls and Fractures

Safety First to Prevent Falls

At any age, people can improve their environments in ways that reduce their risk of falling and breaking a bone.

Outdoor Safety Tips

• In nasty weather, use a walker or cane for added stability.
• Wear warm boots with rubber soles for added traction.
• Look carefully at floor surfaces in public buildings. Many floors are made of highly polished marble or tile that can be very slippery. When floors have plastic or carpet runners in place, stay on them whenever possible.
• Identify community services that can provide assistance, such as 24 hour pharmacies that deliver, grocery stores that take orders over the phone and deliver, especially in poor weather.
• Use a shoulder bag, fanny pack or backpack to leave hands free.
• Stop at curbs and check height before stepping up or down. Be cautious at curbs that have been cut away to allow access for bikes or wheelchairs. The incline up or down, may lead to a fall.

Indoor Safety Tips

• Keep all rooms free from clutter, especially the floors.
• Keep floor surfaces smooth but not slippery. When entering rooms, be aware of differences in floor levels and thresholds.
• Wear supportive, low-heeled shoes even at home. Avoid walking around in socks, stockings or floppy, backless slippers.
• Check that all carpets and area rugs have skid-proof backing or are tacked to the floor, including carpeting on stairs.
• Keep electrical cords and telephone lines out of walkways.
• Be sure that all stairwells are well lit and that stairs have handrails on both sides. Consider placing fluorescent tape on edges of top and bottom steps.
• For optimal safety, install grab bars on bathroom walls beside tubs, showers and toilets. If you are unstable on your feet, consider using a plastic chair with a back and non-skid leg tips in the shower.
• Use a rubber bath mat in the shower or tub.
• Keep a flashlight with fresh batteries beside your bed.
• Add ceiling fixtures to rooms lit by lamps only; or install lamps that can be turned on by a switch near the entry point into the room. Another option is to install voice- or sound-activated lamps.
• Use at least 100-watt bulbs in your home.
• If you must use a step stool for hard to reach areas, use a sturdy one with a handrail and wide steps. A better option is to reorganize work and storage areas to minimize the need for stooping or excessive reaching.
• Consider purchasing a portable phone that you can take with you from room to room. It provides security because not only can you answer the phone without rushing for it, but you can also call for help should an accident occur.
• Don't let prescriptions run low. Always keep at least one week's worth of medications on hand at home. Check prescriptions with your physician and pharmacist to see if they may be increasing your risk of falling. If you take multiple medications, check with your physician and pharmacist about possible interactions between the different medications.
• Arrange with a family member or friend for daily contact. Always have at least one person who knows where you are.
• If you live alone, you may wish to contract with a monitoring company that will respond to your call 24 hours a day.
• Watch yourself in a mirror. Does your body lean or sway back and forth or side to side? People with decreased ability to balance often have a high degree of body sway and are more likely to fall.

Reducing the Force of a Fall

Take steps to lessen your chances of breaking a bone in the event that you do fall.

• Remember that falling sideways or straight down is more likely to result in a hip fracture than falling in other directions. If possible, try to fall forward or to land on your buttocks.
• If possible, land on your hands or use objects around you to break a fall.
• Walk carefully, especially on hard surfaces.
• When possible, wear protective clothing for padding.
• Talk to your doctor about whether you may be a candidate for hip padding.