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Halting steps

New studies show how to detect and reduce the risk of falls among the aged

GABRIEL BITARThe greatest threat to the health and life of the aged is found within homes and in the streets, especially in the mornings and afternoons. This threat is falling. Falls account for 61% of visits to emergency rooms for those over the age of 60, according to Ministry of Health data from 2007. Falls are a common drama among the elderly, but they tend to be regarded by the rest of society as inherent to advancing age. The consequences, however, are too serious for the problem not to be treated as a primordial public health issue. Around 16% of the falls cause fractures and out of every four elderly people hospitalized for femur surgery, one dies within one year, according to the rheumatologist Marcelo Pinheiro, from the Federal University of São Paulo (Unifesp), one of the coordinators of Brazos, the Brazilian Osteoporosis Study, the first to assess the extent of the problem in Brazil. Fortunately, a series of studies has been showing that simple exercises can avoid a substantial part of these accidents and truly improve the quality of life during the period that some prefer to call the “golden years.”

The most serious consequences of falls are due to osteoporosis, the gradual loss of bone density that affects primarily women. It may be the cause of the fall , when something apparently banal, like a sudden movement, can shatter the femur and cause the person to fall, often without knowing why. However, in 90% of the cases, the fracture is caused by the fall, rather than vice-versa, according to Pinheiro.

Based on the questionnaires answered in 2006 by 2,420 people aged over 40, the Brazos study evaluated recurrent falls and fractures in 150 cities in Brazil’s five regions. Besides the prevalence of osteoporosis and its consequences, the results also showed ignorance about the subject. Among the adults interviewed, 15% of the men and 30% of the women who had already suffered fractures had a history compatible with osteoporosis, but 85% of these men and 70% of these women had not been informed about the disease. “The fracture is often treated without densitometry being conducted in order to evaluate the state of the bones,” Pinheiro tells us. Based on the knowledge accrued through other studies and on clinical indications, the Brazos researchers estimate a far greater prevalence of osteoporosis than that  reported in the questionnaires, according to articles published recently in Arquivos Brasileiros de Endocrinologia & Metabologia [Brazilian Archives of Endocrinology and Metabology] and in Cadernos de Saúde Pública [Public Health Notebooks].

The problem is even more alarming given the growth estimates for the aged population in Brazil in forthcoming decades. According to IBGE (the National Geography and Statistics Institute), in 2025, the country will have 35 million inhabitants older than 60, more than 2 million just in the city of São Paulo. From 2000 to 2050, the forecast is that the percentage of the aged relative to the total population should triple, from 5.1% to 14.2%, as a result of a declining birth rate and longer life expectancy.

For the Unifesp rheumatologist, another important finding concerns nutrition. Our diet is fairly balanced in terms of proteins, carbohydrates and fats, but it leaves a lot to be desired when it comes to micronutrients and vitamins. “Brazilians consume 400 milligrams of calcium a day, when the international recommendation is 1,200 milligrams,” he tells us. It is a cultural problem rather than a socioeconomic one, given that even the wealthier people in classes A and B have only about half the calcium that they should. For Pinheiro, an interesting strategy would be to fortify certain foods, as is common in countries such as the United States, or to have micronutrient supplements.

Another important deficiency, directly linked to incorporating calcium into the bones, is vitamin D, abundant in fish such as herring, tuna and salmon, as well as in nuts, almonds and olive oil. “Eating these foods is a northern hemisphere habit; here, we consume five times less than the daily recommendation, about two micrograms a day.” Besides diet, vitamin D production depends on the sun, but even in tropical countries people do not take enough sun. They do not spend much time in the fresh air and, when they do, they use sunscreen, fearful of sun damage, such as skin cancer. “One should expose at least the arms and the neck to the sun for at least 20 minutes a day, with no sunscreen,” recommends Pinheiro.

GABRIEL BITARThe impact of these falls and fractures upon the quality of life is dramatic, as Brazos data show. What causes death within one year of one quarter of the elderly people who break their femur are the consequences of being hospitalized, such as pressure ulcers, pulmonary embolism and infection. Staying in hospital can also cause depression, opening the doors to dementia and increasing dependence due to physical limitations. “It’s like a pressure cooker,” he compares, “the person was fine and suddenly the fracture causes latent problems to emerge.”

To prevent osteoporosis, it is not enough to treat the elderly. “It’s a geriatric disease whose prevention has to start in childhood, with the right diet and physical activity.” The Brazos study, which includes adults as from the age of 40, showed that the younger group lacks awareness of the imminent problem and does not take preventive measures. The chief cause of the accidents that turn thousands of elderly people essentially into invalids each year, according to Pinheiro, is lack of knowledge. Besides prevention, which should include stopping smoking and drinking too much alcohol and coffee, there are now effective treatments for safeguarding bone density. In some states, such as São Paulo, both the medications and the exam that diagnoses osteoporosis (bone densitometry) are available through the Single Healthcare System.

However, diagnosis and treatment are not enough. Osteoporosis and the likelihood of falling are not only linked by bad luck – and understanding this can be crucial in order to prevent fractures. It is muscular activity that helps to keep the bones healthy. Furthermore, the loss of muscle that goes with osteoporosis has a direct impact on balance, according to a study conducted by the physiotherapist Daniela Abreu, from the Medical School of the University of São Paulo (USP) in Ribeirão Preto. This study was published online in 2009 in Osteoporosis International. “We believe that muscle loss takes place along with bone loss,” conjectures Daniela. She used electromagnetic sensors to evaluate the balance of women with osteoporosis, with osteopenia (an intermediary bone loss stage) and with healthy bones and found that the more fragile the bones, the greater the instability.

“The weakness of specific muscle groups causes different types of instability,” explains Daniela. Even after losing a bit of bone mass, women with osteopenia already evidence a forward and backward oscillation similar to the one found  among those who suffer from osteoporosis and greater than that of women with no bone problems. As the bones degrade, muscles also lose mass, giving rise to a vicious circle. According to the sensors, the women with osteoporosis not only oscillate forward and backward, but from side to side as well. The next step, according to Daniela, is to establish in detail what  the most heavily affected muscle groups are in order to design specific training programs for recovery.

While this map of weakened muscles is not provided in detail, the group of rheumatologist Rosa Pereira, from the Medical School of USP’s São Paulo campus, showed that physical exercise for improving balance, besides reducing the incidence of falls, is also effective in improving several elements, such as wellbeing, physical functions and social interaction. During her doctoral research, the physiotherapist Melisa Madureira developed a method to improve the balance of osteoporosis patients. With a series of simple exercises, such as walking forward, sideways, raising one leg and the opposite arm, on tiptoe and on the heels – for 30 minutes once a week, along with stretching and walks, she managed to improve the quality of life and to reduce the incidence of falls among the 30 patients in her experimental group relative to the 30 control patients who did not undergo this training, according to the article already available on the website of the journal Maturitas. The participants in the study were also given an instruction booklet in order to do the exercises at home, further improving results. “Contrary to body building, which calls for individual instructor attention, for this type of exercise constant supervision is unnecessary. Once the exercises have been learnt, they can be done at home with no problems,” Rosa explains. She has already included the booklet in the routine care provided to patients at the osteoporosis clinic of the Rheumatology Service at USP’s Clinicas Hospital. “It’s useless to provide osteoporosis medication without reducing falls, because the fractures continue to happen,” she adds.

Indeed, there is no point in only focusing on osteoporosis, as countless factors can lead to falls. A study coordinated by the epidemiologist Evandro Coutinho, from the Oswaldo Cruz Foundation (Fiocruz), compared 250 cases of falls treated in five Rio de Janeiro hospitals with 250 control cases of people of a similar age, sex and type of residence, and indicated a low index of body mass, a cognitive deficit, strokes, urinary incontinence, use of benzodiazepine medication and muscular relaxants as risk factors for falls that lead to serious fractures, according to an article published in 2008 in BMC Geriatrics. The group did not take osteoporosis into account because diagnosing the disease was not routine in the selected hospitals. “The most surprising thing was detecting the effect of muscle relaxants,” Coutinho tells us, as “most of the studies don’t take this type of medication into account.” These drugs, often prescribed to alleviate the back pains of the elderly, may quadruple the risk of falling. As for the benzodiazepines, they are tranquilizers usually prescribed for those who have trouble sleeping. The problem is that they cause dizziness, sleepiness and diminish muscle strength and contraction, doubling the risk of falls and fractures.

“The aged have slower metabolism, so that when they wake up, they are still under the medication’s effects,” explains the epidemiologist, who was also surprised to find that most of the accidents occur in the mornings and afternoons and not, as he had expected, during the night, in the dark, when the person gets up to go to the bathroom. According to him, before prescribing these kinds of drugs for the elderly, physicians should research better the cause of the pains and sleeping difficulties first, instead of merely treating the symptoms. Moreover, he adds, there are now benzodiazepines that are more suitable for the aged, as they last less time in the organism.

“Out of every 100 old people, 30 will fall in any given year,” Coutinho assesses. However, the risk is greater for those that have already fallen: 60% of the elderly that fall and hurt themselves will fall again within one year, according to the data of the SABE (Health, Wellbeing and Aging) project, a study that monitors the conditions of the life and health of elderly residents in the city of São Paulo over time. “A fall is an indication that the person may fall again”, comments the physician Maria Lúcia Lebrão, from the School of Public Health at the University of São Paulo (USP), who is the project’s coordinator.

For the researcher from the School of Public Health, one must evaluate carefully the causes of the falls in order to correct this. Many of the aged feel dizzy and lose their balance even when there are no obstacles in the way. With less muscle strength and slower reflexes, it becomes much harder to correct unstable positions and those incidents of tripping that, during youth, went unnoticed. To this, one must add environmental factors such as irregular sidewalks, shoes that challenge balance and slippery carpets. Initiated in 2000 (see Pesquisa Fapesp issue 87), the study in which almost 2,500 people have taken part tracks the aging tendencies of the São Paulo inhabitants and is now entering its third stage.

Two thirds of the interviewees reported at least one fall since their 60th birthday. The greater the age, the greater the risk of falling, but what is most surprising is that environmental factors pose an even greater risk than age: the elderly that moved recently are more likely to fall within a home with which they are less familiar than those who have lived for a long time in the same place and have already imprinted the potential obstacles in their memory.

GABRIEL BITARThe study also showed that an important factor regarding falls is the frailty syndrome, which can either cause falls or result from them. The syndrome is present when the patient has three out of the following five indicators: loss of weight for no reason, diminishing muscle strength, fatigue, increasingly slow walking speed and a reduction of physical activity. Yeda Duarte, from USP’s Nursing School, has been analyzing this issue in a sub-project of the SABE study that she is coordinating, in collaboration with Maria Lúcia. Every six months, since 2008, they evaluate elderly people as from the age of 75, alternating home visits with phone interviews.

They have found that the frailty syndrome is more common among women (found in 17.3% of them, vs. 12.3% of the men) and among the more elderly. “Women live longer than men but during these added years many of them may have a worse quality of life, as survival can go hand-in-hand with periods of incapacity”, comments Maria Lúcia.

According to the research, the São Paulo City population appears to become frail earlier than is the case in developed countries, where the syndrome is more common after the age of 85. In the USP study, the researchers found that in São Paulo, frailty is sometimes already present at the age of 65. It will be necessary to include younger elderly in their research in order to better understand how the syndrome has developed in this population.

Frailty per se becomes a severe limitation when the person is not strong enough to keep to a normal routine and takes half an hour to get to the corner of the block. However, its connection with falls makes it even more serious, especially when these falls result in fractures that demand surgery, hospitalization and immobilization for a longer time, all of which helps to make frailty more severe.

“We must break this cycle,” sums up Lúcia, who has partnering arrangements with the Ministry of Health and with corresponding bureaus in the state and in the city of São Paulo, in order to help to implant the interventions that can help to avoid or revert frailty, based on the study.

Health club
One of the main elements that make predisposition to fall more serious is a lack of muscle strength, according to the work of André Rodacki, a biomechanics expert from the Federal University of Paraná (UFPR). During a regular walk, the researcher explains, the flexibility of the musculature of the hips is essential to improve control over the legs and the strength of the knees’ extensor muscles, ensuring larger, firmer steps. In a study on 20 elderly women doing stretching exercises that targeted the hip area three times a week  that was published in 2009 in Gerontology, he showed that four weeks are enough to improve the extent to which people raise their feet, the size of their steps and their walking speed.

This is already a fine step toward reducing the risk of falls, but not the only one. When one tries to keep a key ring from falling on the floor or trips and tries to regain one’s balance, one’s muscles must be able to generate strength very fast, explains Rodacki. Improving this capacity, as he shows this month in Clinical Biomechanics, involves power training for knee muscles, by doing fast movements using a low weight device, a type of exercise rarely suggested for the elderly. He has been researching more interesting ways of maintaining sound walking capability and good balance. “These exercises are effective but very boring,” the researcher tells us. He expects to improve adherence to the exercise program with an especially challenging type of aquafitness training or ballroom dancing with targeted choreography.

The problem, which is not limited to bones and muscles, also affects the mind, affecting elderly people’s safety. The fear of falling is part of the day-to-day life of 42% of the men and 60% of the women over 60, according to Brazos results published this in year in Cadernos de Saúde Pública. No wonder: the aged do indeed have more difficulty integrating the information about their environment and run a higher risk of falling, as the physiotherapist Mariana Callil Voos showed in her doctoral thesis in neuroscience, which she defended in January at USP’s Psychology Institute. “Trust the elderly person’s self-evaluation,” she advises. “Other than in cases of dementia, they are aware of the risk they run.”

Among the participants in her study, those who completed in less time a cognitive test in which the elderly person has to find numbers and letters printed on a piece of paper in the right order, also performed better on the balance scale, involving tasks such as turning around, standing and getting up, as explained in a forthcoming article in the Journal of Geriatric Physical Therapy. Mariana, who works at USP’s Department of Physiotherapy, Speech Therapy and Occupational Therapy, also found a clear correlation between the fear of falling, measured by a questionnaire on day-to-day tasks, and cognitive difficulties.

Besides the fear of falling, Mariana found that the educational level has a substantial effect on the risk of falling, as the difficulty in completing the cognitive test indicates. “The mean level of schooling among the Brazilian elderly is about four years,” she states. The study showed that people with fewer years of schooling have more difficulty integrating information, less memory and coordination, and therefore more precarious balance. Furthermore, the researcher adds, they have lower purchasing power and more limited access to healthcare services and medication, which probably aggravates the problem.

The best solution, according to the physiotherapist, is not to send the aged back to school. She found that simple exercises that train motor cognitive integration – doing a movement while also paying attention to some point in the environment, for instance – help the elderly to become more agile in a short time. Mariana is planning to implement a system of home visits to help older people absorb the information from their own world. For her, the proposal is viable, even financially. “It’s far cheaper for the country to make spot interventions once a month than to keep an elderly person hospital with a broken femur.”

One common point seems to bring together the researchers from various areas of specialization when it comes to the mobility and balance of the aged: walking on the streets, with sidewalks full of holes and steps, need not be harder than an obstacle course that includes a sack race. Simple, effective measures can enable people to recover their vigor and day-to-day pleasure after the age of 60.

The projects
1. Effect of muscle strength training associated or not with hormone replacement therapy in peri- and post-menopausal women on muscle and bone tissues and balance (nº 07/54596-0); Type Regular Research Awards; Coordinator Daniela de Abreu – FMRP/USP; Investment
R$ 59,571.39
2. SABE study – 2005: health, wellbeing and aging. Longitudinal study on living conditions and health of the aged in the city of São Paulo (nº 05/54947-2); Type Thematic Project; Coordinator Ruy Laurenti – FSP/USP; Investment R$ 472,509.34

Scientific articles
VOOS, M. C. et al. Relationship of executive function and educational status with functional balance in older adultsJournal of Geriatric Physical Therapy. Forthcoming.
ABREU, D. C. et al. The association between osteoporosis and static balance in elderly womenOsteoporosis International. Forthcoming.
PINHEIRO, M. M. et al. Risk factors for recurrent falls among Brazilian women and men: the Brazilian Osteoporosis StudyCadernos de Saúde Pública. v. 26, n. 1, p. 89-96. Jan. 2010.
BENTO, P. C. B. et al. Peak torque and rate of torque development in elderly with and without fall historyClinical Biomechanics. v. 25, p. 450-4. Jun. 2010.