Chapter 78
How to Prevent Falls
That falls play such an important role in fracture risk explains a number of apparent osteoporosis paradoxes. For example, although 70 percent of bone density is determined by genes, when it comes to falls heritability is negligible, because the tendency to fall is much less inherited. That also explains the limited predictive value of DEXA scans for future fractures. It also doesn’t help much to add bone density to a hip-fracture risk index that captures only age, sex, height, weight, use of a walking aid, and smoking status. A provocative editorial published in the Journal of Internal Medicine was titled “Osteoporosis: The Emperor Has No Clothes” and suggested that, for that reason, it would be safer and more effective to focus on preventing falls rather than trying to intervene with medications.
Only 5 percent of falls result in a fracture, but among older people, falls are common. In part because of age-related muscle weakness and balance problems, each year more than a third of those over 65 fall. After a hip fracture, fewer than 50 percent of those affected regain their prior walking ability and independence. What can you do to prevent dangerous falls? Exercise. Dozens of randomized controlled trials have found that targeted physical activity is the only intervention that clearly reduces falls.
How to Prevent Falls
81 studies showed that in participants randomized to exercise, the number of falls dropped by 23 percent and the number of fallers decreased by 15 percent, each compared to a control group. So if you follow 1000 people around age 75 for a year and, without exercise, 480 of them fall a total of 850 times, exercise results in 72 fewer people falling and a reduction in the number of falls by 195. Tai chi can reduce falls by 19 percent, balance and functional exercises (such as sit-to-stand) by 24 percent, and combined exercise—usually balance and functional exercises plus strength training—by 34 percent.
With fewer falls, there are also fewer fractures. A more recent meta-analysis showed that exercise interventions—primarily a combination of resistance training for leg muscle strength and balance exercises—nearly halved the number of fractures. After one year of strength training with step and jumping aerobics, which focused primarily on balance and mobility, there were 74 percent fewer bone fractures in the following five years. More than 70 percent of the women in the exercise group did not injure themselves a single time in a fall during those five years, unlike in the control group, where more than half were injured.
Trials of hip protectors made of plastic or foam that are sewn into special underwear to cushion a sideways fall onto the hip often fail because of poor acceptance, mainly because the pads are so uncomfortable, especially in bed. In people living at home, the devices do not seem able to prevent hip fractures, but in nursing and residential care homes, studies found a minimal risk reduction: 11 out of 1000 people avoided a hip fracture because they wore protective devices.
In addition, we can use common sense. Quality-improvement efforts, including patient education, ended with 10 percent fewer falls. For example, you can store things within reach so you don’t have to climb a step stool, you can use non-slip mats in the shower and bathroom, install grab bars on the walls, not leave things lying around, remove small rugs or secure them with double-sided tape, and outfit all stairwells with handrails and adequate lighting. In bad weather, you shouldn’t go for a walk, and dog lovers might consider getting smaller breeds or training larger dogs so they don’t suddenly bolt and yank on the leash.
Otherwise, fractures can’t really be prevented much differently than in the last 30 years, because even back then the famous article “Strategies for Osteoporosis and Hip Fracture Prevention” urged people to “stop smoking, be active, and eat the right thing.”
Maintaining Bowel and Bladder Function
Ancient Egypt was one of the greatest early civilizations and lasted more than 3000 years. Its medicine is greatly underestimated; there were even specializations in many fields. The pharaohs, for example, had physicians who focused entirely on their duties as “Guardians of Royal Digestion”—a free translation of the title from the hieroglyphs, which actually means “Shepherd of the Anus.” How do you put that on a résumé?
To this day, digestion remains an important topic. Calls have been made to view digestion, along with pulse, blood pressure, and respiratory rate, as a vital sign of physical function. The optimal frequency of bowel movements, as I explain at see.nf/bms, would probably be two to three times a day. However, the most important criterion for constipation is not frequency, but inclusion of the most definitive symptom: straining. Ideally, a bowel movement should be effortless.
Constipation
Constipation is among the most common digestive complaints in the United States; each year it is the reason for millions of doctor visits and for 800 000 emergency department cases. Older adults are at higher risk, perhaps because they eat less fiber, drink less, and also move less. Constipation afflicts up to 30 percent of those over 65, more than 50 percent of those over 85, and even two thirds of residents of long-term care facilities. In addition to straining, constipation includes hard stools and irregular bowel movements, abdominal cramps and pain, bloating, nausea, and bleeding with bowel movements. Although it is often harmless, even the slightest sign of blood in the toilet should be examined by a specialist. Other warning signs include unintentional weight loss of more than 10 percent in three months, inflammatory bowel disease or colon cancer in the family, jaundice, unexplained symptoms after 50, and so-called stool urgency, the feeling of needing to empty the bowel but being unable to, even though it actually contains nothing.
Don’t strain!
A systematic review on the impact of constipation on sufferers’ lives found that it worsens quality of life to a degree similar to osteoarthritis, rheumatoid arthritis, chronic allergies, and diabetes. Even though it casts such a shadow over daily life, surveys found that many adults with chronic constipation have never discussed this problem with a health professional. The taboo seems to run both ways, because medical professionals rarely ask about bowel movements. In the meantime, an expert panel has recognized this as a “serious omission” in the medical profession.
It also happens that people suffer from clinical constipation without being aware of it. In a study in Ohio, for example, a quarter of so-called healthy participants reported they could not completely empty their bowels, and about half reported increased straining during bowel movements—so much so that more than half had discovered blood on the toilet paper in the past year.
Trying to squeeze out small, hard pieces of stool can of course be unpleasant, but apart from the pain, hard stool can contribute to a whole range of health problems. For example, more than one in five Americans has a hiatal hernia, meaning part of the stomach is pushed through the diaphragm into the chest. In communities that eat plant-based diets, hiatal hernia is very rare, occurring in about one in a thousand. Why this large discrepancy? Plant eaters produce large amounts of soft stool. If you have to strain repeatedly during bowel movements, over time the increased pressure from bearing down can cause part of the stomach to be pushed up out of the abdomen, so that acid rises into the throat and causes symptoms like heartburn. If this pressure is exerted week after week on the toilet, it can also lead to additional problems, such as hemorrhoids and varicose veins, anal fissures, and other painful symptoms.