•Wet floors, rugs, steps, base of doors pose common dangers in homes
Dr Ajibola Oladiran is a lecturer and consultant orthopaedic and trauma surgeon with subspecialty in hip surgery and sports medicine at the College of Medicine and the University College Hospital (UCH), Ibadan. In this interview by SADE OGUNTOLA, he speaks about fractures and why its prevention, particularly in the elderly.
Why are the elderly prone to fractures from the perspective of medicine?
Elderly people are prone to fractures for several reasons. With age, their agility, balance, and coordination reduce. Their ability to be stable when they move around reduces, and that increases the likelihood of falls. There may also be some form of visual impairment, making them more prone to tripping over objects or slipping over wet floors and other such risks.
Additionally, with age, especially past the age of menopause in women, the density and the strength of the bones start to reduce. The degree to which it reduces varies from person to person. So in people who have been more active at a younger age, the density of the bone is higher, and the rate at which it reduces is less. However, for people who have had a sedentary lifestyle and who didn’t have much bone mass to start with, the rate of reduction of bone mass and bone density is also faster. There are also some differences in how bone density is reduced between the races. So, basically, the quality of the bone itself is a significant factor when there’s a fall in an elderly person as to whether or not a fracture will happen.
About what age does the risk of fracture increase, could be from the mid-40s or mid-50s?
Between the ages of 30 and 40, the average person is no longer forming new bone. By menopause in women, bone density starts to reduce. In men, because men don’t have menopause as it were, the age at which bone density starts to reduce in men is later and is affected more by their level of activity, the bone mass they were starting with, their muscle mass, and whether or not they continue to exercise.
Wolff’s law in orthopaedics states that the architecture of a bone is modified based on the forces to which the bone is subjected by functional stresses and deformity. Essentially, this means that the more pressure you put on the bone, the denser the bone gets. If you look at somebody who has been doing heavy manual labour since a young age, you notice he has thicker fingers, wrists, and hands. He has been subjecting his bones to more stress, and there’s more pressure on them; the body responds by making the bones denser and stronger.
The same thing occurs in somebody who lifts weights; the muscles are bigger and these bigger muscles are pulling on the bone. So the same way the muscles get bigger, the bone that the muscles are pulling on also gets stronger and denser. So, physical activity and exercise within reasonable levels are protective in later life, especially if starte while one is younger, which is one of the important factors for building good bone density.
If one builds a good muscle mass while one is younger and maintains it going forward, then it gives one a good bone density to start with. Even when bone density starts to reduce in old age, one is starting from an advantageous point. It is like a bank, the bigger the bank, the lower the rate of reduction.
As opposed to somebody who is starting with an empty bank already, and then because the bank is half empty, the rate of reduction is higher, they tend to get to a critical point much faster.
What are the common types of fractures you see in the elderly?
In the elderly, the most common is fractures around the wrists (distal radial fractures) because typically when one is falling, the instinctive reaction is to reach out to break the fall. So we classically describe it as falling on an outstretched hand. For those who fall sideways, fractures around the hip are common. Then, fractures around the shoulder are also common in those who land on their side. But by far, those are three of the commonest that we see in elderly people resulting from falls.
Are there other sites where you usually see fractures in the elderly?
Well, essentially, they could occur anywhere depending on how the fall occurs. Ankle fractures are also common, especially when walking on uneven ground and the ankle twists. They miss a step climbing stairs, or they are walking on gravel and their foot twists. Fractures in the spine are also common because the weight of the body is pressing on the bones. And then for those who fall backwards and land on their buttocks, the bones in the spine, especially the lower spine may also collapse.
Can an elderly individual experience a fracture of their bone without a fall?
It’s possible. That’s called a pathological fracture. So that would mean that there’s a disease in the bone that is weakening the bone, and then trivial trauma, things that we normally would experience from day to day, cause a fracture. Somebody is crossing a gutter and takes a step and lands with a little more impact than the regular step. Then a diseased bone may fracture. We often find that in people who have cancers that have spread to the bone, but in severe weakening of the bones, osteoporosis, which is what we call the reduction in bone with age, elderly people may also be more prone.
So like I said earlier, there may be fractures around the ankle, the same place they’ve been walking and the same kind of twist that didn’t result in a fracture four or five years ago. Now the bone has become soft to the point that a twisting of the ankle snaps the bone around the ankle. So, fractures can happen without a fall in the elderly.
What are the common risk factors for fractures in older persons?
Like I mentioned earlier, the severity of the osteoporosis, visual impairments that make them unable to navigate around objects and cause them to trip and fall, then loss of balance and coordination that makes them prone to falling. The other thing we also find is that something unrelated to the bone may have caused them to fall. They may have had a mild stroke, which we often call a transcendent ischemic attack, or TIA for short. They may have had hypotension, the blood pressure drops, they collapse, they fall, and then the bone breaks, but then the blood pressure comes back up. And then we see the fracture, but the period of low blood pressure is missed.
It may be diabetes with elevated blood sugar or low blood sugar (hypoglycemia) that makes them collapse, or it may be a seizure. And sometimes with a seizure, by the time they recover from the seizure, they may not remember exactly what happened. They just wake up and find themselves on the floor and they think they just slipped and fell. So, something else may have caused the fall that now causes them to have a fracture.
Why is it better that you prevent fractures, particularly in the elderly?
Prevention is always better than cure because once a fracture happens, even if it heals, the stress of the healing process, the stress of treatments, the costs (which is another matter entirely) the time and effort of the caregiver, the time away from work, the mental and social demands, and the emotional pain, apart from the physical pain, are all best avoided. It’s also important to note that once there’s a fracture, especially fractures around the ankle or the hip in the elderly, the reduced mobility that is necessary during the period of treatment puts them at risk of a deep vein thrombosis. This is essentially an abnormal blood clot within the vessels, which may now dislodge and clog blood flow to the heart and lungs, with a very high risk of death. There’s also the risk of urinary tract infections (UTIs) if they have to be in bed for a while, loss of appetite, constipation, and bed sores for those who stay in bed for prolonged periods and are unable to turn regularly in bed. So it’s always best to prevent the fractures and avoid having to treat a fracture and the possible complications as well.
It’s also important for the elderly to stay active and to exercise. It may be simple things like a brisk walk within a safe neighbourhood or their compound. They just need to stay mobile and stay active. Yoga stretches also help with balance and muscle strength. So it’s advisable that people consider participating in that.
However, I often advise patients that the best form of exercise for the muscles that does not put weight on the joints, particularly those who already have joint issues, is swimming. In swimming, the buoyancy of the water supports the weight of the body so the weight is not on the joints.
So for people who have access to a pool, I strongly advise swimming. For people who cannot swim, even if they get into the pool and the water is either waist deep or chest deep and they’re just walking to and fro in water that deep, the buoyancy of the water reduces how much weight is on their joints. The resistance of walking through water that deep gives them a good workout. So it helps to strengthen the muscles and improves their balance and their stability. That will also reduce the likelihood of falls.
What about tips they must be mindful of to prevent falls in elderly people?
First and foremost, we’re beginning to pay more attention now to wellness clinics and geriatric care. So the elderly should have regular checkups to identify disease conditions that are common in the elderly early and treat and control them so that they do not lead to complications. So if diabetes or hypertension is found early and treated, the likelihood of complications or the likelihood of a collapse and a fall are less.
If glaucoma or cataracts are found early, then the likelihood of visual impairments is reduced. They are less likely to trip and fall. People who have mobility issues, Parkinson’s, then they can be identified and can be treated or controlled, or they can get support. It’s also important that people who need walking aids should use them. If say at age 70, an elderly person needs to use a walking stick, then they should use it. They have earned the right to use a walking aid.
A right to use a walking aid, how do you mean?
My typical, tongue in cheek, response to an elderly person who is reluctant to use a walking aid is “Whoever questions your need for a walking stick at the age of 80, respond to him or her that he should go and pray that his age will reach your own”. It is better to use a walking stick and let whoever is unwise enough to make snide comments, continue to talk, but the person who is using the walking aid is prevented from falling.
Rather than avoid the use of a walking aid and run the risk of falling and having to treat a fracture and attend to all of the complications, people who need walking aids should use them. For people who are still relatively young, it’s advisable that they exercise, and maintain their mobility and agility so that they are better able to move independently and reduce the likelihood of falling.
What is the intent of the elderly carrying a walking stick?
Human beings walk on two legs, which gives the risk of either falling forwards or backwards, especially for somebody who is unstable. The walking stick gives an extra point of support to the weakerside. If there is no weaker side and it’s just a question of stability, it gives an extra point of support. So they are standing as a tripod rather than just two points. So it’s either to support a weaker side or to give a third point of support. So they have three points of contact with the ground rather than two. Either way, it improves stability if it’s properly used and so reduces the likelihood of falling.
What type of walking stick are they supposed to use? There are different types of walking aids for sale in the market.
So the type they need to use depends on how much support they need. For the simple straight walking stick, it gives an extra point of support. And when the need for support is minimal, that is adequate. But for someone who has issues with stability, that needs something to lean on, they will need the three or four-pointed one. If you put it on the ground, it stands by itself, so that gives a bit more stability than the simple straight one and they can lean on it a bit more.
For those who need more than that, then the walking frame will be the adequate choice for them to use. Again, which one is needed for each person is a decision that will need to be individualised based on the person’s needs or the deficiency we are trying to support. So, the decision of a doctor or a physiotherapist may be required to determine what is best for each person.
Can doctors help in case of fractures?
Definitely! Most fractures of the wrist can be treated with POP casts. Fractures around the wrist in the elderly usually can be treated with a POP cast. Fractures around the hip need surgery. There’s no way around it. The other option would be that they would have to lie down in bed for at least three months, since takes at least three months for the fractures in bones of the lower limbs, the hip and below, to heal. And sometimes they may not heal. So they may end up spending three months in bed and it still will not heal. Now in those three months, they may have pressure sores, UTIs, depression, joint stiffness, and even blood clots.
Fractures around the shoulder usually also can be managed with a POP cast. Fractures around the ankle may need surgery. Sometimes they can be managed with a POP depending on whether or not the fracture has shifted out of place. So the decision about the fracture around the ankle depends on the nature of the fracture and whether or not it has shifted.
Are there things they need to be mindful of to prevent falls and subsequently fractures at home?
A couple of them we’ve mentioned. The elderly are prone to slipping on wet floors. So ensuring that the floor is not wet and that the bathroom floor is not slippery is important to prevent falls. For both men and women, you shouldn’t be attempting to wear your underwear in the bathroom. The tiles may be slippery while you’re trying to stand on one leg. It’s best to come back into the bedroom, sit down and then wear the underwear. This way the risk of falling is less. Clutter on the floor is also important because it increases the likelihood of tripping and falling over objects. That along with visual impairment is also a major risk.
Again, with the likelihood of slipping or tripping, the elderly shouldn’t be going out when it’s raining. Apart from the likelihood of falling, the cold and the rain are also not particularly good. The temperature is lower, and everywhere is wet. Even if they don’t fall, the risk of pneumonia is significant. The elderly should not be climbing chairs or climbing stools to either change bulbs or pick something from a shelf. Even young people fall and get injured. Not to mention elderly people who have issues with balance, who have issues with muscle strength and also have weaker bones. Falling from a table or a stool, the problem may not be a fracture; it may be something much worse because they could land on their head and get a head injury.
From history taking in the clinic, are there peculiar things mentioned that had contributed to cases of falls among the elderly in Nigeria?
Yes, a significant number either trip on a wet floor, trip on the edge of a carpet or a step. So while multi-level bungalows are fanciful, the dining room is on a different level from the sitting room so there’s a step, it looks nice for the aesthetics of the house. Navigating those stairs is a major problem. Doorways also are a problem because when installing security doors, there is a frame which needs to be strong and solid and when it’s installed, the base of the frame is not flush with the ground. The base of the frame is also a place that trips a lot of elderly people. As they are stepping through the door, the base of the frame can trip them. So, wet floors, rugs, steps and the base of a door frame are the common culprits for falls within the house.
Are there other things you notice among them?
Elderly assault is also getting more frequent. Cases of assault leading to fractures are on the rise both in young children and in the elderly. Many times it’s difficult to be sure it is a case of an assault because they will deny the history. But sometimes you see telltale signs; there’s a fracture in the forearm in an elderly person and they have bruises on other parts of the body and we are told that they fell. But the pattern of the fracture doesn’t look like a fall. That’s the history we have. There are specific patterns in fractures that give us an indication of how it happened, whether it is from a direct impact or a twist. Sometimes, the history just does not add up. So sometimes we later get information, and sometimes we never do but such suspicious injuries are increasing in frequency.
So, what is the way forward for Nigeria to ensure that elderly people live well and they stop coming to the hospital because of fractures?
We can reduce the incident, and like the things we’ve mentioned, one of the major issues is again one of the most common phrases that come up in every conversation: the Japa syndrome. The elderly man has seven children; six of them are out of the country. The one that is in the country is in Abuja. He stays somewhere in the southeast, southwest or somewhere in the north. He is living maybe not exactly alone but with a young help who is going about his own thing. So the attention, supervision, care and close-knit family system that we grew up with are no longer like it used to be and our community is becoming more cosmopolitan like the West. Unfortunately, we don’t embrace the elderly care system like it’s embraced in the West. So that’s a major issue.
So more and more, we’re finding elderly people who are living either alone or almost alone without as much care and support. Whether that’s economics or whether it’s change in social dynamics, it is a matter that is open for debate. Other things that we may seem to have better control over are, like I mentioned earlier, identifying disease conditions earlier and controlling them, like treating visual impairments.
The solution may be as simple as getting a pair of glasses so that they can see when they are nearing the staircase, they can see the rug and then they may need to modify the furniture. Elderly people are more prone to irritation from dust so the house may need to be modified and the wall-to-wall carpets that was there before may need to be stripped off and then the beautiful Persian rug that the centre table was sitting on may actually need to be taken out so the elderly don’t trip over the edge and if the house was designed as a split-level building, they may need to convert the steps to a gently sloping ramp.
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