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Menopause Matters

Fractures and Falls: Minimizing the Risks

Risa Kagan, MD

In the United States, approximately 30% of men and women over age 60 years fall at least once per year. Fall prevalence increases with age, rising to an annual rate of 50% in people over age 80 years.1 Older woman are at significantly greater risk for falling than their same-age male counterparts. Falls are precipitating factors in nearly 90% of all fractures in postmenopausal women.2 Injuries from falls can be devastating, resulting in significant morbidity and mortality. Hip fractures take a particularly serious toll, with only about one-third of victims able to return to independent living. Nearly one-quarter of hip fracture victims over age 50 years die within 1 year of the fracture, and approximately one-third become permanent nursing home residents.3

Without treatment, vaginal atrophy may progress to significant thinning of the vaginal epithelium, with loss of subcutaneous fat in the labia majora, shrinkage and retraction of the clitoral prepuce, fusion of the labia minora, and stenosis of the introitus. At this stage of the condition, the woman may experience dyspareunia, postcoital bleeding, and chronic pain. Evaluation with pH testing and microscopy can help to identify atrophy, enabling the practitioner to treat confidently with local estrogen therapy.

Vertebral fractures also can result in serious morbidity and mortality. These fractures may cause substantial pain as well as loss of height and exaggerated thoracic kyphosis. The pain and deformity from vertebral fractures can greatly restrict normal movement, including simple activities such as bending and reaching.

Even if a fall does not cause any significant injury, fear of falling again can cause individuals to avoid previously performed activities, thus limiting their self-reliance and independence.

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• a history of falls, fainting, or loss of consciousness
• muscle weakness or loss of coordination
• dizziness or balance problems
• cognitive impairment
• impaired vision
• arthritis
• difficulty standing or walking
• multiple prescription medication use (four or more).

The greater the number of risk factors, the greater the risk of falling. In one study, having four or more of these risk factors increased the risk by nearly 80%.1

Among the medications found to have the greatest link to increased risk of falling are serotonin reuptake inhibitors, tricyclic antidepressants, neuroleptic agents, benzodiazepines, anticonvulsants, and class IA antiarrhythmic medications.4

Safety hazards in the home and work environment, such as obstacles, scatter rugs, and poor lighting, also contribute to the risk of falls and injuries. These should be assessed by questioning the woman or through a visit to the home and/or workplace by an occupational therapist or other health care professional knowledgeable in fall prevention. Women and their caregivers need to be advised of hazards and preventive measures.

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MANAGEMENT

Several health care interventions have proven effective in reducing the risk of falls. These primarily focus on exercises to improve balance and muscle strength, adjusting medication use (especially psychotropic drugs), and reducing fall hazards in the home.

A home-based exercise program that includes strengthening and balance exercises can reduce the risk of falls in the elderly by nearly 50%.5 Tapering or discontinuing use of benzodiazepines, neuroleptic agents, and antidepressants reduced the risk of falling by more than 60%.6

Regarding safety hazards in the home, implementing relatively inexpensive measures can greatly reduce this risk (Table).

Table not available online

TABLE. Recommendations For Fall Prevention

For frail, elderly adults at high risk for falling, hip protectors may reduce hip fracture risk. These are specialized undergarments with specially engineered cups that fit over the hip (trochanter) and shunt the energy of the fall into soft tissues. Finding an appropriate size and style for each woman, along with appropriate education about the value of the devices, is necessary to achieve compliance and efficacy.

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SUMMARY

Falls resulting in fractures can have a profoundly negative impact on a womanês independence and quality of life. Assessing these risks and implementing strategies to minimize the risk of falling should be a routine part of the medical care for all postmenopausal women.

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Risa Kagan, MD, is Interim Chief Medical Officer of the Foundation for Osteoporosis Research and Education in Oakland, Calif; and Associate Clinical Professor, Department of Obstetrics and Gynecology and Reproductive Sciences at the University of California at San Francisco. She is Chair-Elect of the NAMS Professional Education Committee.

References

1. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med.1988;319(26):1701-1707.
2. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002;359(9319): 1761-1767.
3. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337(18):1279-1284.
4. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis. J Am Geriatr Soc. 1999;47(1):30-50.
5. Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomized controlled trial. BMJ. 2001;322(7288):697-701.
6. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc. 1999;47(7): 850-853.

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