Hip fractures affecting the elderly - the chicken or the egg?

In my previous articles about hip fractures which are leading causes of injury leading to death among the elderly, I omitted to discuss one very important question: "Did the fall cause the fracture, or was it the fracture that caused the fall?"

In most cases we will probably never know. A spontaneous fracture of the hip may happen when an osteoporotic person does a slight, slip, stumble or sudden movement. The next thing you know, he or she is lying prostrate on the floor and you have a medical emergency on your hands. Preventing these injuries, be they spontaneous, or be they from a fall is the name of the game. This starts with ensuring that the environment is free of hazards like loose mats, poor lighting and cats or dogs wandering underfoot! Refer to my earlier article and navigate the link to the ACC website for resources about this.

Prevention also means ensuring that bones, muscles, balance and reflexes are kept in tip-top condition regardless of age. The keys are: a nutrient rich diet, plenty of sunlight, regular exercise including agility drills and keeping medications to a minimum.



Osteoporosis and the general frailty often seen in old age can creep up slowly. This can be despite a mostly active life, if one or more of the ingredients such as adequate dietary minerals or vitamin D are not quite sufficient to maintain bone strength. All that it then takes is an illness or injury that stems activity for a few months, or confines the elderly person to sunless rooms and/or a deficient diet and the dyke can burst - a fractured hip for example.

Desperate Housewives is an interesting programme to watch because of the procession of pre-osteoporotic women that parade up and down the fictional Lysteria Lane in their flash convertibles. They are so thin. Ant-like in appearance. Even their facial bones are thinning! They can't be doing enough chewing. I look and wonder how these emaciated stars could ever be role models to the impressionable world? What hope is there for these fragile people when old age catches up with them?

Whether the fall caused the fracture or the fracture caused the fall, the fracture was a long time in the development and the consequences are exactly the same. We must concentrate on prevention.

Low vitamin D levels linked to increased risk of falling in elderly populations

NEW YORK (Reuters Health) - Older men and women with vitamin D deficiency are more likely to fall multiple times in the course of a year than their peers with adequate vitamin D levels, researchers in The Netherlands have found. Vitamin D may be best known for its role, along with calcium, in maintaining bone health. However, vitamin D is also important for muscle mass and strength, and compromised muscle function may explain the fall risk seen in this study, according to the researchers. The findings suggest that older adults should be sure to get adequate vitamin D from food and multivitamins, lead study author Dr. Marieke B. Snijder, of Vrije Universiteit Amsterdam, told Reuters Health. However, she added, clinical trials are needed to prove that this actually prevents falls. Snijder and her colleagues report their findings in the Journal of Clinical Endocrinology & Metabolism. For their study, the researchers measured blood levels of vitamin D in 1,231 adults age 65 and older, then followed them for one year to track any falls they suffered. During that time, 33 percent fell at least once, according to "fall calendars" that each participant kept. Just over 11 percent fell two or more times. Overall, men and women who were deficient in vitamin D at the outset were 78 percent more likely than those with adequate levels to fall at least twice. Their risk of falling three or more times was more than doubled.
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Gary Moller comments:
Notice that the good researcher conveniently omitted to recommend sunlight as a source of vitamin D! Is it because it is not PC to make such recommendations?

I am currently investigating falls prevention programmes in NZ, of which there are a couple. The Otago exercise programme to prevent falls in older adults is a well researched example that reduces falls injuries by about 35% in over 65's.

While I am impressed with the programme's format and content, I am dismayed that none of the programmes I have looked at so far, this one included, seem to pay any attention at all to assessing participants' nutritional status (including vitamin D) and then correcting any identified deficiencies. When up to 90% of some elderly populations are nutritionally deficient in some way, assessing the nutritional status of elderly populations who are at high risk of falling would seem an obvious thing to do. But it isn't. With regards to vitamin D, it is hardly ever tested. When was the last time you had it done?

If an elderly person is, say, vitamin D deficient, low in dietary protein, anaemic or washed out of essential minerals and vitamins, then no amount of exercise therapy is going to work all that well. While there may be initial gains, this is hardly likely to be sustained and the individual will quickly back-slide. Strong bodies are not created out of thin air - they need good food to be built and to then be maintained over the long term.

I have demonstrated many times with elderly people under my care that it is possible to double their physical work capacity in as little as 12 weeks by taking a comprehensive approach to their care, including tidying their nutrition.

Hip Fractures

The earlier posting about falls and hip fractures received a very good response from readers. The most recent communication was a call last night from an overseas reader whose mother (In her late 70’s and suffering Alzheimer’s) had suffered a hip fracture from a fall earlier in the day and was now dosed up on morphine recovering from surgery. He feared that this might be the last straw for her: He wanted to do everything he could to help her recovery.

First of all, it must be emphasised that it is not the fall that kills the frail elderly; it is the complications that follow as sure as night follows day, including infections and blood clots that do the killing. If the elderly person survives the initial injury, they tend not to fully regain their past independence and quality of life due to incomplete recovery, poor mobility and worsening of existing ailments, like heart disease. The need for additional medication can complicate recovery and may further dull senses that are already at low ebb, including balance. Several days of complete bed rest alone can knock the stuffing out of an elderly person – let alone the stress of the initial physical trauma, drugs, surgery, medications and any complications!

So; survival, let alone recovery from a hip fracture is a complex challenge that may be further complicated by conditions like Alzheimer’s. Here is the advice that I have for him to consider over the first few weeks in rough order of priority:

• Appoint an assertive Guardian Angel to hover over her to ensure that she gets the best care available. In this case, the Angel is you.
• Reduce the risk of infection. This frail woman is vulnerable to infection because she has a deep wound and her immune system is weak. Anybody with a cold or sniffle should be asked to stay away until fully recovered. Start by washing your own hands and insist that everybody who enters her space does the same before touching her. This should include medical staff (even if they are using disposable gloves) and their equipment (namely, the stethoscope) should be sterilised with alcohol. Research has shown that hospital staff is more diligent with hygiene if a patient’s family ask for such care.
• Prevent blood clots. Express your concern of this risk to her specialist and ask what measures are in place to reduce the risk. Get a physiotherapist appointed within 24 hours to commence passive and active mobilisations at the earliest possible time. This should be at least twice daily to minimise physical wasting from bed rest and to keep the blood in the limbs flowing. Daily flax seed oil and fish oil with vitamin E help keep blood thinned; but talk to her specialist about this first, because any prescription anti-clotting medicines may need to be modified in dose.
• Make sure that she has a proper treatment plan. Every hospitalised patient should have a detailed written treatment plan that shows how all the various resources and services are brought together in a coordinated way to smoothly progress her recovery and bring about her eventual discharge. If there is not one, then ask why. As the treatment plan is updated, planning should commence early to include her post-discharge care.
• Get her onto a Super Smoothie within 2-3 days. The Smoothie should include whey protein and anti-oxidant packed red berries. This should be given twice or more times a day and can be regarded as being her primary nutrition source. Make it up at home and bring it in a thermos and get her to consume it while it is fresh (You can drink any that is left over).
• Include a multivitamin (Nutra-Life Women’s Multi in this case) that contains Vitamin D. (Give 2-4 per day during this period of stress). If necessary, pulverise and add to the Smoothie. If a raw egg is added to the Smoothie (recommended), then administer B Vitamins an hour or so either side because raw egg protein inhibits some of the B uptake.
• Give a joint and cartilage repair formulation as a refreshing drink (Nutra-Life Joint and Cartilage Repair is best because it contains creatine that assists restoring muscle strength and energy levels as well. Although designed for joint repair, these also assist bone healing. Add to a Red Seal effervescent drink and you are covering most bases as well as getting fluids into her.
• Give 1-2 grams per day of additional Calcium to assist bone healing and to reduce further bone loss during bed rest. Again, the tablet can be pulverised and added to the Smoothie. Nutra-Life Phyto Calcium or Calcium Complete will do the job.
• Prepare the home. Ask that an Occupational Therapist be appointed to her case early and arrange for a visit to your home. Plan in advance for caring for her at home. Some modifications may have to be made to the home to improve access and extra help may be required with tasks like bathing. Some financial assistance may be available from agencies like ACC for these modifications and ongoing assistance.
• Look after yourself. In rehabilitation, it is the caregiver who is usually the most neglected person: alcoholism, depression, social isolation, financial hardship and sheer physical and emotional exhaustion are common. Talk to the hospital and social services support services about what can be done to assist you during this period of stress and over the long term. Ask for help and do so often.

Note: All of the nutritional products that are recommended in this article are available from http://www.myotec.co.nz/ and can be delivered just about anywhere on the planet.

Teaching your child to fall properly

Latest stats are that around 280,000 accident claims are recorded in NZ each year for falls. Children and young people make up many of these accidents. For the elderly, the consequences may be fatal. Refer to my ealier blog about this.

What is a real concern is the youngsters coming through to their adolescent growth spurts with little in the way of the skills, agility or the strength to safely negotiate a fall. And let's face it; we will all fall over at various stages of our lives, so let's prepare for the inevitable, starting with our kids while they are still small. Safely teach basic movement skills, like leaping and rolling. If a child does not learn basic movement skills, like the forward roll and does not have the strength to withstand impact, serious injury from a fall is inevitable during adulthood.

Teaching your son, daughter or grandchildren to fall safely is great fun. Refer to my earlier blog here, for a start. Here is another game you can introduce your small children to: Balancing on the top of a secure platform, like a large sofa, tossing a ball to the ceiling and leaping up to catch the ball and landing with great skill and on the carpeted floor.

Death by falling over

"Gary,
I am very sad to say, my wifes dad passed away on sunday. He was 84, but as a young man was an excellent athlete, a natural swimmer, track athlete and even played rugby for XYZ Province while the allblacks were on tour (away) one time.
3 years ago he could give me a good game of tennis.
Less than a year ago, he was knocked over by a dog and his hip broke.
He seems to have fallen into the category of people dying after a hip breakage, he died in his sleep in a home in XYZ Town.
What is the link between breaking a hip and a rapid demise in health resulting in death?
Anon"
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Gary Moller comments:
First of all my condolences are extended to the family. Knowing Anon reasonably well, I strongly advise that he gets some tennis coaching right away.

Among older adults, falls are the leading cause of injury deaths and the most common cause of non-fatal injuries and and hospital admissions for trauma. The cause of death is usually a blood clot in the lungs or elsewhere interrupting critical circulation. This is due to the frail state of the person, the immediate tissue trauma of the injury and the formation of blood clots at the injury site and from the immobilisation. Even if they recover from the fracture and are discharged, their even frailer state and the disability from the injury may be so great that their health never recovers and decline can be rapid, usually from pre-existing comorbidities, such as dementia. Getting a dose of the flu may be all that it takes to kill the debilitated person. Anon's family tragedy is being repeated several times daily.

I gained some further details from Anon and learned that his father in law had been on some kind of anti-depressant for many years, as well as medication for blood pressure. It is significant that he had recently gone into a managed care facility. Prior to his fall he had had a number of "turns" which could have been mild strokes. This came as no surprise. Unfortunately, for him and his family, the causes for his demise may have been put in place many years ago when that first pill was prescribed. Here is my speculation about what could have been going on:

• One of the most accurate indicators of decline in health and independence is balance. Medications that are prescribed to alter mood and to control blood pressure may expedite the decline in balance and hasten dulling of the mental faculties. Refer to my article here that expands on this.
• I will add that blood pressure medication does not cure blood pressure problems; it merely hides or suppresses the condition - the wolf remains at the door and the problem becomes more and more difficult to manage as time passes. The same can be said in many cases of prescribing mood altering drugs.
• Blood pressure medication can cause "brain fog". I recall one insurance study several years ago that found that elderly drivers on blood pressure medication had a nine-fold increase in motor vehicle insurance claims as compared to their non-medicated peers.
• Many of these medications can affect nutrition by causing unpleasant side-effects like cotton mouth and poor digestion. Up to 90% of some groups of elderly may suffer malnutrition. Read Should they Eat Cake?. Weak muscles, dementia/brain fog, osteoporosis and poor balance are killers when combined.
• Medications that are being prescribed wholesale to osteoporotic patients nowadays may be causing disastrous problems down the line by hindering bone healing post fracture. Read this Blog
  
• The "turns" that Anon described might have been the inevitable result of progressive cardiovascular disease, including excessively high blood pressure as medication becomes increasingly ineffective. Balance is usually seriously affected by these mini-strokes.
• From personal observation, the very act of institutionalisation may bring about a rapid loss of independence and decline in health status. My article "Should they Eat Cake?" touches on this.
• The survival of the debilitated old person, as per above, is under serious threat from a fall and prospects of making a good recovery are not good.

What can be done to prevent this sort of tragedy happening? The good news is that much can be done, including:

• Blood pressure pills or not, implement agressive lifestyle and diet changes to address the underlying factors that cause blood pressure and otehr cardiovascular ailments. Go here for more information
  and go here
• For mood and behavioural problems, seek drugs-free treatments, including exercise, nutrition and counselling.
• If on medications, question the need and ask your Dr to help devise a plan to either reduce the dose, or preferably to get off them completely. Ask about drug-free alternatives and do not hesitate to seek second and third opinions.
• Exercise vigorously 3-4 times a week. This can be walking and doing resistance exercise like gardening. The Myotec Pocket Gym is designed for safe use by the elderly to keep muscles and bones strong.
• Get outdoors daily to get sunlight on the body. Vitamin D from sunlight + exercise + good nutrition = strong bones and many, many other health benefits.
• If the day is sunless, then get a little Vitamin D (sometimes called cholecalcitrol) from a supplement like cod liver oil or Nutrimon (a low cost chewable multivit for kids; but fine for adults)
• Get multivitamins, including the B Group and Vit C; multi minerals, especially calcium and magnesium; and omega3 oils into the daily diet right away and keep these in place during old age. I am running a special this month on the Red Seal Effergize multivitamin tablets.
• Practice balancing skills now and into old age. This can be as simple as practicing balancing on either foot each day. This is also a good test to see if a new medication is affecting balance. (If balance deteriorates, go back to your Dr immediately and ask for a review). If you get really good at balancing on one leg, then try doing it with your eyes closed.
• Keep agile: Take up tap dancing, martial arts and walk rutted and rooty trails at every opportunity. Ride a bike. Play tennis (get some professional coaching regardless of age and ability).
• Design your house to be "fall friendly". Live in a single level swelling with no hard wood, tile or concrete floors. Fit natural wool carpets with thick underlays. Use non slip surfaces in showers, on steps and paths and light them well. Fit hand rails in bathrooms. Have a proper step ladder for getting up to high cupboards and for changing light bulbs.

If an elderly person is injured from a fall:

• Insist on getting the best treatment by experienced doctors and do not tolerate any delays.
• Make sure hospitalised person has a Guardian Angel appointed to look over them (more about this in a later article).
• Insist on minimal medication and take the opportunity of hospital monitoring to safely get off any unnecessary drugs that were prescribed in the past.
• Insist on high standards of personal hygiene by everyone, including the cleaning of Dr's stethoscopes between patients. Refer to my article about hospital infections.
• Get them onto a Super Smoothie and extra vitamins and minerals as well as Omega3 oil like flaxseed oil quickly. (Discuss the Omega3 oil with the Drs first if the patient is on anticoagulants, because these oils have similar properties and the medication might need to be adjusted). You can either make up the Smoothie at home and bring into hospital, or make it by the bedside with a small blender. The fresher the better. The hospital food will only serve to add to an already malnourished state and healing will be seriously compromised.

Finally, ACC have a number of excellent injury prevention resources to prevent falls. Go here for them.