New fall prevention guidelines for frail seniors

Seniors who live in nursing homes at such high risk of falling and breaking bones? New guidelines may help.

Statistics Canada says more than seven percent of Canada's seniors live in nursing homes -- a number on the rise despite research showing that Canadians in long term care are up to four times more likely to fall and break a hip or fracture  their backbone. New guidelines just published in the Canadian Medical Association Journal may turn things around.

The guidelines - by members of a blue ribbon panel of experts at Osteoporosis Canada - say nursing homes should do a better job identifying frail seniors at high risk of breaking their hip bone.  That includes those who have had prior fractures of the hip, the vertebra and other bones, those with advanced osteoporosis, and those who take medications that cause the bones to thin even more. 

The guideline's authors came up with a number of ways to strengthen bones so that they're less likely to break when a frail senior falls.  They say seniors should have 1200 mg per day of dietary calcium and take calcium supplements if the senior isn't getting enough calcium in the diet.  They also recommend taking between 800 and 2000 IU (international units per day) of Vitamin D. 

More controversial is the recommendation that seniors with good kidney function who have a life expectancy of greater than one year also take one or more prescription drugs approved for osteoporosis with names like alendronate, risedronate, denosumab, zoledronic acid, or teriparatide.

The first point of contention is that many of the drugs I listed are very expensive - well beyond the price range of most Canadians.  As well, not every province covers the full list of medications for all patients.  Different provinces have different ways of deciding what patients get which medications.  So, you might be covered in one province but not another.  The prohibitive cost of some of these medications is an argument in favor of a national pharmacare program, something that's been in the news lately as a possible issue in the federal election.  As well, a significant number of the members of the Scientific Advisory Council receive funding from the very drug companies that stand to profit financially from the decisions made by the panel.

The other major factor is that frail seniors fall a lot -- for a whole bunch of reasons. As they age, their vision dims, and they lose depth perception.  They lose position sense in their feet, which means they lose the ability to perceive when they're standing on solid ground and when they aren't.  They also lose their sense of balance.  To maintain excellent balance, you need all three senses workng well.  Lose one, and the other two senses can usually compensate; lose two, and you start falling.  Falls are no laughing matter; they cause significant pain and disability, and they're one of the leading causes of death in frail seniors.

More can be done to prevent falls.  The guidelines recommend exercises that improve balance as well as strength.  Ironically, though these exercises can help prevent falls, they may put some seniors at risk.  That's why it's important to exercise under the supervision of a doctor, a physiotherapist, a nurse, health coach or some other professional.  This gets back to reducing the impact of falls, but seniors can wear hip protectors which while a bother to some will nonetheless soften the blow.

To me, the guidelines rely too much on expensive prescription drugs and not enough on diet and exercise.  I suspect the main reasons include lack of staff at long term care facilities to help with feeding and supervision during exercise, plus fears of liability should the senior fall while exercising.

In that sense, the guidelines may be emphasizing the wrong things - and a bit of a missed opportunity.

Dr. Brian Goldman is host of CBC Radio's White Coat Black Art, which is on this fall Saturdays at 1 pm (130 pm on the Island) and Sundays at 630 pm (730 pm AT and 8 pm on the Island).


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