This post on Substack was very interesting to me. It presented this question. Is screening for decreased bone mass and increasing it with medication the best way to prevent fractures in the elderly? As you may guess from the question, medication to increase bone density is probably not the best way to prevent fractures. “The traditional strategy for prevention of osteoporotic fractures -- that is, increasing peak bone mass and preventing age related bone loss -- should be changed to include new elements such as prevention of falls and protection of the critical anatomical sites of the body when a fall occurs.”
This is a very important issue for those of us who are older or have loved ones who are older. Once we reach age 65 fractures become much more common. The consequences of these fractures are often terrible. After surgery for a hip fracture, fracture victims have increased complications like blood clots, they may require more assistance, and find it more difficult to care for themselves, they may need support in assisted living or a nursing home. Hip fractures are often fatal with a mortality rate of between 15% and 36% in the year after a fracture and surgery to fix it. Mortality a year after a hip fracture is 3 to 4 times that of the general population. For comparison, the one-year mortality after a heart attack is about 20%. The risks of mortality within a year after heart attack or hip fracture are roughly comparable. That makes these falls and fractures a very serious issue.
Osteoporosis is a major risk factor for fractures in the elderly, but even with osteoporosis, fractures are most often related to falls and injuries. Risk factors for falls include things like weakness, the muscle wasting of aging, balance issues, and unsteadiness. Lack of physical activity, low body weight, excessive alcohol intake, poor vision, dementia, cigarette smoking, and loss of independence like requiring assisted living or nursing home support.
I have extensive professional and personal experience with this topic. I am an internal medicine doctor. My practice was focused on the medical needs of adults. By the time that I stopped seeing patients, over 70% of my patient population was on Medicare and over 65. Many of my patients had fractures related to aging and osteoporosis. Now I am 77. As I have shared with you before, I have severe nerve damage due to chemotherapy that has ruined my balance. I know that I have a very high risk of falling and I have seen up close and personal what can happen to people who fall. It is not just hip fractures of course. One of my patients climbed up a few steps on a ladder, fell, and absolutely crushed his shoulder. I want no part of that. As soon as I realized my increased fall risk was a problem. I started using a cane or a walker very consistently. I will do everything that I can not to fall.
Muscle wasting at my age is also virtually universal. I stopped doing progressive resistance exercises during COVID. The local YMCA was a very high-risk environment for COVID transmission and I lost a lot of ground. Strength training is one way to overcome progressive frailty and muscle wasting and I have started back with my routine at the Y. I can already see that I am making progress with my strength and that climbing stairs and getting up from a chair is easier. Those are pretty simple tests for functional strength that is essential to maintaining independence. I met a man at the YMCA who was about my age. He was also on the machines to preserve his muscle mass. During the course of our conversation, he told me that he had fallen 11 times. He had no assistive device like a cane. I encouraged him to use one. In this case, pride goeth before a fall is literally true.
Exercise is not just important for diabetes and heart disease. Most importantly, exercise helps preserve strength, muscle mass, and the ability to do the things we love most. The best example I have personally seen is a patient who had walked the golf course all his adult life and shot his age twice when he was 89. Just think about the flexibility, strength, and balance required to shoot an 89. He was inspiring. The best way to maintain your muscle mass and strength to avoid falls and frailty is with progressive resistance exercises. Most programs are entirely inadequate to obtain the potential benefit. Best practices involves a very specific approach. Your maximum strength is determined by your ability to move a certain amount of weight once on a machine. A weight that you can move 10-15 times in a set before you have to stop indicates that you are exercising in the 70-85% maximum strength range which is where you will get the greatest effect to preserve muscle mass and increase strength. I do 15 reps so that I can use a lighter weight and avoid injury. In order to get the maximum benefit, technique is also important. Take your time and move the weight through the entire range of motion. For example, if you are doing a bench press, you begin with the hand grips close to your chest and push your arms all the way out and then let the weight back down and repeat. In someone like me, the handles move about two feet. I have seen some people who just move the handles about 4 inches. That isn’t doing them much good, and they are probably using too much weight. It is better to use a weight that you can move with good form for 15 repetitions a set. This link will take you to a more detailed discussion.
I do those exercises to avoid falling, but it is even more important to me to stay independent and keep doing what I love doing. This last weekend, I went fishing with my brother-in-law and my grandson Alex. It was a glorious day and we caught some nice fish as you can see in the photo. I want to keep doing that.
Thank you again. My Dad lived way into his 90's (covid got him) but exercised everyday. He did have knee pain and subsequent surgery which then took some of his mobility away. I used to walk with him and he was so in shape. Also keep in mind exercise helps your brain and may provide less reliance on drugs.
Yup! 💯 %. Walking as much as possible , running short distances, and Strengthening training, quality protein intake at least 1.6 grams per kilogram of body weight or roughly 50 grams per meal, especially in the first meal, are essential for older adults to survive and thrive better and longer.