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Frailty at risk of falls; falls as a risk for frailty: an antithesis about elderly Torna agli editoriali

Anna Giulia Cattaneo
DBSM - University of Insubria, Via J-H Dunant 3 - 21000 Varese.

Falls and gait or balance instability represent a major risk of invalidity in aged persons, and a cause of anxiety. The increasing frequency of falls in older people is directly linked to the peculiar frailty of this group of individuals, and recognizes a wide number of underlying conditions, directly linked to the senile frailty, or due to associated diseases. A fall occurring later in life has usually more serious consequences, and can be life threatening: not only fractures, but even lacerations, internal traumas and injuries to soft tissues can recovery slowly and require more expensive care than when comparable events occur in younger subjects.

Permanent additional frailty and even invalidity after healing are frequently seen. Sitting on a wheelchair introduces an additional risk of dangerous falls. The awareness of the older patients to be at risk for falls, in turn, enhances anxiety and reduces the spontaneous mobility; it can affect negatively the social relationships and the quality of life. The shift from an active through a sedentary lifestyle himself can be deleterious, enhancing the risk for osteoporosis, overweight, depression and isolation, all conditions potentially enhancing the risk of serious consequences after falls.
This problem is a hot topic in the field of socio-sanitary care of elderly. A number of institutions for health control support researches and encourage social measures aimed to prevent falls and their consequences, to improve recovery and promote active ageing.

All the four Regional Office of the World Health Organization propose a program for "active ageing". Two points at the program of the Regional Office of Europe mention the need of ensuring autonomous and safe walking in streets. Promoting exercise schedules to avoid lack of mobility in elderly is also recommended. The National Institute of Health of USA provides at the present day supervision and financial support to at least 23 clinical trials to study, prevent and repair the causes and consequences of falls and/or promote active lifestyle in elderly people. Trials are worldwide distributed: 8 are ongoing and recruiting patients in USA and Central America; 2 in Commonwealth countries, namely Canada and Australia; 2 in Asia (Japan and Taiwan); 1 in the Middle East (Israel) and 6 in Europe (France, Netherlands, Switzerland and Norway). More than 6500 patients and controls are expected to be recruited. The European Community granted in 2007 two studies on elderly, in near fields of interest (abuse on elderly and active life promotion, in Sweden and Austria). In Italy, the ISS (Istituto Superiore di Sanità) and the CNR (National Council for Researches) do not publish ongoing researches in this area, at least in their web portals.

From the cohort of planned research one will expect better knowledge of risk factors for falls and higher ability in recognizing and supporting "at risk" patients. Preventive and rehabilitative programs will be more personalized and focused on problems actually existing in the case in question. The expected result should be a consistent amelioration of quality of life for the old person at risk, a reduced burden for the caregivers and for the society.
Accurate diagnostic measures are proposed to evaluate a large range of risk factors. Those included in the disorders affecting the cardiovascular system are not considered, representing a too large group. Instead, the diagnostic procedures at the emergency room should be modified in order to identify subjects at risk of further falls or near-fall. Impaired mobility associated to mental illness (impaired cognitive function and dementia, depression and anxiety) will be distinctively treated from impaired function with cognitive adequacy, as is the case in somatosensory defects (proprioception, visual and vestibular function. Neural disease more frequent later in life, like the stroke and its sequelae, the Parkinson's disease and some types of seizures can adversely affect the ability to move and walk independently, while the use of a wheelchair is in itself a risk factor for falls. All these conditions will be selectively considered by the planned studies. Medications and their side effects on gait, balance and walking abilities are considered, as well as their discontinuation, as adequate. Joint, bone and muscle defects in mass, strength and function are carefully studied.

A study at the Karolinska Institutet (Stockholm, Sweden) should be cited apart from the other, being a large multinational survey on the abuse of the elder, a not uncommon cause of traumas in frail persons possibly confused with accidents.

I n addition to a better understanding of the underlying physiology of walking and falling processes, the rehabilitative programs are planned in order to optimize the quality of life and the functional recovery of older people, and to reduce expenses and social burden. Selected, abovementioned risk factors require specialized approach, in which the use of modern computerized technologies for walking, gait and balance evaluation and training are often of great value.
However, a great attention is paid on general, multifactorial intervention programs aimed to ameliorate the active life in older ages. Schedules selectively studied to face the needs of the oldest individuals are proposed and evaluated. The easy accessibility to sporting clubs, not only a day's fashion, should be precious to obtain durable results in fitness in old ages. Physical training is usually proposed in small groups, with professional trainers and medical counselling; regular home exercise will be added to session at the sporting club. Studies consider as beneficial even non traditional approaches to active life, like aquatic exercise (considered to be especially beneficial after hip fractures), chiropractic care and yoga: the common aim is to improve gait, mobility and muscle elasticity and prevent osteoporosis. The beneficial effects on cardiovascular, mental and psychological conditions are postulated as a part of the treatment.

These studies depict a very living and interesting field of interest, from which a very real improvement of knowledge and care should be expected. As a conclusive remarks, and personal opinion, I regret that the policy of research institutions in our country does not permit to know ongoing researches through open database, and does not give any opportunity for recruiting cases in the web. The most recent trial reported in the portal of the CNR is a large survey launched in a parallel field and promoted in 1999 by the Institute for Research on Population and Social Policies (CNR, Roma). A more open access to researches is not threatening for the privacy of the studies in USA; it should be safe even in Italy. And it should be a sign of confidence that every citizen should appreciate and endorse.

Anna Giulia Cattaneo
DBSM - University of Insubria, Via J-H Dunant 3 - 21000 Varese.

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