Why an elderly person falls in a while. Falls in the elderly. What to pay attention to

Warning of falls
In elderly and old age

The causes of the principles of diagnosis and the prevention of falls in people of elderly and senile age are given; The main components of nursing care.

WHO determines the drop as "the incident at which a person suddenly turns out to be on Earth or
On another low surface, with the exception of cases that are a consequence of an impaired strike, loss of consciousness, a sudden paralysis or epileptic seizure. " Falls are the second to significance the cause of death as a result of accidents and unintentional injuries. Every year in the world
There are 424 thousand deaths as a result of falls, 80% of which are recorded in low- and middle-income countries. Most
The number of deaths with a fairly serious consequences in which medical care is required, account for people over 65 years (WHO).
In young age, falls are often limited to bruises or abrasions, and in the elderly, they are often accompanied by serious injuries.
and fractures that can change all your life lead to disability, immobility and early, often painful, death. Injuries for falling can be the most diverse. The most dangerous, enhanced complications, - cranopy and brain injuries, fractures of the neck of the hip, dislocations of the joints, the injuries of the spine, injured soft tissues. Why are healthy, actively moving people rarely fall?

First, thanks to the reflex regulation of movements, the right job
Equilibrium centers and vestibular apparatus, providing walking and equilibrium. Secondly, thanks to good vision, which allows us to correctly navigate the environment and bypass obstacles. Older and old people fall often, in particular due to age-related changes of the musculoskeletal system. Prevalence of violations
Walking and equilibrium increases as agrees:

• from 25% aged 70-74 years
• up to 60% in the age group of 80-84 years.

Can notice how after 60
Years the gait change slightly, and after 75 years old people, as a rule, walks slowly, swinging during walking. This is due to a decrease in the length of the step and the height to which the stop rises. In young people, the end of the foot lift is equal to 30º, and the elderly is only 10º. Sensitivity, muscle force is reduced to old age, the coordination of movements is often distinguished. In older and old people
"Decreases" the duration of an individual minute and reduces the speed of simple motor
reactions. For elderly and senile ages, socio-psychic deadaption is characterized, the reasons for which are: retirement; loss of loved ones; restriction of the ability to communicate with the survivors; self-service difficulties; deterioration of the economic situation; Dependence on others. This leads to the development of sense of sense of inferiority, powerlessness and loneliness in people of senior age groups, which contributes to the development of psycho-emotional violations (anxiety, assessment, depression, mania, nonsense, reducing cognitive functions). For example, depression manifestations are noted in 60 and 20% of patients with senior age groups, respectively, with severe and easy course of diseases. It has been established that depressive states
Along with violations of vision and coordination, there are a significant factor in random falls in the elderly. The nurse must be remembered
About faces of senior age groups with increased risk of development of psycho-emotional disorders,
contributing to falls. These are 80 years old patients and older living alone, including widows; Couples living isolated, including childless
spouses; persons suffering from severe diseases and physical ailments; Forced to live on the minimum government benefit.
The main risk factors of falls, more often
Meeting of elderly and senile age: disorders of equilibrium; walking disorders; consequences of stroke; pathology
joints; violations; Ortostatic hypotension; disorders of cognitive (cognitive functions); depression; simultaneous reception
Enth 4 drugs and more.
The likelihood of falls is increasing with an increase in the number of risk factors:

• in persons without risk factors, there are found in 8% of cases,
• in persons with 4 risk factor and more, 78%.

The risk of falling increases significantly with the development of a new or exacerbation of a patient's chronic somatic disease. In old age, dizziness and orthostatic hypotension (condition in which after
a sharp transition from horizontal to the vertical position of blood does not have time in sufficient quantity to enter the brain, resulting in dizziness, darkens in the eyes, violated
equilibrium). At the same time, 30% of patients fall from bed (mainly in the evening and at night when trying to get up), 28% - from chairs and chairs that do not have
locking mechanisms, 20% - in the toilet (mostly women, getting up from the toilet after the bladder emptying).
The reception of many drugs changes the state of the vascular tone. These are diuretic drugs (Furademid, hypothiazide), preparations for reducing blood pressure (clofelin, which
Rinfar, Enalapril, Perindopril, Lisonopril), β-blockers, demolitioning heart rate (metoprolol, atenolol), nitrates, anticonvulsant drugs, benzodiazepines (diazepams, clonenes, tensiles), antidepressants, sleeping pills and sedatives. Significantly increases the risk of falling the reception of several listed drugs at the same time. Alcohol abuse contributes to the statistics of falling in the elderly. With the age reduction of visual acuity, it is necessary to correctly pick up glasses. Booting without good glasses, especially at twilight on the dark staircase staircase or broken asphalt of the yard, often leads to a drop.
People who falling often need a medical examination to eliminate such states as a violation of heart rhythm, epilepsy, Parkinsonism, anemia, transient (transient) brain circulation disorders, a carotid sinus syndrome. The development of the latter is associated with the gear of the vertebral arteries that feed the brain, with osteochondrosis of the cervical spine. In people suffering from osteochondrosis, there may be a sudden perplexation of consciousness, as a result of which the fall occurs.
The risk of falling is great in people who are not enough, not more than 4 hours per day, are in a vertical position, as well as those who are small-resistant when it costs, inhibit and depressive, can not get out of the chairs
without hands. Elderly suffering from syncopal states under which the short-term shutdown of consciousness occurs, need extraneous assistance and supervision when exiting the street
And especially in transport. Syncopal states are due to a decrease in the delivery of oxygen in the brain due to heart rate violations and conductivity, tachyarhythmias, overdose medicines - nitrates, hypotensive drugs, etc. So older people need extraneous assistance in motion and organization
safe housing.
External causes of falls related to the incorrect organization of safe movement (uncomfortable shoes, bad glasses, lack of auxiliary devices - canes, walkers), and dwelling, internal - with age-related changes of the support apparatus, organ
vision and cardiovascular system.
Whatever the factors contributing to the falls should take them into account, avoid and warn.
Conditions in the elderly and senile age should be careful Do not go outside alone when ice, at dusk,
Under fog or snowfall: equilibrium disorders and gait; dizziness; confusion of consciousness; loss of vision; Syncopal states.
If a old man Fell with witnesses and received a serious injury, the description of them of its fall can help the nurse find out the circumstances of the fall and correctly determine its cause.
Where are the most often falling? At half past cases - at home, especially in the toilet, bathroom and bedroom. Then the hospitals are followed, in which the elderly is often treated. Therefore, relatives
Always warn the staff of that hospital, where the patient of old age comes, about the possibility of its fall. This question must ask a nurse to the patient and his relatives.
If medical personnel will be aware of the patient's predisposition to falls, it will help them avoid. Many patients (about 80%) are falling without witnesses, which deprives them of quick care.
Outside the house of the fall, more often occur on slippery sidewalks, wet asphalt, during the transition through the wet of the sidewalk, output from public transport. Falls on the street without witnesses often lead not only to injury, but also to supercooling,
Development subsequently pneumonia, urinary tract infection and other diseases.

In many foreign countries, there is a practice when the patient arrives in the hospital already in the receiving department to endure a special diagnosis of "Falls" ("Falls") on the front side of the History of the disease. It focuses medical
Sonal on the need to comply with the prevention of falling, careful examination of the patient and the importance of the consequences of the fall.
It must be remembered that the deterioration of the current disease, the change in the situation, including hospitalization, are for an elderly patient
The stressful situation (violation of the prevailing life stereotypes is a familiar situation, communicating with loved ones), which can lead to decompensation of mental status (depression or delirium).

The 1st week of hospitalization is especially dangerous. Patients begin to abandon meals, poorly focusing in the environment. There may be episodes of confusion of consciousness, incontinence
urine, inexplicable falls. The risk associated with the hospitalization of elderly and senile ages,
may exceed the risk of reasons for hospitalization. Especially sharply react to hospitalization patients with vascular brain disorders, soft forms of depression and dementia. In such patients quickly and sometimes unexpectedly for others (nurses, doctor, neighbors on the ward, relatives) competes the decompensation of the psychic
Status, which contributes to falls with relevant consequences.
Nursing examination of patients with falls Includes a survey, physical inspection, study of the ability of a patient to independently movement and an assessment of the surrounding patient of the situation.
The nurse asks the patient and his relatives about cases of falls during the last year, clarifies their features: place; suddenness; provoking factors: slopes and movements; shoes and clothing; environment; lighting; noise; Medicinal preparations and alcohol. Elderly patients with impaired psyche and deterioration
Memory may not remember the episodes of their falls; In these cases, information should be referred to relatives or care faces.
Questions to the patient and its relatives who will help the nurse to draw up a plan of measures to prevent falls:
Were there any cases of falling earlier?
If we were, as far as they are frequent and predictable?
What time of day it happens more often
falls;
Where the fall happened: on the street, stairs, houses (toilet, bath)?
What caused a fall: fast stacking from bed, chairs, toilet, turns and tilting of the body, delivery of items high?
Was there no alcohol intake?
Does the patient epilepsy?
Does he have heartbeat and interruptions
In the work of the heart?
Is blood pressure monitoring and does the patient remember his numbers?
Does the patient do not suffer with diabetes me, does not receive insulin preparations?
How many drugs at the same time takes the patient (receiving 4 or more drugs significantly increases the risk of falling)?
Was there recent hospitalization or restrictions on motor activity in the next 2 months?
You need to know what medicines the patient gets; there was no interruption in their admission (especially - antiarrhythmic); whether their doses and the reception mode did not change; Have recently appointed new drugs.
Nurse need to find out not only the conditions in which there are falls, but also the accompanying symptoms; The time of day when the fall and the behavior of the patient after it occurred.

Functional tests to assess the risk of falling.

1. Test "Get up and go" , time performed. For testing, a chair with armrests is needed (48 cm height seat, the height of the armrests is 68 cm), the stopwatch and space of 3 m long. The patient is asked to get out of the chair, pass 3 m,
   Bypassing the floor on the floor, return and sit down again on the chair. The patient warn that the time for which it will perform this action will be measured, and it can use any familiar tool for walking (for example, a cane). Normal result: the patient performed a test for 10 s or less
   Doubtful - 11-29 p. If the test is made in 30 s or more, this indicates a deterioration in the function
   rather opportunities and increasing risk of drops.
2. Test "Lifting from Chair" . Needed chair without armrests, stopwatch. The patient is asked to get out of the chair 5 times in a row with hands folded on
   Breasts, knees must be completely dispersed with each lift. The patient reports that the time spent will be measured. The test provides information about the strength and speed of the muscles of the lower extremities. Time 10 C and less indicates good functionality, and 11 C and more reflects the instability of the gait .
3. Test for equilibrium . The patient is offered 10 with to simultane in the position of the "feet are compressed together", then 10 C - in the "One foot before the other" position, and then in the "Tandem" position. Impossible
   Standing in the position "Tandem" 10 C predicts a high risk of falling. If the patient is able to stand on 1 leg less than 10 seconds, the risk of fractures increases 9 times, and the inability to pass more than 100 m increases the risk of fracture.

The most common cause of the death of sick elderly and elderly age from injury obtained in re cause of falling, - Fracture of the hip neck. This is due to the fact that the nature of the fall is changing with age: if younger people are more likely falling in the oldest direction, then in the older groups the most typical falling side. Osteoporosis and developing in the process of aging, a generalized reduction in the mass of skeletal muscles (sarkopenia), leading to gradual loss of muscle mass and strength, is also important, which causes a reliable increase in the frequency of fractures of the hip necks over 75 years. Treatment (with conservative
Tive tactics), as a rule, long, sometimes up to 6 months. Patients are forced to lie in the gypsum for a long time, and then for several months restore motor activity, they suffer from
Stable pneumonia, infection, laying out.

In 20% of cases of fracture of the hip, death comes from complications. Half of the elderly patients after this injury becomes deep disabled people in need of constant care. A large proportion of injuries after falling in older people falls on fractures of the bones of wrist . The process of capturing
Male is much time - from 6 weeks to 3-6 months - and significantly limits the ability of a person to self-service.

Spinal fractures It is often painless and proceed almost unnoticed. After some time, the fracture becomes noticeable in the form of an "senile hump". For treating similar
Injuries require a long period (1-2 years) without complete recovery confidence. According to statistics, older women fall and get injuries more often
Men. This is explained by the fact that women at this age suffer from osteoporosis - increased fragility of bones. In addition, older women live longer men, and their more.
The tendency to repeated drops is considered one of the components of the "standard susceptibility phenotype", which is characterized by a combination of 3
and more of the following signs: a rapid decline in body weight; weakness; lack of forces; Slow speed when walking and low physical activity. Patients who, according to the specified criteria are defined as weak, have increased risk of falls, fractures (including -
hips) and death.
Treatment of the consequences of falls is expensive and the patient, and society. A person has to experience mental injury: re-gain confidence in its physical abilities, overcome
Fear of repeated falls. The consequences of the fracture are often loss of independence, the need to hire a nurse, asking for the help of relatives,
Friends. The restriction of the ability to move makes the recoverable long to lie, which adversely affects its condition: arise
constipation, breakdown, due to age-related violations of thermoregulation-perheclation and pneumonia. Often
It happens that, carried out the difficult operation on the neck of the thigh and spent a lot of strength and means for treatment, an elderly person dies from pneumonia or sepsis caused by prladen. Overall world
Statistics of injury and mortality of older people as a result of the fall looks like this:

• 60% of older people over 65 fall into the hospital as a result of falling;
• 15-20% of them have fractures;
• 5-20% die from complications;
• 40% after discharge losing autonomy and become addicted to others.

Analysis of this data leads to the conclusion that it is necessary to accept
Prevention measures of falls and fractures. The UN identified the rights of elderly and old people from socio-political positions: independence, participation, care, dignity (Vienna International
Native plan for aging, 1982). The concept of active longevity and health promotion, as opposed to a long dependent life, provides for the independence of material and physical assistance of loved ones or soci-
workers, diseases and ailments, from material conditions.
It is necessary to customize the elderly to be more attentive to their health; To do this, you need to use any possibilities for them.
Learning on questions: diet; exercise; creating a favorable environment; risk factors for the development of diseases; Change
habits and cultural traditions negatively acting on health.
The value of the physical activity of the elderly
people for the prevention of falls is confirmed in "Global Recommendations for Physical Activities
health benefits "(WHO, 2010):
Older people should devote the physical activity of the average intensity at least 150 minutes per week, or perform high-intensity aerobics exercises at least 75 minutes per week, or have an equivalent volume of physical activity of medium and high intensity;
Aerobics exercises should be carried out by series duration of at least 10 minutes;
For additional health benefits, it is necessary to increase the duration of the aerobics of average intensity to 300 minutes per week, or in aerobics
high intensity up to 150 minutes per week, or have an equivalent amount of physical activity of medium and high intensity;
Elderly with motion activity problems must carry out exercises for the balance and prevention of drops 3 and more days
in Week;
Power exercises should be performed
Creating the main muscle groups, 2 days or more days per week;
If the elderly people cannot receive the physical activity recommended by them, they should perform exercises corresponding to their capabilities and health status.
Regular exercise give positive physiological results: help adjust blood glucose levels; Neutralize the negative effect of catecholamines (adrenaline and norepinenaline); Improve sleep quality, function of all elements of the cardiovascular system; Strengthen the muscular system, which extends the period of independence in old age; Exercises, stimulating movements, help preserve and restore flexibility, "move" the attack of age associated with the deterioration of coordination of movements, which is the main cause of falls.
Exercise positively affect psychological status:
reduce the manifestations of depression and anxiety;
Can reduce the negative effect of stress.

Physical activity contributes:
preservation and strengthening social status (helps to play a more active role in the production activities of the family and society);
Reduces the cost of medical and social assistance.
Prevention of falls . It has been established that 15% of the elderly people are potentially preventing. Programs for the prevention of emergence of elderly should include the following components (WHO):
Verification of the household environment in order to identify the risk factors;
Events for determining risk factors (verification and change of medical purposes, treatment of reduced blood pressure, additional appointment of vitamin D, calcium and treatment of violations of violations);
Evaluation of household conditions and a change in the surrounding conditions in people with well-known risk factors or those who have already had drops;
appointing proper auxiliary devices in the presence of physical and sensory disorders;
strengthening muscles and restoring the vestibular function;
training prevention of falls and exercises aimed at preserving dynamic equilibrium and the development of force;
The use of special protective devices for the hip neck in people, at risk of fracture of the hip cervix resulting from a fall.
Life and dwelling safety Basically depends on the organization of space in the apartment, the placement of furniture, the availability of auxiliary devices in the bathroom and the toilet, allowing the elderly to perform the necessary procedures. Often the fall occurs in the bathroom on slippery floor. It is better to replace the bath with a shower, putting a special chair (fitted chair), sitting on which you can wash. If it is impossible, it is necessary to put on the bottom of the bath with a rubber rug on suction cups, wash standing or sitting on a special bath seat. If an elderly person intends to take a bath lying,
It must be remembered that it is first to fill the bath with water of the desired temperature and only then enter
in it. This reduces the risk of burning hot water. For the elderly, water temperature is recommended 35-36 ° C, warmer water should be avoided. You can not direct a jet of hot water on the head. Generally weakened elderly people cannot be broken alone, it is recommended to seek help from relatives or social workers. Close in the bathroom and toilet people with risk of falling.
Elderly people with weakened eyesight move around the apartment to the touch or by memory, focusing on the furnishings, touching the furniture. Finding into an unusual situation - in someone else's
Apartment, hospital or boarding, they are lost, fear appears, sometimes confusion. Carpets, rugs at the threshold, thresholds, glass doors, dark long corridors, cluttered things can provoke a drop. You need to carefully think over all the details to make the life of an old person safe. Handrails better arrange near the bathroom and toilet on
The level of ray-taking joint. Sometimes the handrails are installed next to the bed, in the corridor, in places where there are steps. If an elderly person uses a cane or walkers, they must be correctly chosen - the handle should be on
The level of ray-taking joint. If, after stroke or injury, one of the sides of the body is weakened, it is necessary to rely on the cane follows the stronger hand.
The most part of the day the elderly weak man spends in the bedroom, where falls often occur. This may be associated with an uncomfortable, too high or too low a bed, saving a mattress, lack of
A typhus device, which can be reached by hand, lying in bed. The height of the bed must be about 60 cm depending on human growth. If necessary, you can build legs
Beds, so that an elderly person could easily sit on the bed and get up. The mattress is better to choose individually - not too soft, the best-of-stepped one. If there is no such possibility, you should evaluate the mattress for several parameters. Mattress, easily deforming under the weight of a person, quickly forming pits, lumps, badly
Given hygienic processing is not suitable. Too soft mattress does not affect the condition of the spine, causing pain and suffering. The bedside table should not be too far from the head of the headboard, it is recommended to place a night light or a conventional lamp with adjustable light power.
Since the dream of the elderly people is often disturbed, they often wake up, read at night, sometimes take medicine. Therefore, all the necessary items - glasses, books, newspapers, medicines,
Water for drinking, clock, phone - must lie next to the headboard. This will help avoid night walk around the room and reduce the risk of falling. In cases where the night stroke from the bed is avoided
It is possible, especially for men with a disease of the prostate gland, patients with heart failure, which have night Eninur, people,
suffering from renal failure, it is necessary to ensure sufficient lighting of the night "route". In a state of waste, especially with poor lighting, there are often nightlife
Dénia. On the way to the toilet should not be wires, unnecessary objects, shoes, bowls for animals, bags and other items. Next to the bed
At night, a ship or a duck should always be, and you need to wear diapers for the night. If there is a staircase in the apartment (house), it should be with the railings, and the first and last stage of the ladder is better to paint in
Retot color (yellow, white, red); The edge of each stage is glued with a rubber strip 2-3 cm wide, so as not to sculp the sole.

Home shoes should be well chosen on the leg, should not slide on linoleum and parquet, the heel should be low, and the back - soft. If a person is difficult to launch shoes, it is advisable to sew wide gum instead of shoelars or make a fastener on velcro. Not recommended as a home shielding slippers without backs, wearing such shoes increases the risk of falling, the leg in it is unstable, the slippers are often scrupped with legs. An older person is not recommended to independently get items from the upper shelves and the mezzanine, to become a ladder and chairs, because at the same time the hands and head are raised up, often there are dizziness, leading to drops, and trauma, most often arising with such a fall - the cervix fracture hips. The chair of the elderly person in which he spends quite a long time should be shallow, with a high back and headrest, with low comfortable armrests. It is important that the edge of the chair does not give to the popliteate pate, as it disrupts blood circulation in the legs and increases the risk of thrombosis,
thromboembolism.
In the prevention of falls, a larger role is played by a diet. The adverse effect of alcohol on the cardiovascular system of an elderly person is proved, its consumption is often caused by falling. Some elderly with vessel diseases internal organs After hot and abundant food, blood flow to the stomach is enhanced and decreases -
To the brain. This causes an attack of illuminated, dizziness, darkening in the eyes and can lead to a fall. In such cases, the patient advises to limit the amount of food taken for 1 reception, eat fractionally, often, small portions. After eating, you should lie down.
The complexity of learning the principles of healthy nutrition, the refusal of bad habits is known. A.P. Chekhov in a letter A.S. Suvorin reported: "In general, I in my practice and in my homework I noticed that
When old people advise less, they take it almost for personal insult. "

It is necessary to remember both the failure of food as the cause of falls. In the elderly and old people, this may be associated with socio-economic insecurity, physical wealth, insulation, household inconveniences, dental problems and a decrease in nutritional needs due to low exercise. If the elderly revealed violations of gait, equilibrium and increased risk of falls,
The nurse must be discussed with the doctor the expediency of prescribing vitamin D, which helps to reduce the frequency of falls by more than 20%.
Nurse Tips for Elderly Safety Patient its motor activity and life. Do not lift heavy things, do not strain your back, do not wear items heavier than 2 kg, carry the load in front of yourself, pressed to the body. When walking, especially on the street, use the cane or walkers. Purchase special protective pads that protect the neck of the thigh from the fracture. They are invested in panties and not
interfere with walking. Do not make sharp movements from which the head can be spinning or the vertebrae displacement. Sitting on a chair or in a chair,
When not lean to the side to get something from the floor. If you want to raise some object from the floor, do not lean, sneeze with a smooth back and take it. If you have been a fracture
hip necks, use another safe way - go on a table about a table or other steady support, stand on intact leg, bend the torso and simultaneously assign the driving
Putting back back, and take a free hand. When we awakened, do not get up with bed too sharply, since reflex reactions do not have time to ensure adequate blood flow in the vessels
Brain and can turn the head. The spine in the first 15 minutes after awakening is also very vulnerable. First, slowly take a vertical position in bed, leaning on the hands of
Back, gently bend the legs and cross in the ankles, then turn the pelvis and legs at the same time to the edge of the bed, twist the legs and slowly stand out the bed. Do not need to dramatically get up from the chair or chair. Avoid deep, too soft and low chairs. You can not sit on a chair or chair, putting the leg to the leg if you have been operated on
The neck of the hip neck. Try to sit on a chair or in a chair so that the legs are at right angles to the body. The most suitable chairs and armchairs for you
Those who are regulated by the height of the seat and the inclination of the back and there are armrests. Stop, leaning on both hands on the back of the chair or chairs.

Stand correctly, leaning on both legs, heels together, socks apart or legs on the width of shoulders. If a you have been operated by the joints of the hip neck, always turn back and on the sides only slowly, turning the legs and the pelvis at the same time. Neverstand and do not go too long, make small breaks for rest.

Dressed in old age difficult, souse non-slip fixtureslinen, clothes and shoes. Make for clothes"Long Hands", take 2 rails with a length of 35-45 cm,at the end of each, attach on the clothespinor climb from suspenders. Hold clothespins beltor a gum of that object of the wardrobe thatyou can wear to wear - panties, pants or skirt, takereiki for the ends and, sitting on a chair, wear underwear.When tighten the wardrobe item yousoko, remove the clothespins and wear underwear with your hands.Traveling, with the help of "long hands"wear socks and stockings. To wear socksbetter, attach the rail to the horn for shoes andgive them to the heel of sock. Wear shoes and bootsyou can with the help of a conventional stool. Stand in frontstool, hold on with my right hand for the back, in the lefttake a shoe, bend my left foot and putleno on the seat chair. Put the shoe on the foot, helpnear your leg and hand and put on another shoe.

To remove shoes and shoes will help a special shoe board with a V-shaped drank at one end and nailed to the middle at the bottom of BR. Put one leg to the end without drank, press the board
To the floor, the end with a drink will raise up thanks to the bar. Insert the shoe pad on the other foot to the V-shaped drank and remove the leg of the shoes. Do the same with different shoes.
Some devices help to use the toilet and bathroom. Increase the toilet to the height convenient for you so that the legs are bent at right angles. Sit down to the stool and get up, holding the handraille in the walls and leaning on both legs. For washing in the bath, use a special stool of one height with a bath or just above, a hinged seat for a bath, a special rubber rug on suction cups. Bed on the bottom of the bath rubber rug, sit on the stool,
Put in the bath at first one leg, then another. Hold your hand for the handrail on the wall and when both legs will be in the bath, slowly get up and sit down on the mounted seat. In the same way, leave the bath after washing. You can instead of the mounted seats to mow in the wall above the bathroom folding seat. Use a sponge or brush for washing your feet
On a long handle. At home, the nurse after consultation with the doctor may recommend a patient with simple exercise complexes.
Should avoid sharp movements.

Several exercises to strengthen the muscles and ligaments of the lower extremities

Source position - standing, legs together, hands on the waist. Raise your foot forward and up, slowly remove to the side, go back to the original position. Repeat another foot.

1. Source position is the same. Raise the leg forward and up, bend in the knee, break, return to the starting position. Repeat with the other foot.
2. Source position is the same. Squats at a moderate pace.
3. Source position - standing, legs on the width of the shoulders, hands on the waist. Slowly sneeze, without taking heels from the floor, as low as possible, slowly return to its original position.
4. Source position - standing, legs together, hands down. Make a fear of foot forward, putting your hands on your knee, return to the starting position. Repeat another foot.
5. Source position is the same. Climb on socks, come back at home.

Several exercises for the development and support of flexibility

1. Source position - standing, legs on the width of the shoulders, hands on the waist. Tilt forward, to side, back.
2. Source position is the same. Circular movements of the torso right, then left.
3. Source position is the same. Lean forward, try to get the right hand
   Left, repeat the other hand.

Exercises for strengthening muscles and ligaments belly and pelvis

Source position - sitting on the floor, hands rest in the floor behind his back. Alternately bend and instill legs in the knees.
Falls of people are due to a variety of internal and external factors. Persons regularly falling, need a thorough examination, which includes a detailed collection of anamnesis, inspection and evaluation of functional status. Warning of falls provides for the treatment of sharp and chronic diseases nervous, cardiovascular, hematopoietic systems, musculoskeletal system, organs of vision, hearing, etc., as well as an increase in physical activity, systematic studies of therapeutic physical education. In preventive plan, the assessment of the home apparatus is required and, if necessary, its correction, the creation of a safe-hospital medium.

13.04.2016

Prevention of falls

Often, the prevention begin to think only after the misfortune happens - for example, the fall and. Meanwhile, it is always easier to warn trouble than to eliminate its consequences, to treat a fracture and long care for the victims and help him recover.

Even if it already happened, it is worth thinking about the future of prevention to no longer get into a similar situation.

In Germany, the so-called expert standard for the prevention of falls has been developed in the departure science. There are a number of such standards - for example, "pain", "dystrophy", "proleezzi", they relate to the most important aspects of the health and quality of the patient's life. Falling prevention is one of these aspects. The standard describes everything that needs to be done in order for an elderly person and / or the disabled person to fall, and, accordingly, so that such misfortunes do not happen as a fracture of the thigh. It defines the causes of falls, groups of persons with an increased risk of falls, the investigation of falls, events in the event of a fall and finally, a variety of measures to prevent falls.

If you have older people or disabled at home, it is possible to estimate their risk of falling and take appropriate measures.

The causes of falls are divided into two groups: internal and external.

The inner includes various diseases of the musculoskeletal system, nervous system or cardiovascular system. In order not to complicate, I just note: if a person is lame, suffers from pain in the back or joints, unstable when walking - naturally, the risk of drops is increased. It is elevated with Parkinson syndrome or multiple sclerosis, when muscle tone and coordination of movements are impaired. In any case, if a person is difficult to move - this is a risk. Also increased risk of falls, if a person suffers from dizziness, heart failure, low arterial pressure, violations of heart rhythm; Also, hypoglycemia in diabetes is the risk of dizziness / weakness and falls.

All people with dementia, even in a weak form, the risk of falls is increased, since there is no sufficient cognitive environmental assessment.

The risk of falling increases and receive some medicines, for example, many psychotropic drugs, sedative, antiarrhythmic.

Internal factors are also the fear of falling. If your relative has already fallen, got injured - there will be a fear of falling in the future, and this does not reduce it, but on the contrary, increases the risk.

As for external risk factors, everything is easier: it is inconvenient clothing and bad shoes (talk later), wires on the floor and swimming items, poor lighting, narrow passes, slippery gender (or ice on face), no objects or handrails, For which you can stay.

And now actually about the prevention. It has two goals: to warn the fall in general and minimize its consequences.

Prevention of falls in a residential room. What measures to do this can be done?

· - Remove from the room where the patient has a risk of falling, carpets on the floor, wires, unnecessary items.

· - Paul coating should be non-slip: carpet, rough linoleum, etc.

· - Preferably the lack of steps and thresholds.

· - In the shower and bath should be put rubber mats.

· - Bright sufficient lighting, but not blinding.

· - Arrange the furniture so that it does not interfere with when walking.

· - Install, if possible on the walls of the handrail for keeping - especially this is important in the toilet / bathroom and in the corridor.

· - Special high toilet seat, preferably with handrails.

· - In the room of an elderly person, things should not be kept on the mezzanine and highly located cabinets, it is not necessary to use stewners and similar appliances for climbing.

· - In order for the patient not to bend, special devices are desirable, for example, grasp for lifting items.

Be sure to consider how to care may be called to the aid. In Germany, for this you can install a home signaling system, while the patient has a special bracelet, and can call the mobile home service directly from the bracelet. It seems that there are no such possibilities in Russia yet, so if an elderly person or a disabled person lives or for a long time one, it is worth teaching it or use it a mobile phone (perhaps you need a phone with large buttons) and constantly carry it with you. Otherwise, there is a risk that a person falls and will lie on the floor of the clock, unable to call for help.

It is important, of course, to treat basic diseases, say, in diabetes, do not allow hypoglycemia, with poor eyesight wearing glasses.

At night, near bed, you can install a toilet chair so that the patient does not go through the entire apartment in the toilet.

Clothes should be comfortable, and shoes should be given great attention. How many older people are falling only because they wear slap slaps "Neither step back" or cozy woolen slippers! This, of course, is convenient - but is fraught with danger. Soles of shoes must be anti-slip, shoes should have backs. Sometimes it is worth taking care of orthopedic shoes.

The prevention of falls includes therapeutic physical culture and exercise - the stronger the muscles and ligaments than a confident person keeps on his legs, the less likely that he falls. Physical culture helps to overcome fear of falls.

Finally, various auxiliary means can be used to prevent falls. These are rollators, walking sticks, crutches (the latter are commonly used temporarily, after injury).

But there are also protector for the head and for the thighs. This is especially true for patients with dementia. Often to prevent the drop in the dementary patient is completely impossible - after all, he or she overestimate its capabilities, cannot call for help, stand up and move as they want, without thinking about danger. Therefore, it is necessary to at least minimize the consequences of falls. And the most dangerous injuries in the falls are just shocking the brain and fractures of the hip neck.

Protectors on the hips are put on pants and soften the blow when falling.

Contrary to everyday ideas, fixing the patient (tie in bed, to the chair, etc.) is not a method for preventing drops.

I still remember the times when almost all dementary patients in the care hospital were sitting or lying fixed by belts. But, in addition to ethical considerations, statistics showed that fixation does not reduce, but increases the number of drops! It is logical: someday a person will still have to untie, and having evolved from free movement, it falls almost immediately. Patients were confused in belts, even deaths are known. The raised lattice bed led to the fact that the patient slewed over her - and fell on the floor from height.

Now in our hospital for the care we very much apply fixation. Of course, complex patients who night did not want to lie at night, but they themselves were not able to go - they got up and fell. We in such cases put on the mattress next to the bed. We had one patient even slept on the floor on the mattress, so as not to fall at night from the bed. Now we use special rugs for dementary patients, when you have a call to the sister's duty. These rugs significantly reduce the risk of falling - when a sister or nurse call, it immediately runs to the patient's room and provides him with help - get to the toilet or go to bed again.

At home, this is, of course, it is unlikely possible. But as you can see, there are many simpler, elementary measures, using which, you can achieve a reduction in the risk of falls - and the fact that your relative will no longer break the neck of the thigh.

In essence, you just need to think about it and do not miss simple things out of sight.

Yana Zavatsaya
Tags: prevention of elderly falls
Description for announcement:
Start of activity (date): 04/13/2016 10:15:00
Who created (id): 6
Keywords: prevention of falls, fracture of the hip cervix, treat a fracture, pain, dystrophy, breakdown, the quality of life of the patient, a man is lame, suffering from back pain, unstable when walking, Parkinson's syndrome, multiple sclerosis, coordination of movements, a person suffers from dizziness, heart failure , low arterial pressure, heart rate disorders, hypoglycemia in diabetes, dementia, cognitive environmental assessment, fear of falling, prevention of falls in a residential room, telephone with large buttons, toilet chair, rollators, walking sticks, crutches, head and head protector and For the hips, brain concussion, fractures of the hips, protectors on the hips, patient fixation, ties in bed, dementary patients, get to the toilet, go to bed

Older people, especially women, are often falling. In 30% of residents of the nursing houses, there are at least once a year; With age, their frequency increases. Falls can not be considered by chance and inevitability, they must be treated to prevent.

Causes of fall. A person can maintain balance and move only with the well-coordinated interaction of cognitive functions, the senses, a neuromuscular apparatus and a cardiovascular system, which ensures the ability to quickly respond to environmental changes. With age, the ability to maintain balance weakens. Violation of the function of any of the equilibrium systems can lead to a drop. Therefore, falls are often a sign of severe diseases, such as pneumonia or myocardial infarction.

However, most often the reason for the fall becomes any obstacle on the way, which weakened by an elderly person does not have time to notice or cannot overcome.

Weakness, impairment of vision, equilibrium, cognitive disorders can cause the increasing and injury to the slightest irregularity of the floor, not representing the danger to the healthy, full forces of a person.

Most often, the fall is associated with several reasons. These reasons can be divided into two groups - associated with the condition of the patient (disease, the side effect of drugs) and related to the terms of its life and everyday activities.

The cause of falls may be a violation of perception, disruption of intelligence, violation of the regulation of blood pressure, a violation of equilibrium, a breakdown of gait and slowing the reaction (Table 9.4), as well as the use of alcohol and the reception of some medicines.

Some causes of drops are easy to eliminate. Examples can serve postprandial hypotension (the most pronounced 30-60 minutes after meals), insomnia, imperative urge on urination, stop diseases and swelling (2-5 kg \u200b\u200bof excess weight in the edema, weaken it and violate the gait).

The external causes of falls are listed in Table. 9.5. With most of them, the patient faces at home or in the courtyard, so a visit to the house of a cartridge sister, a specialist in the exercise of a lecturer or a doctor can bring undoubted benefits.

Consequences and prevention. Each fourth drop leads to injury. 5% of falls end in fractures and as much - serious damage to soft tissues. Falls occupy the sixth place among the causes of death of the elderly and serve the cause of 40% of the directions to the nursing home. Consequences of falls, such as cervical fracture femoral bone And the fear of falling can lead to loss of self-service ability.

In cases where, after falling in an elderly person, unexplained neurological disorders appear (even if it is only a confusion of consciousness, not accompanied by a headache), should be suspected

For an elderly, a fall,
Non-hazardous for young, can be very
An unpleasant event. Part of such falls
may end with fatal outcome, among
other complications can be called fractures
bones, head injuries and soft damage
fabrics. Often in the elderly as a result of falling
formed "fear" syndrome ", which can
lead to no less sad consequences
What the results of physical injury. Fear of fall
is the most common reason for the reduction
Activity in the elderly.

Why are healthy, actively moving people rarely fall?

First, thanks to
Reflex regulation
movements correct
Equilibrium and
vestibular apparatus.
Secondly thanks
good vision that
Allows you to
Focus B.
Environment I.
Bypass obstacles.
Violation of at least one of
Listed mechanisms
Increases the risk of falling.

All causes of falls in old age can be divided into two groups.

External reasons associated with incorrect
Organization of safe movement: uncomfortable
Shoes, bad glasses, lack of auxiliary
means of movement (canes, walkers); Low
Housing safety.
Internal reasons associated with age
Changes in the musculoskeletal system, organ
vision and cardiovascular system.

The causes of the fall of the elderly. Age-related changes

Slow reaction I.
Bay disorders
Coordination violation
Muscle weakness
Reduction of visual acuity and
Dizziness
Perception of depth
Diseases (pain, restrictions
Mobility of the joints, muscular
Weakness violation of the function
CNS)
Environmental factors
Accepted medicinal
facilities

Osteoporosis - risk of fractures

Consequences of falls

Fractures of bones
Head injuries
Soft damage
fabrics
Formation
"Fear of fear"

Localization and features of the flow of injuries in the elderly

Wrist
Spine
Mining about 6.
weeks and up to 3-6
months
Fractures often
painless.
Healing 4-
6 weeks
Restoration
Full activity
For complete
Recovery
1-2 needed
of the year
Hip
6-month loss
Mobility, including
hospitalization, operation and
Homemade peace. 20% of patients
die over the year from
Complications. 20% of the survivors
patients will not be capable
live without assistance and
constantly need to
outpatient treatment

What to pay attention to:

Were there any cases of falling earlier?
If you were, how often are frequent and predictable?
Does the patient epilepsy?
Are there tachycardia alone or heartbroke
rhythm?
How many drugs at the same time takes
Patient (reception of 4 or more drugs significantly
increases the risk of falling)?
Availability of recent hospitalization or limitation
Motor activity in the next 2 months.

Survey

Physical
The survey should
Include a vital assessment
important functions of rhythm and pulse frequency,
arterial pressure,
Body temperature.
When examining the head and
Neck special attention
Pay test
Acute view, noise
Over carnation arteries

Survey

Detection of Cardiovascular Diseases
(arrhythmias and valve velocities)
Evaluation of mental abilities as well
Detection of focal seizures of sensory and
motor functions.
"Toll samples" when the doctor pushes the patient in
breasts and observes the reaction of recovery
Sustainable position.
Deformation and artiritical joints of the joints
Lower extremities

Survey

Evaluation
Functional
Status:
as a patient rises
From the chair, it is without
support walks by
Direct and turns
on the run. Determine
Putty patient
to take on their own
object and rise with
Floor.

If the patient is in the vertical
position less than 4 hours a day, not capable
Stand off the chair without the help of hands, unstable in
vertical position, inhibit, with
long periods of depression,
It is necessary to explain to relatives,
How big is the risk of falling and injury from such
Patient and assistance needed
With his movements. Need to detail
tell how to such patients correctly
organize safe life to
Maximum reduce the possibility of injuries.

Differential diagnosis

E - epilepsy
T - transient brain disorders
blood circulation
A - arrhythmia
P - attacks caused by syndrome
Carotid sinus

Carotid sinus syndrome

Repeating attacks with sudden permanent
Consciousness associated with certain movements
heads and necks, while consciousness is saved, but
There is no ability to active movements
Because of the sharp inflection of the vestibular arteries on
Osteochondrose background
Violation of the neck mechanoreceptors, leading to
loss of muscle tone with sharp movements
Head

Medical events

Treatment of urinary system infections,
heart failure
Cancel provoking
Drops of medicines
(tranquilizers or
sleeping bags)
Measures contributing
An increase in mobility
Joints, Improve
Functions external
breathing

Prevention of falls

organization of safe life and dwellings;
Gymnastics classes for
Increase in the strength of sinks
Use of medicinal
Preparations for reduced
severity dizziness -
Osteoporosis treatment and treatment.

Household factors

Situation
First of all, the falls are frequent in an unfamiliar
atmosphere or with the permutation of furniture because
Older people rely more on the developed
habit than vision. Move to new
The situation can cause disorientation and even
confusion of consciousness.

Household factors

Bath
Often the elderly people fall
in the bathroom devoid of handrails
Or near her on slippery floor.
It is necessary to put a rubber bath on the bottom
Rug with a convex pattern that prevents
slide. It is important to explain to the patient that
It is necessary to first fill the bath with warm water, and
Already then sit down in it (when this rule is not
Complied, the risk of obtaining burns,
When an elderly person, being in the bath, opens
Crane to add hot water).

Especially should be mentioned about the falls of the elderly,
associated with arising orthostatic
hypotension with a rapid transition from
horizontal in vertical position,
Getting up from a bed or armchair. Hypotension
enhanced in patients taking
Hypotensive means. It often develops
Short-term brain deficiency and
Coronary blood circulation. Risk of falling in this
The state is preserved for 20-30 minutes.

Household factors

Handrails
At what distance from the floor are the handrails placed?
With individual selection at home
guided by the rule - the handrail must
be at the level of the rayscass
patient. This rule applies to
Bathroom equipment, toilet, as well as in selection
Cane or walkers. Need to remember that when
one-sided defeat cane follows
Substitute for support from "Healthy side".

Household factors

Bed
Elderly deserves special attention
man. It should be no less than 60 cm, not soft,
little warming under the patient. It will relieve
Patient from pain caused by
Changes in the spine (osteochondrosis,
Spondligratosis).
Old people sleep at night less, often read,
get up, walk around the room, eat at home and
Even cook food.

Household factors

Armchair
Chair for an elderly person
must have low
comfortable armrests
Shallow, with high enough
back for head support.
Since older people spend a lot of time
sitting, important to the edge of the chair not pressed
area of \u200b\u200bpopliteal pits, which causes a violation
blood circulation in the lower limbs and leads to
venous thrombosis.

Household factors

It is important that the passages in the apartment are moved
the elderly man was liberated from unnecessary
Objects, furniture and wires. Floor covering -
Smooth, not slippery. On the stairs if it is in
house - mandatory railing and rubber strips
The edge of each stage is 2-3 cm width,
Preventing leg scoring. All routes
following an elderly person in the house should be
sufficiently lit. At night it is desirable
Leave the shaded light from the toilet room.

Household factors

Footwear
Patient shoes should be
low heel or without
it is on rubber or
non-slip soles, very
Convenient - type of sports shoes with lacing or
fastener. Danced any kind of "slippers", since
They create an additional risk of falling,
Increased leg instability and slipping
shoes with her.

Regardless of which factors cause the fall of the elderly, here are some tips that will prevent falling:

regular physical training for muscle strengthening
and bones
Remove the things that can contribute
Fall
Necessary stuffing things in easily accessible places
On the floor, use non-slip mats
In the bathroom, make handles and railing
Ladder and hallways keep well lit
When using drugs, be sure to interest
physician about the possible action of them on the bone (do not cause
they are their fragility)
Wear comfortable shoes with a non-slip sole

Prevention of drops and injuries

The most common cause of the death of sick elderly
and elderly age from injury obtained in
The result of falling is a fracture of the hip neck.
Treatment, as a rule, long, sometimes up to 6
months. Patients forced first long
lie in the gypsum and then for several months
restore the motor function, suffer from
Blooding, stagnant pneumonia, infection. IN 20%
All cases of the fracture of the thigh female is death
from complications. Half of the elderly patients after
This injury becomes deep disabled,
requiring continuous care.

SO:

Large share of injuries after falling in older people
Associate on fractures of wrist bones. Establishing process
It takes a long period of time - from 6 weeks to 3-6
months and significantly limits the ability of a person to
self-service.
Spinal fractures are often painless and
They leak almost unnoticed. After some time, the fracture
It becomes noticeable in the form of an "senile hump". On the
radiographs such a fracture of the spine is clearly visible in
lateral projection. Treatment of such an injury requires
long period of time, and full recovery
Comes 1-2 years after treatment.

According to statistics, older women fall and get injuries more often than men.

This is explained by the fact that women are in the elderly
age suffer from osteoporosis - elevated
Bone fragility. In addition, older women
live longer than older men and their
Quantity more.

Prevention of falls

When entering the boarding house, ask relatives,
how the elderly man moves, whether he needs him
Help, cane, walkers, wheelchair.
Accompany the ward with the high risk of falls and
injuries (about this risk aware of a boarding house and
Medical sisters) in the hall, for walking.
Patients with dizziness and unstable gait
must themselves, without the help of personnel, get up, walk and
Replacing in a chair-toilet. Such customers
It is necessary to explain that they, if you wish to get up with
Beds should call the nurse.

Prevention of falls

In the daytime, all rooms should be good
Illuminated, windows are smashed. At night should
To be included on duty lighting.
Need to explain newly arrived customers that they
Must move on boarding house corridors
Holding the handrail.
Passages in the rooms must be free. On the floor
There should be no wires and rugs for which
Stroke an elderly man with poor eyesight.
At night, patients with high risk
drops and injuries should be in beds with
raised sides: about such clients of the nurses
Informs duty nurse.

Prevention of falls

The floor should be dry. To do this, you need to carefully wipe
Paul after wet cleaning, in the toilet (can pour on the floor
untidy customers), as well as in rooms and halls, where
Take food (can pour tea, compote). If you
Noticed the liquid on the floor - swing immediately or
Ask this to make a cleaning lady.
In case of falling a living nurse immediately
Causes a nurse and / or physician to him. Only
After examining a nurse fallen or a doctor for the subject
Detection of signs of fracture Customer carefully stacked
on the bed. Severely observes such a person and
the slightest change in his well-being, the occurrence of pain
- Immediately reports a nurse or doctor.

Citation:Schwartz G.Ya. Osteoporosis, falls and fractures in old age: the role of the D-endocrine system // RMG. 2008. №10. P. 660.

Demographic changes that have occurred in the last decades of the twentieth century. And ongoing in the XXI century., among which - a noticeable increase in life expectancy, led to a significant increase in the population of the share of senior ages. According to the 2007 population report prepared by the United Nations Population Foundation and presented in June 2007, in the structure of the Earth's population, which is currently 6.6 billion, the number of persons over the age of 60 is more than 705 million . With a distinct tendency to an increase in industrial-developed countries. In Russia, the share of elderly people (60-75 years old) and senile (75-85 years) age is close to indicators for Western Europe and the United States and is about 30 million, which exceeds 20% of the country's total population. The study of the contingent of elderly persons shows that this group is extremely heterogeneous in somatic, psychological and mental status. According to the classification of age periods of WHO (1973), women aged 55-74 years and men - 60-74 years old are considered the elderly, 75-89 years old - old age, 90 or more years - long-livers. With an increase in human age, the morbidity structure varies significantly as a result of a decrease in the number acute diseases and increasing the prevalence and morbidity of diseases associated with the progression of chronic pathological processes. The state of health of the elderly and senile age is characterized by a high level of accumulation of pathology against the background of pronounced age-related changes in various organs and systems (primarily kidneys, heart, gastrointestinal tract, glands of internal secretion, etc.). For an elderly population, a high incidence in general is characterized, among which cardiovascular and cancer and cancer diseases are leading, as well as diseases of the musculoskeletal system, among which osteoporosis (OP). In connection with the high medical and social significance in the last 10-15 years in the entire circle of issues related to OP (epidemiology, pathogenesis, clinic, diagnosis, treatment, medical and social and economic aspects, etc.), considerable attention is paid. Each of these issues is important, and without them the problem of OP cannot be discussed. A peculiarity of this systemic skeletal disease, characterized by a progressive decrease in the mass of bone in a unit of volume and a violation of bone microarchitectonics, is poor clinical symptoms, which necessitates insufficient attention to the possible availability of op as patients and health care workers. The outcomes of the OP is an increase in the brittleness of bones and their fractures are often the basis for setting the post-facts of the diagnosis of the disease and the start of therapy.
The main features of OP, falls
and fractures in old age
The distribution curve of fractures in the population has a bimodal character with peaks in the children-young and elderly (Fig. 1). It is believed that fractures forming early peak are not related to OP. They are represented by fractures of the bones of the skull in infants, traumatic fractures of the bones of the limbs (mainly the diaphysis of long tubular bones, brushes and fingers) in adolescents (5-14 years old) and young adults (mainly male) due to high physical activity (games , sports, etc.). The late peak of the frequency of fractures, beginning in women aged 55-64 and in men aged 65-74, is presented mainly by fractures of the vertebral bodies, as well as the so-called peripheral fractures - the proximal femoral department, the distal department of the forearm (Collis Fracture), Several less often - the proximal separation of the shoulder bone and bones of the pelvis and some other localizations. This peak of the frequency of fractures until recently was associated with OP. From epidemiological positions, these fractures are characterized by: 1) frequency indicators that increase significantly with age; 2) sexual differences are much more often observed in women (in 2 or more times more often), and only at the age of 85-90 years of fractures in both sexes come closer; 3) dependence on the insignificant / moderate injury of those areas of the skeleton, which contain sufficiently large volumes of trabecular bones.
As a rule, OP is developing aged 60-70 years, and more than 80% of all cases of the disease are observed in women. Thus, the main contingent of patients with this disease is faces: a) elderly and senile age; b) commisive female, which reflects its functional connection both with age and with the floor. AT clinical practice OP is found in the form of a number of types and forms. Taking into account etiology and pathogenesis distinguish the primary and secondary OP. The primary OP combines the two most common forms of the disease - postmenopausal OD and sedenie of OP, constituting up to 85% of all its cases. In addition, the primary referred to relatively rare cases of idiopathic OP (OP in men, OP obscure etiology in adults), as well as juvenile op. The etiology of the primary OP remains unclear and is the subject of intense, including genetic, studies. As for the secondary OP, the causes of its occurrence and the main stones of pathogenesis are clearer, because Its variants and forms are largely related to specific diseases, in particular, endocrine genesis, tractology of the gastrointestinal tract, kidney, blood system, yatrogenic effects (the use of glucocorticoid hormones, anti-epileptic means, etc.).
The peculiarities of the elderly patients, including patients of OP, include a decrease against the background of endocrine-immune dysfunction of the general muscle mass (sarkopenia) and the presence of weakness of arbitrary muscles (weakness syndrome), reduction of vision (decrease in the severity and narrowing of fields of vision) and adequate functioning of the vestibular The device, which is accompanied by an increase in the risk of falls and caused by these injuries and fractures (Table 1, Scheme 1). It is known that more than 50% of patients with OP have sarkopenia, about 25% of them suffer from postural hypotension, and the overwhelming majority weakened vision and partially broken the ability to move.
The role of drops associated with internal reasons, Including with impairment of the function of the musculoskeletal system (muscles, bone, sense of equilibrium, proprioceptive reflexes, etc.). Changes gait appear in 50% of the elderly and in 100% of old people. They manifest themselves shortening the step, the height of the foot lift (the angle of lifting the foot in the old people is close to 10 ° in contrast to 30 ° in people of young and middle age). Strengthening when walking and decreases the depth of the surface perception (decrease in the tactile and deep muscular sensitivity of the stop). The speed of walking and coordination of movements is reduced, the reaction time increases, there is a noticeable reduction in muscle strength and endurance (fatigue syndrome), prevails a sense of fatigue (scheme 2).
In these violations, sarkopenia, joint pain and reduction of their mobility play a leading role. Age reducing physical performance and endurance, any violation of the function of the lower extremities leads to a violation of the motor stereotype. The gait in the old people becomes screaming, insecure, they barely overcome even small obstacles, which indicates the presence of space-motor disadaptation. Many of the fallen drops have fear of repeating them. For this reason, they regularly limit physical activity (including physical education classes, walking, etc.) that, in turn, increases the risk of repeated falls.
When considering the bonds of falling and fractures, the elderly important is important and taking into account the direction of fall. If the faces of young age fall predominantly in the direction of the forward, then the faces of the elderly and the old people usually falling the side. This direction of the fall is accompanied by a maximum attachment of the blow strength on the surface to the area of \u200b\u200bthe pelvic / hip joint / neck of the femoral space / femoral bone. Against the background of a somewhat observed in an elderly population of a loss of body weight, the redistribution of subcutaneous fat from the hips to other areas, as well as sarkopenia, the natural mechanical protection of the femoral region is significantly reduced, which increases the risk of fracture of the hip neck.
Internal causes of elderly and senile ages, internal causes (age-related changes of systems that support body balance, weakness syndrome, a number of diseases - neurological and somatic, receiving some drugs) and external causes (insufficient illumination, steep stairs, etc.) . Unlike young people, only 14-15% of falls in the elderly are due exclusively by external reasons, for example, drops on the icy sidewalk. In other cases, falls are associated with internal factors and occur at home or in the hospital ward. The risk of falling and their complications is significantly higher in patients who were in bed for a long time. Long-term immobilization is accompanied by OP, muscle weakness, often determined by social isolation and development of depression.
The change in the gait in the elderly predisposes to the emergence of falls. With age, walking becomes slower, a step is shortened, the duration of the repulsion period from the support decreases, the period of support on both legs increases. Falls in the elderly women are more common than in older men, which may be due to sexual features of walking in aging. Women with age, there is a tendency to walking in turning, with near-locked legs; In men, a flexor posture is more common, a trend towards small chambers, with widespread legs. At the same time, a large part of the elderly (up to 20%) of clinically explicit breaks is not detected. It is assumed that disorders of the elderly and senile ages are associated not so much with aging, as with various diseases, including clinically not clearly manifested (myelopathy of various genesis, the initial stages of Parkinson's disease, normalzic hydrocephalus, etc.). It should be noted that the emergence of walking disorders is an unfavorable prognostic sign of the subsequent development of dementia (especially vascular dementia).
Maintaining postures and equilibrium depends on the functioning of the system complex: sensory, motor, bone-muscular. Aging and diseases in the elderly can involve any component of those listed above, and the combination of existing factors is often summed up. However, in most cases, the presenter pathological factor can be distinguished, treatment to eliminate and the treatment should be directed.
Sensory information comes by proprioceptive, visual and vestibular paths. These SIS-te-we are very plastic, and with the pathology of one of them, two others take on the function damaged. However, in the event of suffering (damage) of two systems, the entire load on the operation of the functioning is accounted for, and in case of insufficiency, there is a malfunction of equilibrium and the likelihood of falls increases. With age, there is a decrease in the number of deep sensitivity receptors, especially significantly expressed in patients with rheumatoid arthritis and cervical spondylosis. This leads to a decrease in the affamentation of the spinal cord in the overlying department of the CNS. It is assumed that part of the patients, such a decrease in propriumception leads to clinical picture The so-called vertebro-basal insufficiency, although in fact doubly disorders in the vertebro-basilar system of a significant role in the genesis of such disorders do not play. The cause of pathological muscle fatigue may be miastic, the frequency of occurrence of which among elderly and senile ages is often underestimated. Often, the cause of falls is alcoholism or domestic abuse of alcohol, especially in persons with depression or living in relative social isolation. The risk of falling on the background of even small doses of alcohol increases significantly, since the tolerance of alcohol is reduced with age.
The likelihood of falls is increasing with an increase in the number of risk factors: individuals without falling factors are found in 8% of cases, and in persons with 4 risk factor and more - at 78%. Only in a small percentage of incidence of falling, under the influence of one factor, most of the elderly patients have several factors predisposing to falls, in a complex reinforcing the adverse effect of each of them. It should be emphasized that the risk of falls is significantly increasing in acute development or exacerbation of chronically occurring somatic diseases.
The external factors leading to drops include poor lighting of the premises, an uneven or slippery surface of the floor, uncomfortable shoes and other drops more often occur when the staircase is designed, as well as when you get up from the chair / chair or bed. Promotes drops insufficient care for patients who are especially having multi-intellectual disorders. The risk of falling increases in the first days after hospitalization or immediately after the abolition of beddown.
Among the causes of falls in the elderly, various cardiovascular disorders accompanied by synopal phenomena (faint result) occupy a significant place. In particular, the rapid development of the loss of consciousness followed by recovery is characteristic of arrhythmias, whereas when epilepsy, the rapid development of the loss of consciousness is replaced by slow recovery. For vasopressor syncopal states, a quick start with pro-domal phenomena is characterized (often on the background of emotional stress) with the subsequent rapid recovery. A thorough examination allows you to identify an orthostatic hypotension in almost 30% of elderly and senile persons. In this case, a significant part of these patients are not observed dizziness or any visual disorders when rising. The predisposing factors that may be accompanied by the development of syncopal states, cough, sneezing, sharp change in the position of the body (rode).
The factors that increase the risk of falling and fractures in elderly patients with OPs, and the Polyphrampia or Polyprigmiasis) of drugs (Table 2), are also predisposing to violations of coordination and motor functions in the elderly (Table 2), primarily from groups of sleeping pills, en-Tidepressants, and Antihypertensive, etc., which can increase the risk of drops by more than 40%. In this regard, the presence of yatrogenic problems, i.e. related S. medical influencesis quite characteristic of the elderly feature. Polyprigmation in old age is a very common and difficult managerial phenomenon associated not only with the use of a prescribed therapy, but also with self-treatment, with an up-to-step of non-presidential drugs (so-called, out-medications).
Epidemiology and medical and social characteristics of falling in the elderly
In Russia, in the overall structure of the causes of mortality, unfortunate knocks and injuries occupy from the late 80s. last century, second place after cardiovascular diseases. Unfortunately, in official statistics, the place of falls in the structure of morbidity, injuries, disability and mortality is not disclosed. At the same time, such statistics and analysis are conducted abroad. In particular, in the structure of the US Department of Health, there is a center for morbidity and prevention, which pays serious attention to the problem of falls. So, in particular, according to this center, among the US population, more than 1/3 people aged 65 and older postpone the fall at least once a year, and the falls themselves are the leading cause of traumatic deaths and non-infamous injuries requiring hospitalization. In 2005, 15,800 old people died due to injuries obtained in unintentional drops; 1.8 million persons aged 65 and older, due to falls, appealed to ambulance departments; 433000 - were hospitalized in traumatological offices. Conduance analysis made it possible to conclude that the mortality rate among old men increased significantly in the last decade. Up to 30% of persons undergoing drops, have severe traumatic lesions, including subdural hematomas, hip neck fractures and head injuries. It is shown that most of the fractures of any localization are associated with drops. For men, the risk of ending death (fatal) drops is 49% higher than women. In 2000, in the United States, the general medical costs associated with the treatment of fatal falls amounted to $ 179 million, and for the treatment of non-phantal drops of more than $ 19 billion. According to WHO (2004), up to 30% of people over 65 years old and 50% - at the age of 80 and older, at least, 1 time per year is transferred to fall, 30% of which are accompanied by serious injuries (fractures, head injuries and spine, shaking brain, damage to soft tissues, etc.). At the same time, about half of them, the falls are marked more than 1 time per year. Among the most frequent causes of falls are: accidents associated with external reasons (slippery, uneven, with road obstacles) - 31% of cases, with internal reasons: muscle weakness and equilibrium disorders - in 27%, dizziness - in 13% of cases, arthrosis The joints of the lower extremities - in 11%, depression - in 3%, violation of vision - in 2%, etc. The risk of fractures due to falls is particularly significant in patients who have impaired motor functions (paresa, ataxia) after a stroke. In persons who have undergone incidence, in 5% of cases there are peripheral fractures and in 1% of cases - the fractures of the neck of the disinfect bone. According to available data, more than 90% of the fractures of the femoral neck are associated with drops.
The role of D-deficit in the pathogenesis of falls
In the past two decades, modern ideas about Vitamin D3 (cholecalciferole) are not as, in fact, vitamin in the classical understanding of this term, but as a steroid biologically inactive progeormon, which turns into the body into an active metabolite - D-hormone, which has a powerful regulatory influence On the exchange of calcium near other important biological functions.
In the body, vitamin D3 is formed from the predecessor (provitamin D3) - 7-dehydroholesterol under the influence of short-wave ultraviolet irradiation. Vitamin D3 coming in small quantities with food or formed in the body in the process of endogenous synthesis, as a result of two consecutive hydroxylation reactions in the liver and kidney turns into an active hormonal form - 1A, 25-dihydroxyvitamin D3 (called also D-hormone, calcitrigol or 1a 25 (OH) 2 D3).
D-hormone together with parathyroid hormone and calcitonine is traditionally combined into a group of calcium-controlling hormones, the function of which is to maintain the physiological level of calcium in the blood plasma due to both direct and indirect influence on target organs. In addition to maintaining calcium homeostasis, 1a, 25-dihydroxyvita-min D3 also affects a number of organism systems, such as immune and hematopoietic, regulates the growth and differentiation of cells, etc.
The molecular mechanism of action 1a, 25-dihydro-xivitamin D3 is similar to other steroid hormones and is interacting in tissues with specific receptors, which received the name of vitamin D-receptors (PBD, or in English transcription - VDR). These receptors are widely represented in the body and detected at least in 35 organs and tissues, and not only in classical target organs for vitamin D (intestines, kidneys and bones), but also in the brain, heart, skeletal muscles, pancreas, parachitoid and prostate glands, intestines, organs of excretory and reproductive systems, as well as other organs and tissues, which is another proof that 1A, 25-di-dro-xivitamin D3 is a typical hormone, carrying out many regulatory functions .
One of the main and most detailed functions of vitamin D and D-hormone functions is to participate in maintaining calcium homeostasis: due to the interaction with PBDs in target organs, D-hormone causes the synthesis of calcium-binding proteins that carry out calcium absorption in the gastrointestinal tract, reabsorption in kidneys, fixation in the skeleton.
D-hormone, in addition to the participation in maintaining calcium homeostasis, the development of the skeleton and processes of bone remodeling, has an impact on the functions of skeletal (sin. Arbitrary or cross-striped) muscles in which there are specific PPDs.
In the mid-70s of the XX century, it was found that vitamin D and its metabolites have a stimulating effect on the metabolism of skeletal muscles. In the future, PPDs were found in animal muscles and people. Genetic studies have made it possible to establish that the removal of the gene encoding the expression of the PRD proteins in animals ("knockout" in this genine animals) is accompanied by the development of pathologically modified (shortened and different sizes) of muscle fibers while maintaining the normal differentiation of myocytes. At the same time, significant metabolic disorders in the muscles were found in the "knockout" animals: hypocalcemia, hypophosphatemia, accompanied by an unusually high and persistent products of pathologically modified muscle proteins, such as MyF5, Moiogenin, E2A, Miosin's light chains, and others. Especially important The Basel University (Switzerland) obtained in the orthopedic blade of the Basel University (Switzerland), that in the muscular tissue in the elderly and senile ages there is a progressive decrease in the number of PBDs (Fig. 2).
According to modern ideas, the D-hormone stimulates the capture (influers) by the arbitrary S2 + muscles due to the nuclear mechanism, the 2-phase formation of diacylglyzerine (DAG), and the second phase of this process is independent of phosphoinositide hydrolysis under the influence of phospholyphasis S. It stimulates phosphosphatidylcholine hydrolysis in mammalian tissues The account of the phosphalipase d catalyzed by the mechanism in which the Ca2 + ions, as well as proteinkinase C and G-proteins participate.
In recent years, molecular mechanisms of action 1.25 (OH) D3 in the skeletal muscle were significantly detailed. It was shown that D-hormone modulates calcium homeostasis in skeletal muscle cells, both due to the classical genomic action, which is to control the expression of genes and the participation of the negro mechanism, which includes direct membrane effects of the hormone, mediating various signaling systems. This steroid quickly modulates the CA2 + inflows due to the mediochable G-white-kami activation of phospholipase C and adenylate cyclase, leading to the activation of phosphocainees C and A, the release of Ca2 + from intracellular depot (tank) and activation of the potential-dependent Ca2 + L-type channels.
It is also established that the rapid change in the entrance of the labeled 45S2 +, caused 1.25 (OH) D3 in the muscles and in the culture of myoblasts, is accompanied by a parallel increase in the level of squamodulin protein (km) associated with membranes while reducing the concentration of KM in cytosole without changes in its total Quantities in the cell. D-hormone quickly changes calcium homeostasis in skeletal muscle cells due to the shift of the signal transmission mechanism, which contributes to the release of CA2 + from the depot and input from outside to the cell through the potential-dependent L channels and depot-operated Ca2 + -Kanals.
Another characteristic of the D-hormone biological effect is the effect on proliferation and differentiation of cells. It is also manifested in relation to the cells of skeletal muscles and is associated with the effect on the RAF-1 protein. This protein, open as the first member of the cytoplasmic serine / trendino-chip family, plays a leading role in activating the classic cytoplasmic signal cascade, which is involved in the regulation of cell proliferation, differentiation and apoptosis. Activation of RAF-1, as a consequence of activation of protein-tir-zine-kinase receptors, with RAS-GTF-binding proteins, which are necessary to stimulate the activity of RAF-1 kinase. Then Raf-1 phosphorylates and activates the kinase of mitogen-activated protein kinase, known as MEK (MITOGEN-ACTIVATED PROTEIN KINASA (MAPK), which launching a protein-ki cascade, which leads to phosphorylation and activation of the extracellular signal-adjustable protein (mar ) - Kinases (Mark) existing in 2 isoforms: Erk1 and Erk2. In connection with the activation of Mar Kinase (Mark), it moves from the cytoplasm to the kernel, where it phosphorylates transcription factors and thus launches the processes of proliferation or differentiation of different types of cells. It was found that 1?, 25 (OH) 2D3 in target cells - myoblasts (embryonic we-sponsor chicken cells) causes activation of RAF-1 via Ras and phosphocainase of Ca-dependent serine phosphorylation and that the specified mechanism plays a central role in the hormone stimulation Mark signal paths that run the proliferation of muscle cells.
Thus, the D-hormone plays an important role in both the differentiation and proliferation of skeletal muscle cells and in the implementation of CA2 +-dependent mechanisms that are one of the central in the process of muscle contraction.
Violation of the formation of hormones and their deficit are important causes of many human diseases. The deficiency of one of them is D-hormone (more often indicated as vitamin D deficiency) also has negative consequences and underlies a number of types of pathological conditions and diseases. The following is considered as a characteristic of vitamin D deficiency and its role in the occurrence and development of common diseases.
In physiological conditions, the need for vitamin D is varying from 200 me (in adults) to 400 meters (in children) per day. It is believed that short-term (for 10-30 min) solar irradiation of the face and open hands is equivalent to reception of approximately 200 meters of vitamin D, while the re-staying in the sun is nude with the appearance of moderate skin erythema causes an increase in the level of the level of 2nd above the above-observed introduction In a dose of 10,000 meters (250 μg) per day.
The D-hormone deficiency is more often represented by D-hypo-Vita-Minoz or D-vitamin deficiency. In contrast, for example, from a dramatic reduction in the level of estrogen in postmenopausal, this term is indicated, as a rule, a decrease in the level of formation in the or-ha-bottoms 25thd and 1a, 25 (O) 2 D3 and the violation of its re-chasing. D-deficiency plays a significant role in the pathogenesis of not only the primary OP (involutionary types of osteoporosis (OP) - postmenopausal and sedensee, juvenile OD) and secondary forms of this disease (steroid OP et al.), As well as some other types of skeletal and out-of -ilet pathology.
There are two main types of D-Mount-Mo-on deficiency, sometimes referred to as "D-under-accuracy syndrome". The first one is due to the deficiency / deficiency of vitamin D3 - the natural coammon form, from which the active (E) metabolite (s) (1a, 25 (O) 2 D3) is formed. This type of vitamin D deficiency is associated with insufficient stay in the sun and its admission with food, as well as by constant wearing a closing body of clothing, which reduces the formation of natural vitamin in the skin and leads to a decrease in the level of 25-end serum in the blood serum. Such a situation was previously observed mainly in children and essentially was synonymous with Rakhita. Currently in most industrial countries in the world due to artificial enrichment of products baby food Vitamin D deficiency / non-fast accuracy of the latter is relatively rarely observed in children. However, due to the demographic situation changed in the second half of the twentieth century, such a deficit often occurs in elderly people, especially those living in countries and in areas with low natural insolation, having an infant or unbalanced food diet and insufficient motor activity. It is shown that people at the age of 65 and older observes a 4-fold reduction in the ability to form vitamin D to the skin. Due to the fact that the 25thD is a substrate for the enzyme 1A-hydroxylase, and its transformation rate into active metabolitis is proportional to the level of serum substrate, the decrease in this indicator below 30 ng / ml violates the formation of adequate amounts 1a, 25 (O) 2 D3. It was this level of reduction in the 2nd of the serum in serum that was revealed in 36% of men and 47% of the elderly women as a result of the study (Euronut Seneca Program), conducted in 11 countries in Western Europe. And although the lower limit of the concentration of the 25-end serum in the blood serum required to maintain the normal level of formation 1a, 25 (O) 2 D3 is not known, apparently, its threshold values \u200b\u200brange from 12 to 15 ng / ml (30-35 nmol / l) .
The deficit of the 25thD is considered in close connection with impaired kidney and age functions, including the number of years leaving after the onset of menopause. At the same time, both geographic and age differences in the level of this indicator and its time dependence, i.e. From the level of solar insolation / number of sunny days, which must be taken into account when conducting relevant research and analysis of the data obtained.
The deficiency of 25-end was also detected in Malabsorption syndrome, Crohn's disease, states after subtotal gastrectomy or bypass operations on the intestines, insufficient secretion of pancreatic juice, liver cirrhosis, congenital atresia of bile duct, long-term use of anticonvulsant (anti-epileptic) drugs, nephrosis.
Another type of vitamin D deficiency is not always determined by the decrease in the production of D-hormone in the kidneys (while the type of deficiency can be observed both normal and even slightly elevated level of D-hormone in blood serum), but is characterized by a decrease in its reception in tissues (resistance to resistance Hormon), which is considered as a function of age. Nevertheless, the reduction in the level of 1a, 25 (OH) 2 D3 in plasma in aging, especially in the age group over 65, many authors are celebrated. Reducing renal products 1A, 25 (OH) 2 D3 is often observed at OP, kidney diseases (renal failure, etc.), in the elderly (\u003e 65 years), with a shortage of sex hormones, hypophosphatemic osteomalysis of tumor genesis, PTH deficient hypoparathyroidism , PTH-resistant hypoparathyroidism, diabetes, under the influence of glucocorticosteroids and others. Development of resistance to 1a, 25 (OH) 2 D3 is due to a decrease in the number of PBDs in target tissues (primarily in the intestine and kidneys). In addition, a decrease in the expression of PBDs in arbitrary muscles in the elderly was found. Both variants of vitamin D deficiency are essential units of the pathogenesis of the main types and the forms of the OP.
The most significant role of the violation of the formation and reception of the D-hormone is played with the main involutional form of the OP - Senylov OP. This type of OP in the elderly patients of both sexes is characterized by the RA-go-biting of the initially related processes of remodeling (reducing the formation of a new bone against the background of increasing its resorption). Among the pathogenetic mechanisms of the specified state, along with a decrease in the products of sex hormones (estrogen and testosterone), the so-called somatopause (deficit of the production of growth hormone and insulin-like growth factor, the IPFR), the primary and secondary deficiencies of the D-hormone, due to a number of reasons, are important . Among them, a decrease in the motor aktivity of the elderly and their stay in the sun, a decrease in the formation of D-hormone in the kidneys and bones due to the reduction of 1a-hydroxylase activity (at the age of 70, this decrease reaches 50%), reduction in organs -In the number of RVDs and their affinity for liganda. These changes lead to a reduction in the absorption of CA2 + in the intestines and increase its flushing from the bones to maintain the stability of the blood plasma concentration, which is implemented by the development of secondary hyperparathyroidism, enhancing the PTH synthesis and caused by the activation of the resorption process and OP. In addition, the D-hormone deficiency leads to a limitation of the synthesis of proteins of the bone matrix due to the decrease in the formation, differentiation and activity of osteoblasts, the synthesis of these cells of cytokines involved in the conjugation and intensity of remodeling processes, which has an adverse effect on the mass and the quality of the bone. It should be noted that the reduction of D-hormone products leads to a violation of the normal functioning of the neuromuscular apparatus, since Conducting nerve pulses with motor nerves on cross-striped muscles and the shortage of the latter are sa-dependent processes. In this regard, the deficiency / deficiency of vitamin D contributes to violations of motor activity in elderly patients, disorders of coordination of movements and, as a result, increases the risk of falls with which most cases of fractures are associated with sedenie.
The problem of falls
and vitamin D deficiency
According to modern ideas, one of the important and common causes of sarkopenia in a geriatric population is a shortage of vitamin D, accompanied by muscle weakness. The development of vitamin D deficiency in old age is connected mainly with the following reasons:
- Unbalanced nutrition and use in food products with insufficient content of vitamin D,
- rare and short stay in the sun,
- skin sinking (reducing the thickness of the dermal layer - the place of formation of vitamin D),
- violation of the processes of hydroxylation of the progestomonal forms of vitamin D in the liver and kidneys,
- Violation of the reception 1.25 (OH) 2D3 in tissues.
The widespread distribution of D-deficit in the Elderly, in particular, the results of the study of 824 persons aged 70 years and older, conducted in 11 countries of Western Europe: in 36% of men and 47% of women in winter time concentration 25 (OH) D3 in serum was<30 нмол/л. Важно отметить и то, что количество рецепторов к витамину D (РВD) в ядрах мышечных клеток с возрастом резко снижается. В частности, при иммуногистологическом исследовании биопсийных образцов m. gluteus medius, полученных от женщин (n=20, ср. возраст 71,6 года) при проведении хи-рур-гических операций тотальной артропластики шейки бедренной кости, и биоптатов m. transversospinalis от 12 женщин (ср. возраст 55,2 лет) при проведении операций на позвоночнике было выявлено прогрессирующее в возрастом снижение числа РВD в обеих исследованных мышцах (r=0,5, p=0,004, рис. 2). При этом не было обнаружено сильной корреляционной связи между экспрессией РВD и уровнями 25ОНD и 1,25(ОН)2D3 в сыворотке крови. В то же время мультивариантный анализ результатов исследования позволил авторам сделать вывод о том, что пожилой возраст является важным предсказательным фактором корреляции между снижением числа РВD и уровнем 25(ОН)D3.
Undoubted practical interest is the data on high correlations between the level of D-hormone in the serum and creatinine clearance. Muscular weakness associated with vitamin D deficiency is usually manifested mainly in the groups of proximal muscles and is accompanied by a feeling of gravity or pains in the legs, fast fatigue, difficulties when lifting the stairs and getting up from the chair. In this case, the changes affect mainly the muscle groups of the lower limbs responsible for the vertical position of the body and walking. These violations that reach the level of distinct myopathy can be partially eliminated during nutritionalization of nutrition, in the sun and receiving vitamin D drugs.
Along with the genomic and neglect mechanisms regulating the intake of CA2 + ions in the skeletal muscle and necessary for the implementation of its abbreviations, the genetic mechanisms, dependent on the RVD genotype, make a noticeable contribution to the implementation of the effects of 1.25 (OH) 2D3. In particular, in the study of older twin women, 2 homozygous types discovered differences in 23% in the strength of the teddy muscle and 7% of the grip of the hands of hands. There are other studies indicating the relationship between the PPF polymorphism and the state of arbitrary muscles.
Accordingly, with a shortage of vitamin D, there is a decrease in muscle strength, the ability to extend the lower extremities in the knee joint, the distance and walking speed.
Despite numerous studies on this issue, made with different depths and with the participation of significant groups of elderly, final clarity regarding the drug prevention and treatment of muscle disorders caused by vitamin D deficiency until there is no. In some cases, positive results were obtained using native vitamin D preparations that appear in reducing cases of drops and related fractures. There are observations that the use of native vitamin D drugs is not accompanied by a reliable influence on the state of the muscular system and does not prevent fall in the elderly. At the same time, in a placebo-controlled study with the participation of 378 older men and women, it was found that the daily reception of the D-hormone analogue is an alphacidol preparation at a dose of 1 μg / day. For 36 weeks, it leads to a reliable reduction in both the number of falls and the number of patients who have observed. Apparently, such inhomogeneous results reflect differences in research methods, the number of patients included in them, the effect of season time, etc. More homogeneous positive results were obtained in studies using drugs of active metabolites Vitamin D. However, there are insufficient effectiveness among them. Therapy.
Nevertheless, among these studies, there are those that can be considered as very serious, giving the highest possible objectification of the results. These primarily refers to the Stop / IT study (SITES Testing Osteoporosis Prevention and Intervention Treatments), conducted on the basis of the Craletonian Me-Di Qing University (Omaha, USA), in which 489 women with postmenopausal OP participated. In this double-blind randomized by a placebo-controlled study, three methods of pharmacotherapy were compared: (1) replacement hormone therapy of conjugated estrogens in combination with a medroxyprogesterone acetate, (2) use of active vitamin D-D-hormone metabolite (calcitriol) and (3) combination of both types Pharmacotherapy.
During the first phase of the study, 8,000 women aged 67-77 years were examined (CP. 71 years), of which 489 were randomized included in three groups. In accordance with the criteria for the inclusion of the patient did not have severe concomitant diseases. The treatment period was 3 years. To estimate the duration of the effect within the second phase of the study, the patients were re-examined 2 years after the cessation of pharmacotherapy. The study protocol provided for assessing the frequency of new fractures with the help of an X-ray method. During the study, the patient was obtained with 700 mg of calcium per day; Additionally, calcium preparations were not assigned.
In the process of treatment, an increase in the IPT in both groups of patients received by the UGT was noted. In a group received by Calcitriol, an increase in this indicator was also observed, and, however, to a lesser extent, than in the group of combination therapy (HRT + Calcitriol). In the placebo group, there was a decrease in the IPT in comparison with the initial level.
As a result of the conducted studies, it was found that in the group of patients received by calcitriol, the frequency of new fractures was 2 times lower than in groups of the UGT and placebo. The effect of combined pharmacotherapy on the frequency of fractures did not exceed the similar effect of monotherapy with calcitriol. Urgen-non-NEV did not led to a decrease in the frequency of new fractures, despite the significant, compared with the Calcitrile group, the increase in CCT. From these results, the authors were made by two very important and interconnected conclusions: 1) the use of calcitriol significantly reduces the frequency of new fractures; 2) To prevent fractures, improving the quality of bone tissue is greater than the increase in the PCT.
Another Stop / IT study aspect is important in the context of this section associated with the influence of various types of pharmacotherapy on the frequency of falls with which most fractures are associated in old age. As it was found, the initial fall was common in all groups of patients: at least 50% of patients included in it have fallen at least once in 3 years. When analyzing the data, it was found that in groups of obtaining UGT and placebo, the frequency of the falls was the same, whereas in the group received by calcitriol, this indicator was statistically reliably lower. Compared to the placebo group, the frequency of falls in patients received by calcitriol was 15% lower, and in terms of 1 person - by 30% lower. This result was unexpected, first of all because the patients did not have a serious vitamin D deficiency: the level of 25-year serum was an average of about 30 ng / ml (75 nmol / l).
Thus, this study showed that the decrease in the frequency of fractures is a consequence of the use of calcitriol, which not only has a positive effect on the quality of the bone, but also reduces the frequency of fractures. At the same time, the authors of the study concluded that this drug of active metabolite of vitamin D in elderly patients with postmenopausal OP increases muscle strength, improves neuro-muscular coordination and the balance of functioning of flexors-extensors, imaging, applying Mu, not only directly on the skeletal muscles, but also probably on the central mechanisms of motor functions, because PBD was found in the CNS. It was also done, in addition, having a fundamental importance of the conclusion, which is currently divided by leading specialists in OP, that pharmacotherapy, directed only to an increase in ICT, does not reduce the risk of peripheral fractures, since it does not reduce the frequency of drops.
Combusizing data on the positive effect of another drug from the group of active metabolite vitamin D - alfakalcidol on the state of arbitrary muscles and the frequency of the falls were obtained in a double-blind placebo-controlled study in patients of both sexes (age 65 years and older) with reduced clearance of creatinine. It was shown that the use of the drug in a daily dose of 1 μg for 36 weeks is accompanied by a decrease in the risk of drops by 71% compared with the placebo group (P \u003d 0.019) (Fig. 3). At the same time, not only the frequency of falls, but also the number of patients who have been observed before the study began noticeably. The obtained data on the prevention of falls when using alphaqylcidol - the drug has been widely used in our country (Alpha-D3-Teva®) for the treatment of all types and forms of osteoporosis and some other calcium-dependent diseases, significantly complements its characterization and creates prerequisites To expand the testimony to use.
Failure prevention is a new aspect in the treatment strategy of OP, aimed at preventing peripheral fractures. On high interest in studying the problem of falls in general, the disclosure of their mechanisms and the development of preventive measures was stated by the National Institute of Health of the United States.
When discussing the relationship between this problem and vitamin D, in conclusion, it is necessary to once again notice a few points. First, it became apparent that the already moderate deficiency of vitamin D is accompanied by negative consequences not only in the bone system, but also in the functioning of arbitrary muscles. Secondly, in the elderly, the specified deficit is as a factor / link of pathogenesis of OP, and predisposes to impaired motor function and increases the risk of falling - the immediate cause of fractures. Thirdly, due to the above decrease in the number of PBDs and the reception 1.25 (O) 2D3 in the elder age for the treatment of OP and the prevention of fractures, it is necessary to use preparations of active metabolites of vitamin D (calcitriol, alpha cellsidol).
It is known that the appointment of drugs of biologically inactive native vitamin D does not reduce the frequency of falls, since the ability of the body to form a D-hormone decreases in the elderly (1,25 (O) 2D3) in the kidneys. In the studies of Chapuy et al. (1997), Pfeiffer et al. (2002), BISCHOFF ET AL. (2003) It was shown that the appointment of native vitamin D drugs with patients with a level of 2,2d in serum below 10 ng / ml can noticeably increase this indicator, but not level 1.25 (O) 2D3. In particular, in the work of Bischoff et al. (2003) The use of cholecalciferol in a daily dose of 800 IU for 12 weeks was accompanied by an increase in the average values \u200b\u200bof the 2nd 2D in series of blood by 71%, while the concentration of 1.25 (it) 2D3 increased by only 8%. The analysis of these data indicates the need for use in order to prevent the falls of the drugs of active metabolite vitamin D (alpha D3-TEV), which do not need (in contrast to the drugs of native vitamin D) in biotransformation in the kidneys for the formation of a biologically active form - D-hormone.
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