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The American Geriatrics Society and the British Geriatric Society have issued updated guidelines for preventing falls in older people. It is the first such update in over 10 years.

“There is always evidence that is coming out and in area like falling, we are learning more about it every day,” says Mary Tinetti, MD, a professor of medicine at Yale University School of Medicine, New Have, Ct., and a co-chair of the panel that came up with the guidelines. “We want to make sure the guidelines are as timely and accurate as possible.”

While the guidelines, which appear in the January 2011 issue of the Journal of the American Geriatrics Society, target older patients, they apply to patients of any age with rheumatic disease involving gait.

“It relates to all of our patients who have lower extremity disorders,” says Nortin M. Hadler, MD, attending rheumatologist at UNC Hospitals and professor of medicine and microbiology/immunology at University of North Carolina at Chapel Hill.

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“Gait is quite remarkable. It’s a highly integrated biological function that requires heel strike and push off of toes, knees that are supple and hips with reasonable range of motion, “says Dr. Hadler. “All of these things we take for granted, but if anyone has any impairment, they don’t take it for granted.” Dr. Hadler notes that patients with rheumatic disease also fall “less well” because they are less able to brace themselves when they do fall.

The new guidelines call for a complete risk assessment for patients who simply report difficulties with gait or balance in addition to those who have a history of falling. The assessment should include evaluation for muscle weakness, balance problems, orthostatic hypotension (a fall in blood pressure when a person stands up from a sitting or lying down position), as well as an examination of the feet and footwear, and an evaluation of both daily living skills and the use of adaptive equipment and mobility aids. Health care professionals should also ask patients about the fear of falling.“Falls are a very serious problem and they often have a complex set of causes that can be a challenge to sort out. One of those things is that we are fearful,” says Sharon Brangman, MD, president of the American Geriatric Society. “Patients can be so fearful that it limits mobility, which sets up a vicious cycle: We are fearful, so we restrict our activities, and our muscles get weaker and so we are more likely to fall.” “The main thing is that these guidelines were developed by a panel of experts who scoured the literature and scientific information to find guidelines based in science,” says Dr. Brangman. “We knew things anecdotally, but these guidelines have evidence behind them.”Within the new guidelines are recommendations for intervention that include:

an exercise component that combines balance and strength training, such as tai chi or physical therapy.

cataract surgery when needed (but only in conjunction with other interventions).

medication reduction or withdrawal, especially drugs that affect the central nervous system, such as sleep medications and antidepressants.

appropriate management of heart rate and rhythm abnormalities, and orthostatic hypotension.

a daily 800 IU vitamin D supplement.

“The new guidelines are not all doctor-oriented,” says Dr. Brangman. “They have practical pieces that people can carry out on own: finding safer shoes, removing clutter in your home, clearing off stairs and installing handrails in bathrooms and on steps.”

But the interventions must be followed. “It really made a difference in how carefully all the interventions were carried out,” says Dr. Tinetti. “It’s important not just to say that something needed to be done, but to do it.”

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Pain Management: Treating Mind and Body

Scheman stresses the importance of approaching pain both physically and emotionally and addressing "people as entire human beings.” So while chronic pain medication can be effective and important for pain management for many people, it isn't the only tool available when it comes to pain treatment, and it shouldn't be the only tool that's used.

Medications. "There are a lot of medications that are prescribed for pain," says Scheman, although she notes that opioids (narcotics) and benzodiazepines may not be the best options. Those treatments "have their own problems, and there are no good studies on using opioids for long periods of time for the treatment of chronic pain."

Types of chronic pain medication used include:

NSAIDs (non-steroidal anti-inflammatory drugs), including ibuprofen, naproxen, and aspirin
Acetaminophen (Tylenol)
Antidepressants, which can improve sleep and alleviate pain
Anti-seizure medications, which can be effective in treating pain related to nerve damage or injury
Steroids, like dexamethasone and prednisone, to alleviate inflammation and pain
Therapy. Therapy can be aimed at both the mind and the body. Says Scheman, "I try to look at any of these therapies as not being purely physical or purely psychological — we are always a mixture of both of those things."

Physical therapy is a very important part of any pain management program. Pain can be worsened by exercise that isn't done correctly (or interpreted incorrectly as pain rather than overuse), and a physical therapist can tailor the right exercise regimen for you. Proper exercise slowly builds your tolerance and reduces your pain — you won’t end up overdoing it and giving up because it hurts.
Cognitive-behavioral therapy allows people to "learn and have a better understanding of what the pain is from, and what they can do about it," says Scheman. This therapy is really about understanding the role of pain in your life and what it actually means for you, add Scheman.
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Anti-inflammatory medications
Non-steroidal anti-inflammatory drugs (NSAIDs) can be taken to alleviate the pain caused by inflammation.
They counteract an enzyme that contributes to inflammation. This either prevents or reduces pain.
Examples of NSAIDs include naproxen, ibuprofen, and aspirin, which are available to purchase online.

Avoid the long-term use of NSAIDs unless advised by a doctor. They increase a person's risk of stomach ulcers, which can result in severe, life-threatening bleeding.
NSAIDs may also worsen asthma symptoms, cause kidney damage, and increase the risk of having a stroke or heart attack.
Acetaminophen, such as paracetamol or Tylenol, can reduce pain without affecting the inflammation. They may be ideal for those wishing to treat just the pain while allowing the healing factor of the inflammation to run its course.
Corticosteroids
Corticosteroids, such as cortisol, are a class of steroid hormones that prevent a number of mechanisms involved in inflammation.
There are two sets of corticosteroids:
Glucocorticoids: These are prescribed for a range of conditions, including:
Arthritis, temporal arteritis, dermatitis, inflammatory bowel disease (IBS), systemic lupus, hepatitis, asthma, allergic reactions, sarcoidosis
Creams and ointments may be prescribed for inflammation of the skin, eyes, lungs, bowels, and nose.
Mineralocorticoids: These are used to treat cerebral salt wasting, and to replace important hormones for patients with adrenal insufficiency.
The side effects of corticosteroids are more likely if taken by mouth. Taking them with inhalers or injections can reduce the risk.
Inhaled medications, such as those used long-term to treat asthma, raise the risk of developing oral thrush. Rinsing the mouth out with water after each use can help prevent oral thrush.
Glucocorticoids can also cause Cushing's syndrome, while mineralocorticoids can cause high blood pressure, low blood potassium levels, connective tissue weakness, and problems with the levels of acids and alkalis in body tissue.