PREVENIR LAS CAÍDAS

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La caídas y sus consecuencias, la prevención debe ser uno de los objetivos prioritarios para tener en cuenta en personas mayores.

ANTECEDENTES

En 45 años el número de habitantes del planeta con 65 años o más pasará de 184 a 678 millones. América Latina en 1980 tenía 23.3 millones (6.4%) de personas de 60 años y más, para el 2000 se estimó en 41 millones (7.2%) y para el 2025 se estima en 93.3 millones (10.8%) aunque actualmente la población de más de 60 años supera el 10 % en 4 países de América Latina (Uruguay, Argentina, Barbados y Cuba).
Según las previsiones de la Organización de Naciones Unidas, para el año 2050 el 30% de los habitantes del planeta serán personas de edad avanzada, de nueve mil cuatrocientos a diez mil millones de personas se estiman que habiten el mundo para el año 2050. Faltan 37 años solamente, para entonces yo tendría alrededor de 100 años de edad, es obvio que ya no existiré, pero ¿mis hijos, mis nietos? ¿Qué les tocará vivir?

Por ser los accidentes y específicamente las caídas, una problemática que va en aumento con repercusión directa en la morbilidad y mortalidad de las personas mayores de 60 años, el objetivo de prevención médica y evitar en la medida de lo posible las caídas debe tener un instrumento de trabajo que permita conocer los factores de riesgos fundamentales de las mismas, para accionar en su prevención, y con vistas a esto elaborar estrategias de trabajo para la prolongación de la vida con calidad evitando que el adulto mayor se convierta en una carga familiar y económica tanto para el mismo como para la sociedad.

Los organismos de salud deben tener sus parámetros para calificar esta problemática que se avecina a pasos acelerados.

El proceso de envejecimiento conlleva a la disminución paulatina de innumerables funciones vitales, específicamente funciones motoras, sensoriales y de autorregulación cuya alteración hace que las personas de edad avanzada, tengan un mayor riesgo de sufrir accidentes como consecuencia de su capacidad disminuida de reacción, cuando fuerzas externas o su propio peso los lleva a perder el equilibrio.

Según la Organización Mundial de la Salud, una caída es “la consecuencia de cualquier acontecimiento que precipita al paciente al suelo en contra de su voluntad. Es el desplazamiento del cuerpo en forma inadvertida y súbita hacia un plano inferior con relación a la presencia de uno o varios factores, con o sin pérdida del estado de conciencia o lesión”.

Una tercera parte de las personas mayores de 65 años que viven en la comunidad se caen por lo menos una vez al año, siendo más frecuente en mujeres y personas institucionalizadas por lo que constituyen los accidentes más frecuentes en las personas mayores y en muchos casos los accidentes son fatales o, cuando menos, muy incapacitantes. La incidencia anual de caídas entre personas ancianas que viven en la comunidad aumenta del 25% entre los 65-70 años, al 35% después de los 75. La mitad de las personas mayores que se caen lo hacen repetidas veces y son más frecuentes en hogares de ancianos y residencias. Las mujeres parecen sufrir más caídas que los hombres hasta los 75 años, a partir de esta edad la frecuencia es similar en ambos sexos. La caídas provocan lesiones importantes y fracturas que en los pacientes de edad geriátrica con llevan a una larga y difícil rehabilitación, pudiendo llegar a ser en ocasiones fatales; además traen consigo, por leves que sean, factores físicos o psicológicos, pérdida de la movilidad y para las personas ancianas, esto es tan precioso como la vida misma.

La problemática que tienen las caídas accidentales es su nombre, que por su significado habitual se entiende como un suceso casual, fortuito debido a la suerte. No obstante, cuando se tiene en cuenta que pueden ocurrir, pueden evitarse o al menos disminuir la gravedad de sus consecuencias (invalidez, incapacidad y otras).

Las consecuencias que pueden traer las caídas es un problema frecuentemente ignorado por los pacientes, la familia y los mismos médicos, por lo que es muy importante preguntarlo en forma directa, sin embargo cuando el paciente o la familia lo mencionan se describe como caídas accidentales, desmayos, pérdidas repentinas del estado de conciencia o como pérdida súbita de la fuerza en las piernas, h ay que tener en cuenta que muchos pacientes ocultan las caídas para evitar ser restringidos en su vida cotidiana.
Los servicios de salud de muchos países están preocupados por este problema cada vez más creciente. La edad, es el factor más importante para sufrir caídas y la pérdida de la fuerza para mantener el equilibrio es su principal causa. La reeducación de la marcha, el fortalecimiento muscular, la vitamina D han sido considerados como elementos que pueden disminuir las caídas.

CAÍDAS

Las caídas pueden ser el antecedente de otro tipo de enfermedades que pudieran no haberse detectado en ese momento, como enfermedades en general, mareo y vértigo, hipotensión, alteración en la marcha, alteraciones de la vista o la audición y esto unado a las caídas pueden llevar a un deterioro mayor.
Las personas que se han caído tienen más riesgo de hacerlo varias veces, las mujeres llegan a caerse hasta cuatro veces más al año y esto puede provocar que tengan que hospitalizarse debido a las lesiones que provacan una caída, como la fractura de cadera (que en un 90% son quirúrgicas) y llega a causar fallecimiento de una de cada tres pacientes post/operadas dentro del año posterior; de las dos pacientes que llegan a sobrevivir una tiene que ingresar a una residencia para atención de pacientes de la tercera edad, la otra tiene que estar al cuidado de un familiar en forma cercana; además de que se disminuye su movilidad e independencia y el riesgo de sufrir una muerte prematura se presenta con mayor frecuencia. Mucho se ha escrito en relación a que las caídas están asociadas a fracturas de cadera. Algunos autores consideran que la persona se cae debido a una fractura que se produce antes y que conduce a una caída y, otros apuntan, a que la fractura es consecuencia del percance.

CORREGIR FACTORES DE RIESGO

Las caídas pueden corresponder a una manifestación atípica, a veces, de una enfermedad aguda o la exacerbación de una enfermedad crónica.
Aproximadamente el 10% de las mismas en adultos mayores es atribuible a enfermedades agudas y son las que se definen como caída centinela.
Ciertas enfermedades crónicas que cursan con limitaciones funcionales de los órganos y sistemas implicados en el equilibrio se asocian a un mayor riesgo de caídas .
También determinados síndromes geriátricos (deterioro cognitivo, incontinencia urinaria, polifarmacia) favorecen las caídas en este grupo de edades.
Patología cardiovascular: Trastornos del ritmo, lesiones valvulares, hipotensión fotostática, cardiopatía isquémica, hipotensión postprandial, insuficiencia cardiaca
Patología neurológica/psiquiátrica: Accidente cerebrovascular, enfermedad de Parkinson, hidrocefalia, extrapiramidalismo,
crisis epilépticas, tumores intracraneanos,
deterioro cognitivo, depresión, ansiedad.
Patología sistémica: Trastornos endocrino/metabólicos, trastornos hematológicos, infecciones
Patología del aparato locomotor: enfermedad inflamatoria (artritis reumatoide, espondilitis), artrosis, osteoporosis, trastornos de miembros pélvicos.
Patología sensorial: engloba toda patología ocular, propioceptiva y del equilibrio.
Fármacos que se asocian a caídas: Antihipertensivos, calcio antagonistas, beta bloqueadores, IECA, Los antagonistas de los receptores AT1 de la angiotensina II, diuréticos. Psicotrópicos, neurolépticos, antidepresivos.

Antibióticos, aminoglucósidos, tetraciclina, macrólidos, glucopéptidos, anfotericina B-
Tóxicos cerebelosos, alcohol, fenitoína
Otros: Ácido acetilsalicílico, antiinflamatorios no esteroideos, metales pesados.

FACTORES AMBIENTALES

En el hogar: Suelos: irregulares, deslizantes, con desniveles, contrastes de colores, alfombras, cables sueltos, juguetes, iluminación insuficiente o muy brillantes.

Escaleras con iluminación inadecuada, ausencia de pasamanos, escalones irregulares, desnivelados, muy altos o muy bajos. Cocina con muebles situados a una altura incorrecta, suelos resbaladizos, con escaleras.
Baño: tinas, ausencia de barras en la ducha, ausencia de suelos antideslizantes, artefactos a alturas inadecuadas, tazas de excusado o muy altas o muy bajas. Dormitorio: camas altas y estrechas, cables sueltos, muebles inestables, alfombras o tapetes no fijos, objeto tirados en el piso.
En la vía pública: pavimento defectuoso, mal conservado, situación que es terrible en cualquier ciudad, por falta de mantenimiento y que hace que las personas, mejor caminen bajo de la banqueta. Semáforos de corta duración, bancos de jardines y plazas de alturas inadecuadas. Aceras estrechas, con desniveles y obstáculos sobre todo del comercio ambulante y fuera de la ley.

En los medios de transporte:Escalones inadecuados en ómnibus, transporte colectivo deteriorado y sin facilidades para personas mayores, movimientos bruscos del vehículo y sobre todo choferes irresponsables y faltos de sensibilidad humana (son una raza aparte).
Así, evitando o corrigiendo estos factores de riesgo es posible evitar caídas, lo que exige identificarlos muy bien para poder contrarrestarlos adecuadamente.

En el entorno de personas con riesgo alto se colocan contenciones, como barandas en camas y baños, para minimizar el riesgo de caídas. Además, se debe evitar suelos resbaladizos, alfombras y cualquier obstáculo con el que se pueda tropezar. También hay que asegurarse de que utilicen un calzado cómodo y adecuado. Cuando el origen del problema es la visión, hay que acudir al oftalmólogo; si está tomando antidepresivos, debe acudir a su médico ya que, aunque sea imposible retirarlos, quizás se pueda ajustar la dosis o cambiar la pauta; y para prevenir la osteoporosis, es preciso seguir una alimentación sana y tomar suplementos de calcio cuando el médico lo considere oportuno.

En el caso de personas sanas que practican actividad física de forma regular, es importante no perder este hábito porque mejora la flexibilidad y capacidad de reacción, el equilibrio y, con ello, se previene el riesgo de caídas y fracturas. El ejercicio y alimentación con hábitos saludables, son pilares para envejecer saludablemente y evitar episodios como las caídas. Por más que se intente prevenir o eliminar el riesgo de caídas es muy difícil, aunque es posible disminuirlo.

RECOMENDACIONES

Las recomendaciones de la USPSTF (United States Preventive Services Task Force) Grupo de trabajo de los servicios preventivos de los E.U., son una actualización de las guías de 1996. Desde entonces, se realizó una gran cantidad de estudios sobre qué deberían hacer los adultos mayores para prevenir las caídas y qué sería lo más efectivo.

Este trabajo publicado en mayo del 2012, señala que la USPSTF recomienda el ejercicio o la terapia física y los suplementos de vitamina D para prevenir las caídas en adultos residentes en la comunidad de 65 años o más que tienen un mayor riesgo de caídas.

Consideran que el consumo de vitamina D, el ejercicio y la fisioterapia son moderadamente efectivas al reducir el riesgo un 13 a un 17 por ciento. Eso se traduce en que cada año tendrían una caída 26 de cada 100 adultos mayores en lugar de 30 de cada 100. Al revisar las pruebas sobre la vitamina D, la USPSTF halló que 10 adultos mayores tendrían que tomar suplementos para evitar que uno se caiga. Se indicó que la dosis habitual es de 800 unidades internacionales (UI) por día y que los estudios sugieren tomar vitamina D durante un año para notar los beneficios.

En una conclusión que se desprende de una revisión que acaba de publicar la editorial “Biblioteca Cochrane”, cuyos autores han analizado 111 investigaciones previas; lo que ha supuesto examinar a más de 55.000 sujetos de edad avanzada. Llegan a concluir que: ni los suplementos de vitamina D para mejorar la absorción del calcio y fortalecer los huesos y la musculatura, ni proveer el hogar de dispositivos para aumentar la seguridad doméstica (barandas, rampas, superficies almohadilladas, entre otros) han demostrado tantas ventajas para evitar las caídas de las personas mayores como el ejercicio. Las ventajas del ejercicio son muchas.

En relación a la prevención de caídas, se basan en el incremento de la fuerza, la resistencia, la flexibilidad y, sobre todo, el equilibrio del paciente, que no solo se desenvuelve con mayor soltura, sino que también reacciona mejor ante una eventualidad que pueda precipitarle contra el suelo (tropiezos, resbalones, presencia de obstáculos, etc.).

Por su parte, la vitamina D sólo demostró ser eficaz en sujetos que tenían serias carencias de este micronutriente; aunque sabemos que en México existe una deficiencia endémica de vitamina D, se tendrían que realizar estudios de laboratorio a toda la población mayor de 60 años que en estos momentos es de aproximadamente de cinco millones de personas. ¿Habrá presupuesto para esto? Obviamente que no. Y que otros métodos para incrementar la seguridad doméstica únicamente sirvieron a los individuos con discapacidades importantes.

La fisioterapia, aunque todavía no se haya podido validar al 100%, parece ser eficaz para mantener o mejorar el equilibrio. Se comenta que son normales las caídas y atribuibles al inevitable proceso de envejecimiento, pero no a la intervención de fisioterapia. Lograr mantener a esta población -que en residencias supera los 70 años- en constante movimiento y con buena fuerza muscular dentro de su disminuida masa magra ya debe considerarse un éxito. En lo sucesivo, nuevos estudios irán precisando y permitirán validar cuál es el papel de la fisioterapia en las personas mayores con riesgo de caídas.

¿QUÉ ES LA ACTIVIDAD FÍSICA?

La actividad física es cualquier movimiento corporal producido por el músculo esquelético y que resulta en un incremento sustancial del gasto energético. Tiene tres componentes:

  • El trabajo ocupacional: todas las actividades que se realizan para desempeñar un trabajo.
  • Las labores domésticas y otras tareas que forma parte del día a día.
  • La actividad recreativa: actividades que el individuo elige en su tiempo libre y que generalmente son seleccionadas a partir de necesidades e intereses, lo cual incluye al ejercicio y al deporte.

Es aquí en donde un buen terapista físico tendrá un trabajo enorme para los años que vienen, enseñando y diseñando programas de mantenimiento y mejoramiento de la masa muscular de las personas mayores, que cada día, seremos más.
El 65% del gasto energético total depende de la actividad física y estará determinado por las características de la actividad física que se realice, modalidad, intensidad, duración y frecuencia y de las condiciones físicas de la persona, estructura corporal, costumbres, edad, enfermedades agregadas, condición física, etc.

CONCLUSIÓN FINAL

Como se podrá ver cada grupo de estudiosos o de investigación, da sus puntos de vista en relación a prevenir o no las caídas, en rehabilitar o no a las personas mayores, en los medicamentos necesarios, en las medidas preventivas que debemos tener en el trabajo, la calle, nuestro hogar, etc. Lo que si queda claro al final de los comentarios es: que a medida que avancemos en edad nos caeremos más, que debemos mantener una actividad física más o menos adecuada para que nuestros músculos, huesos, tendones, ligamentos estén en buenas condiciones para soportar nuestro peso y nos podamos mover; y que en la medida de nuestras posiblidades, estemos controlados de las enfermedades crónico degenerativas que nos afectan o nos van a afectar en el futuro.

Tenemos mucho trabajo por hacer ¿estaremos dispuestos a aceptar el reto?

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