Osteoporosis is a disease of the skeleton, leading to bone fractures that can occur even after minor trauma (so-called osteoporotic fractures). They most often affect the spine, forearm, and hip bones, but can also occur elsewhere. results from a decrease in bone mineral density and disturbance of its structure and quality.

Primary and secondary osteoporosis

Primary osteoporosisis the most common consequence of aging of the skeletal system. It develops in postmenopausal women and in elderly men. Loss of bone mineral density is an inevitable age-related process that begins around the age of 40 for women and 45 for men. However, there are many factors that can speed up its course. Some of them can be prevented by lifestyle changes. The development of osteoporosis is accelerated by:

• poor diet (mainly low calcium supply, vitamin D, malnutrition)
• smoking tobacco
• alcohol abuse
• little physical activity
• and insufficient exposure to sunlight.

Less common issecondary osteoporosisas a result of other diseases or the use of certain medications. This form of osteoporosis affects people of all ages. The causes of secondary osteoporosis include hormonal disorders (hyperthyroidism, hyperparathyroidism, diabetes, premature menopause), diseases of the digestive system with malabsorption, and chronic inflammatory rheumatic diseases. Drugs that promote the development of secondary osteoporosis include, i.a. glucocorticoids, anti-epileptics, and heparin.

Dig. 1.The most common osteoporotic fractures and their cause – inferior quality of bone tissue

How common is osteoporosis?

Osteoporosis is an extremely common disease in the elderly. Due to its insidious, often asymptomatic course, it is called a “silent epidemic”. Every third woman after menopause suffers from it. In 50-year-old women, the lifetime risk of bone fracture as a result of osteoporosis is approximately 40%, and in men it is 13–22%.

Osteoporosis and its complications are one of the most common causes of death in developed countries—bone fractures cause many complications such as chronic pain, muscle atrophy, immobilization,bedsores,pulmonary embolism, and an increased incidence of infections. Their treatment usually requires a long stay in the hospital, persistent rehabilitation, and often long-term care from others.

How does osteoporosis manifest?

Osteoporosis initially has no noticeable symptoms. They do not appear until a bone fracture occurs, although even then they may be overlooked or ignored.

Dig. 2.Osteoporotic vertebral fractures lead to reduced height, hunchback and disability

The most common are vertebral fractures, half of which are hidden, gradually leading to a decrease in height, slouching (the so-called widow’s hump), problems with movement and deterioration of mood, and evendepression. As a consequence, it leads to disability and permanent dependence on help from other people.

Fractures of the vertebral bodies often cause chronic back pain syndrome, usually treated as a “normal” symptom of old age and degenerative changes in the spine. As a rule, patients are unable to recall the injury that resulted in a vertebral fracture (it may be caused by a slight movement,coughing, bending down, picking up an object).

Dig. 3.Fracture of the neck of the femur

More rarely, there is a sudden onset of severe pain in the spine– it begins in the area of ​​the fractured vertebra, may be girdling, accompanied by tension in the adjacent muscles; the fractured vertebra may compress the surrounding nerve roots, causing, for example, pain, numbness and lower limb paresis.

Long bone fracturesmost often occur in the fall-winter season, which is associated with an increased number of slips and falls. Typical for osteoporosis is a forearm fracture (in the wrist – when supported by a hand), as well asa femoral neck fracture. These fractures are accompanied by severe pain, limited mobility and distortion of the surrounding tissues. After a fall, the sick person may not be able to get up and call for help, which may lead to many serious complications, and even death.

What to do in the event of osteoporosis symptoms?

Osteoporosis is secretive initially, so you should think about it before you break a bone.People at risk of developing it (postmenopausal women, men over 65 and people with other risk factors for osteoporosis) should see a doctor in order to determine the further procedure.

Rapid diagnosis for osteoporosis is necessary in patients who develop symptomatic osteoporotic fractures or their indirect signs, such as reduced height, permanent slouching or chronic back pain.

Important

If you experience sudden severe pain in the spine,especially if it is accompanied by malaise, weakness or other disturbing symptoms, you should call the ambulance service as soon as possible (999 or 112). Similar ailments can also occur for other life-threatening reasons.

In the event of a fall after which you feel pain in your spine, chest, hip or thigh, you cannot get up or you are in severe pain to get up,call the ambulance service (999 or 112) to take you to the ER – it could be a fracture vertebra or neck of the femur.

If you fall on your hand or forearm, which causes pain in your wrist, forearm, or swelling of these areas,see a GP or emergency room doctor – it may be a fracture of a forearm bone.

Remember the number of the ambulance service: 999 or 112.

How is the diagnosis made by the doctor?

When diagnosing osteoporosis, the doctor takes into account a number of information, especially regarding the risk factors for its development and the history of bone fractures in the past.

On this basis, it determines whether the risk of osteoporotic fractures in a given patient is increased and what treatment to implement.

Methods helpful in diagnosing osteoporosis

FRAX calculator
It allows you to assess a person’s risk of developing an osteoporotic fracture in the next 10 years; is widely available on the Internet, also for the Polish population (see:FRAX calculator). On its basis, patients are distinguished from the group of low, medium or high risk, which allows for quick determination of appropriate management. Special tables are also used to assess the risk of fractures.

Bone densitometry using the DEXA technique(dual energy X-ray absorptiometry).
Evaluates bone mineral density; used in the diagnosis of osteoporosis and in the assessment of the effectiveness of the drugs used. This examination should not be the only decisive factor in initiating treatment, as it does not sufficiently determine the risk of osteoporotic fractures – in many people at risk of fracture (who should be treated), bone mineral density is normal or only slightly decreased. This is because other factors also affect a bone’s susceptibility to fracture.

Radiological examination
It is performed in the case of suspected bone fracture, used to determine the nature of the fracture, e.g. before orthopedic supplies.

Other imaging tests,
such ascomputed tomographyor magnetic resonance imaging, are not needed to diagnose osteoporosis, but are helpful in special situations, for example before a planned spine surgery.

Laboratory tests
In each patient with osteoporosis, basic laboratory tests (blood counts, kidney and liver function tests) and calcium and phosphate metabolism should be assessed. Blood is taken to determine calcium andphosphoruslevels , urinary calcium excretion is assessed, and in some cases other tests are performed (e.g. parahormone, vitamin D, bone turnover markers).

What are the treatments for osteoporosis?

The goal of treating osteoporosis is to prevent bone fractures and the complications that result from them. The decisive factor in the effective fight against the disease is good cooperation between the patient and the doctor. Realizing the hidden course of the disease (until a bone fracture occurs) should motivate you to modify your lifestyle early enough and use medications on a regular basis. Unfortunately, most medications have to be taken for a long time (usually several years), and the preventive measures should be consistently led to the end of life.

Important

It is worth remembering, however, that thanks to appropriate procedures (see points below) it is possible to effectively prevent bone fractures and maintain the fitness of the locomotor system until an old age.

The elimination of risk factorsis essential for both the prevention and effective treatment of osteoporosis (this is discussed in detail inWhat can I do to avoid osteoporosis?See below).

Supplementation of calcium and vitamin D.Proper intake of calcium and vitamin D is a prerequisite for the effective treatment of osteoporosis. Diet alone is often not enough and it is necessary to use appropriate preparations, most often for the rest of your life. During treatment, the body’s calcium balance should be monitored (blood calcium levels, urinary calcium excretion).

• Calcium.Several preparations are available with different levels of elemental calcium. The greatest amount, 40%, is contained in calcium carbonate preparations. They are taken with meals to improve their absorption. During treatment, side effects from the digestive system (constipationordiarrhea,flatulence) may occur, but with the correct dosage, the risk ofnephrolithiasisdoes not increase .
• Vitamin D.Vitamin D (cholecalciferol) or analogues thereof (egalphacalcidol, calcitriol) are used. The dosage of the drug depends on the season of the year – in the summer, when there is plenty of sunshine (in Poland from mid-June to mid-September), the drug is discontinued or its dose reduced by half. Vitamin D overdose leads to elevated calcium levels, kidney damage and even the life-threatening hypercalcemic syndrome.

See also: Adequate Diet (below).

Medicines to reduce the risk of bone fractures.Several groups of drugs are used to treat osteoporosis. They are characterized by different effects (some reduce bone loss, others increase its reconstruction), as well as different activity depending on gender, age and other factors. It is important to select the drug for a given patient so that the therapy brings the greatest benefit and is the safest. Drugs proven to be effective in preventing fractures should be used. The mere increase in bone mineral density determined in the densitometric test is not always associated with an increase in its mechanical resistance. The treatment period should not exceed the duration of clinical trials in which the efficacy and safety of a given drug was assessed. Medicines with different mechanisms of action may be used sequentially, ie “one by one”.

• Bisphosphonates
  They work by reducing the rate of bone loss (the so-called anti-resorptive effect). Some preparations in this group (alendronate, risedronate, zoledronate) have proven efficacy in reducing the risk of all fractures, including the femoral neck, while ibandronate mainly reduces the risk of vertebral fractures in postmenopausal women and the risk of hip fractures only in a selected group of women with advanced osteoporosis.
  These drugs are usually taken orally once a week (alendronate,risedronate) or once a month (ibandronate). Intravenous administration is possible with ibandronate (once every 3 months) and zoledronate (once a year). When taken orally, it is very important to take the tablets correctly, as they increase their absorption from the gastrointestinal tract and reduce the risk of gastrointestinal side effects: the tablets must be swallowed whole, on an empty stomach, and washed down with plenty of still water; after taking at least 30 minutes (preferably an hour), you must remain sitting or standing.
  The side effects mainly affect the gastrointestinal tract; the most common ones are: abdominal pain, nausea, vomiting, constipation or diarrhea, and flatulence. Occasionally severe complications such as dysphagia, irritation and narrowing of the esophagus occur. In the case of poor tolerance of orally administered drugs, consideration should be given to changing the route of drug administration to intravenous or to administering the drug from a different group. Other less common side effects include bone, muscle and joint pain, decreased blood calcium, and rash. Flu-like symptoms may occur after an infusion in patients treated with intravenous zoledronate.
  Adequate supply of calcium and vitamin D should be ensured during treatment, and calcium balance and bone density should be periodically monitored by densitometry.
• Strontium ranelate
  It combines both mechanisms to improve bone quality: it reduces bone loss and stimulates bone regeneration. Strontium ranelate is administered orally daily, preferably at least two hours before and two hours after a meal. It reduces the risk of vertebral and other bone fractures, including the hip fracture in women (regardless of age, also in women over 80).
  Diarrhea and other symptoms of food intolerance may occur at the beginning of treatment.
• Teriparatide
  It is a recombinant preparation ofparathyroid hormone(a hormone that plays an important role in bone processes). It stimulates bone reconstruction and increases the concentration of calcium in the blood. It is administered subcutaneously daily. The duration of therapy is limited to 18 months due to the potential risk of bonecancer development.After termination of such therapy, it is recommended that treatment with bisphosphonates be continued. Teriparatide has been shown to be effective in preventing fractures of the vertebrae and other bones in both women and men. The preparation is reserved for the treatment of severe forms of osteoporosis with multiple fractures that do not respond to other treatments.
  Side effects such aspain in the extremities may occur during therapy, headache,dizziness, nausea, vomiting, gastroesophageal reflux disease, depression, local injection site reactions, and increases in blooduric acidand calcium.
• Salmoncalcitonin
  It is used intranasally. It is not recommended for the prevention of bone fractures, but is used as a medicine that relieves pain in recent fractures.
• Hormone replacement therapy (HRT)
  is currently not recommended for the prevention and treatment of osteoporosis. Although it reduces the risk of osteoporotic fractures in postmenopausal women, its benefits are less than its possible side effects (HRT increases the risk of thromboembolism, ischemic heart disease, andbreastand uterine cancer).
• Raloxifene
  It belongs to the so-called selective estrogen receptor modulators (SERMs). Unlike hormone replacement therapy, it reduces the risk of breast cancer. Its use in the treatment of osteoporosis in women with risk factors for this cancer may be considered. Raloxifene reduces the number of vertebral fractures but does not affect other bone fractures.
  Side effects include an increased risk of blood clotting complications and an increase in menopausal symptoms (e.g. hot flushes).
• Denosumab
  In recent years, the results of research on a new drug used in the treatment of osteoporosis, with a completely different mechanism of action, have been published. It isdenosumab, a monoclonal antibody belonging to the so-called biological drugs. It has been proven to be effective in preventing fractures of vertebrae and other bones, including the neck of the femur (only women were included in the study). Due to its favorable safety profile and convenient method of administration (it is used in subcutaneous injections once every six months), it may in the future play an important role in the treatment of osteoporosis.

Injury prevention and fall preventionare essential parts of the management of any osteoporosis patient (this is discussed in detail in the last section of this chapter:What to do to avoid osteoporosis?).

Treatment of fractures.After a bone fracture has occurred, it is important to relieve pain and minimize disability that results from it. Depending on the fracture site and the patient’s condition, surgical treatment (e.g. femoral fusion, vertebroplasty) or conservative treatment is used. It is important to prevent complications resulting from immobilization (prevention of thrombotic complications with heparin, prevention and treatment of pressure ulcers and infections, and prevention of malnutrition). At a later stage, appropriate rehabilitation and osteoporosis treatment are necessary to avoid further fractures.

Secondary osteoporosis

Treatment of secondary osteoporosis depends on the underlying cause. In all cases, the underlying disease should be treated as far as possible and general rules of procedure to reduce the risk of fractures should be followed. Some of the most common examples are listed below.

Posteroid osteoporosis.In any case of using glucocorticosteroids in a dose of> 5 mg of prednisone daily for longer than 3 months, calcium and vitamin D supplements should be administered. This treatment is sufficient in the case of a daily dose of <15 mg prednisone. In many cases, especially with long-term treatment and the use of higher doses of glucocorticosteroids, drugs that reduce the risk of bone fractures (e.g. bisphosphonates) should be administered.

Osteoporosis in chronic joint diseases.

• Rheumatoid arthritis.It is important to stop disease activity quickly and effectively (by administering drugs that modify its course), which itself leads to bone destruction. An additional factor contributing to osteoporosis is the frequent use of glucocorticosteroids. Drugs that reduce the risk of bone fractures should be started early.
• Ankylosing spondylitis(AS).For prophylaxis, regular daily physical activity and treatment of the disease itself are important. Bisphosphonates are used in the treatment of osteoporosis, but there are no clear guidelines.
• Systemic lupus erythematosus.Prophylaxis is based on the early and active treatment of the disease with the rarest possible use of glucocorticosteroids. The initiation of appropriate osteoporosis treatment should be considered early.

Primary hyperparathyroidismis one of the few causes of osteoporosis that can be completely cured at an early stage of the disease (surgical removal of the affected parathyroid glands). If contraindications to surgery are found (e.g. older age, mild disease), blood calcium levels should be regularly monitored (at least twice a year) and its excretion in urine, as well as bone density by densitometry (once a year). Patients should drink a lot and avoid immobilization and the use of thiazide diuretics. Factors that increase the risk of fractures should be avoided and the use of bisphosphonates may be considered in patients with low bone mass.

Is it possible to recover completely?

Primary osteoporosis is the result of the aging of the body and therefore it is not possible to cure it completely. However, thanks to the appropriate action, it is possible to stop the course of the disease. Prophylaxis should be started at an early age to achieve the highest possible peak bone density – an adequate supply of calcium and vitamin D and regular physical activity are particularly important. It is estimated that up to half of the later osteoporotic fractures can be prevented in this way.

By making appropriate lifestyle changes in adulthood, bone loss can be reduced by about 1/3. By using drugs to reduce the risk of bone fractures, up to 60% of vertebral fractures and up to 40% of non-vertebral fractures (e.g. wrists, hip fractures) can be prevented.

On the other hand, osteoporotic fractures are associated with high mortality and a deterioration in the quality of life of patients. For example, as a result of a fracture of the neck of the femur, every fifth person dies within a year, while half of them do not regain their fitness before the injury (this fracture affects approx. 12% of older people). On the other hand, after a vertebral fracture, which often goes undiagnosed, every fifth person dies within 5 years.

In the case of secondary osteoporosis, the possibility of inhibition or possible recovery depends on the underlying disease.

What should I do after treatment is finished?

Lifestyle changes to prevent bone fractures should be indefinite. Periodic medical inspection (usually 1-2 times a year) is necessary to assess the effectiveness of the methods used and consider indications for further treatment. Periodic monitoring of calcium and phosphate metabolism may be necessary, and in some patients bone densitometry (depending on individual indications once a year or less). A bone fracture requires urgent contact with a doctor.

What to do to avoid getting osteoporosis?

Prevention of osteoporotic fractures consists in the elimination of risk factors for osteoporosis and the use of an adequate supply of calcium and vitamin D. In the elderly, a very important preventive element is the assessment of the risk of falls and appropriate counteracting them.The most important methods of fighting osteoporosis are discussed below.

Adequate diet

Calcium.It is an essential component of healthy bone, which is why it is so important to provide the body with the right amount. The daily requirement for calcium varies:

• in children up to 10 years of age it is 800 mg
• in adolescents and adults, 1000 mg
• in pregnant women, during breastfeeding and after menopause, and in the elderly – 1500 mg.
  • The best source of calcium is food, unfortunately in the Polish diet its supply is often even half the recommended amount. The greatest amount of calcium is provided by milk and its products, other foods contain too little of it or it is poorly absorbed from the gastrointestinal tract.
    For example,about 1,000 mg of calcium is contained in 3 glasses of milk, 2 glasses of milk and 2 slices of cheese, 3-4 kefirs, 1,000 mg of cottage cheese, and 3 yoghurts. Low-fat foods contain the same amount of calcium as full-fat foods. For those who cannot tolerate milk, lactase-enriched milk or kefirs and yoghurts are recommended.
    Many foods such as breakfast cereals and fruit juices are enriched with calcium. Foods that reduce calcium absorption include spinach and other vegetables containing oxalic acid, cereal grains containing phytic acid such as wheat bran (consumed in large amounts), and possibly tea as well.
    If it is not possible to cover the demand for calcium with diet alone, it is advisable to use calcium supplements.Vitamin D.It is necessary to maintain the proper level of calcium in the body. Its source is food; it is also produced in the skin when exposed to sunlight. In Poland, adequate sun exposure is from mid-June to mid-September, and a sufficient time of staying in the sun is 2–3 times a week for 15 minutes. In the remaining months, you should supplement vitamin D with food – it is recommended to eat a medium portion of fatty fish (eg herring, mackerel, sardines) once a week or take vitamin D supplements. Fish oil, milk, margarine and eggs are also good sources of vitamin D.Phosphorus.Both its insufficient and excessive consumption adversely affect the concentration of calcium in the body.The daily requirement for this element is 700–900 mg; its sources are cheese, meat, fish, bread and eggs.Due to its widespread distribution and easy absorption from the gastrointestinal tract, phosphorus deficiency is rarely found for dietary reasons.Protein.The recommended daily intake of protein is 1-1.5 g / kg bw. Adequate protein intake is essential to maintain the fitness of the locomotor system. Protein deficiency in children leads to calcium absorption disorders, and in the elderly it causes bone loss, reduced muscle strength (which promotes falls), and poor healing of fractures. It should be remembered that too much protein intake also adversely affects the calcium metabolism, increasing its loss in the urine.Coffee.It is believed that consumption of more than 3 cups of coffee a day, especially with insufficient calcium intake, accelerates the development of osteoporosis.Other dietary factors.The deficiency of magnesium, vitamin C and vitamin K as well as an excess of sodium and fluoride also have an unfavorable effect .Stop smokingSmoking accelerates the development of osteoporosis. By increasing the concentration of various toxic substances (e.g. cadmium), it reduces the concentration of calcium and worsens its incorporation into the bone. An earlier menopause is also seen in smoking women. It is recommended to completely stop smoking.Avoiding alcohol abuseExcessive alcohol consumption leads to liver damage, malnutrition, decreased vitamin D and calcium levels, and accelerated bone destruction. It also increases the risk of falls leading to bone fractures. Moderate alcohol consumption in perimenopausal women may have a beneficial effect by increasing the levels of hormones (estrogens, calcitonin) that protect bone tissue.Physical activityBone is a living tissue that adjusts its structure to best meet the daily stresses. Their lack causes its weakness and increased susceptibility to fractures; poor mobility increases the risk of falls. Therefore , it isrecommended to perform moderate physical activity (e.g. walking, swimming) at least 3 times a week for 30 minutes.
    See also:Physical recreation in rheumatic diseasesInjury prevention and fall preventionThey aim to reduce the incidence of injuries that are the direct cause of bone fractures. Assessing the risk of falls and preventing them accordingly is particularly important in the elderly. Consideration should be given to:
    • rehabilitation to improve physical fitness, including balance exercises and fall training
    • improving visual acuity with properly selected glasses
    • elimination of environmental factors: adequate lighting of the rooms, no thresholds, anti-slip tiles, avoiding slippery ground, well-chosen footwear (non-slip sole, stable foot support)
    • if necessary, the use of crutches and walkers; the use of hip protectors may also be considered, although their usefulness seems questionable
    • Consult your doctor about the medications you are taking: in some people, medications can cause a significant drop in blood pressure when standing up from a lying or standing position, dizziness and excessive sleepiness, which increases the risk of falls (especially sleeping pills, sedatives, some medicines used to treathigh blood pressure ) arterial).
    Osteoporosis in questions and answersSpecialists’ answers to frequently asked questions:1. What is Osteoporosis?Osteoporosis is a disease in which bones break. It is common, especially in older people. Its course is insidious – initially it does not give any noticeable symptoms, which is why it is called a “silent epidemic”.2. What is osteoporosis caused?It is an age-related disease. Already after the age of 40, there is a gradual loss of bone tissue. Its development is accelerated by hormonal changes occurring in women during menopause, therefore osteoporosis occurs more often and faster in women.3. Are everyone at the same risk of developing an osteoporotic fracture?Many factors contribute to the development of osteoporosis and the increased risk of bone fractures. Apart from age and gender, the most important of them are:
    • diagnosed osteoporosis or an osteoporotic fracture in the parents
    • frequent falls
    • past bone fracture
    • sex hormone deficiency
      • in women: menopause before the age of 45, removal of the ovaries before the age of 50, menstruation interruptions lasting more than 12 months (except during pregnancy and puerperium)
      • in men: decreased potency
    • low physical activity (less than 30 minutes of physical effort per day)
    • low body weight (BMI <19 kg / m²)
    • growth reduction
    • prolonged immobilization
    • a diet low in calcium and vitamin D.
    • smoking
    • alcohol abuse
    • long-term use of certain medications, e.g. glucocorticosteroids, for more than 3 months
    • other comorbidities, e.g. arthritis, hyperthyroidism, hyperparathyroidism,type 1 diabetes, anorexia, chronic bowel and liver diseases, renal failure.
    4. Does osteoporosis hurt?At first, osteoporosis does not cause any discomfort. They only appear when a bone is broken. For example, half of the people who have vertebral fractures suffer from back pain (in half, the vertebral fracture does not show any noticeable symptoms!). A very painful fracture leading to severe complications, and even death, is a hip fracture.5. Am I at risk of / at risk of osteoporosis?Early diagnosis and effective treatment of osteoporosis are important. If you belong to a group of people who have risk factors for osteoporosis (see sections 2 and 3), see your doctor to assess your risk of bone fractures. There are various simple methods of assessing this risk (appropriate tables, FRAX algorithm).It can be helpful to perform a densitometric test, but it must be remembered that its result does not determine the initiation of treatment.6. How can I protect myself against osteoporosis?Bone aging cannot be fully prevented, but we have an influence on the pace of this process. It is worth starting the fight against osteoporosis as early as possible, preferably in youth.The best way to get strong bones is regular exercise and a proper diet – make sure you get enough calcium and vitamin D. Remember that smoking and alcohol also harm your bones – this is another reason to fight addictions. For other (equally important) bone influencing factors – see question 9.7. Is osteoporosis life-threatening?Osteoporosis is one of the most common causes of death in the world. After fracture of the hip bone, every fifth person dies within a year, and after vertebral fracture, every fifth person in five years. Osteoporosis is also responsible for deteriorating quality of life, disability, and dependence on other people.8. Can osteoporosis be treated effectively?There are several classes of drugs that are effective in reducing the number of osteoporotic fractures. Adequate supply of calcium and vitamin D is also essential.The most important part of treatment is regular medication and lifestyle changes that reduce the risk of fractures (section 9).9. Can young people suffer from osteoporosis?Osteoporosis may develop in young people with other factors that damage bone tissue secondary, most often malabsorption syndromes, chronic inflammatory bowel diseases, systemic connective tissue diseases, chronic use of glucocorticosteroids or antiepileptic drugs. It is important to take early measures to stop the disease and reduce the risk of bone fractures.10. How can falls be avoided?Falls are caused by many factors that can be effectively avoided. For this purpose:
    • keep fit by exercising regularly – pay special attention to exercises in posture, balance and safe falling; it is worth signing up for a properly selected rehabilitation
    • visit an ophthalmologist regularly (at least once a year) to check visual acuity and choose the right glasses
    • if necessary, use a crutch and walkers to maintain a steady gait, wear well-chosen shoes with a flat sole that supports the heel well
    • consult your doctor on the list of medications you take; report dizziness, balance disorders or other disturbing symptoms – very often they are caused by medications (especially sleeping pills, sedatives, some medications used to treat hypertension)
    • pay attention to any obstacles in your environment that may lead to a fall (adequate lighting of the rooms, no thresholds, non-slip tiles and mats, avoiding slippery floors, special handles in the toilet and at the stairs).