Gait disturbances and neurologic disorders such as Parkinson disease can make ambulation difficult.

With aging, persons lose muscle mass and strength, lose joint flexibility, have impaired sensory input (vision, hearing, proprioception), and have slowed cognition and reaction times. Arthritis limits motion, reduces activity, and limits the ability to respond to conditions that might lead to falls. All of these factors make it more difficult to negotiate situations such as going down stairs or ambulating over uneven ground. Hence, older persons are more likely to fall from decreased ability to cope with environment.

Osteoporosis is a major risk for fractures because of the accelerated bone loss, most prominent in postmenopausal women. There is no metabolic abnormality, and the bone is histologically normal, there is just less of it. The classic areas most affected are: hip, wrist, vertebrae.

Osteomalacia is the adult form of vitamin D deficiency. The bone matrix does not become properly calcified, and the bone is weaker. From a clinical standpoint, osteomalacia appears similar to osteoporosis. An elderly person with a history of fracture can be evaluated to determine if a dietary deficiency contributed to the problem.

Bone densitometry aids in determining the extent and rate of bone loss. The procedure uses xrays and the three regions typically assessed are hip, wrist, and vertebrae.

Bedridden state: in older persons, a hip fracture can be very debilitating. Concomitant disease conditions, such as serious heart or lung disease, may make it difficult to choose surgical options for repair of the fracture or joint replacement. With prolonged bedrest, pressure ulcers may develop, particularly over pressure points such as the lower back or feet.

Pneumonia: persons who are not active and not mobile have decreased respirations and are at increased risk for respiratory tract infections. Pneumonia is the most common immediate cause of death in persons who are debilitated for any reason.

Pulmonary embolus: persons who are not active and mobile are more likely to develop deep venous thrombosis. Thrombosis is more likely with aging as well. Deep venous thrombosis can lead to pulmonary embolization.

Urinary incontinence: older persons have decreased bladder capacity, decreased sensation of bladder fullness, and decreased voluntary control over bladder emptying. Disturbances of bowel function including constipation and stool impaction are associated with urinary incontinence. In health care settings, patients often don't have much voluntary control of their activities.

Diet and exercise therapy are useful in at least slowing the rate of bone loss. Exercise helps to strengthen supporting muscles that can reduce the risk of subsequent falls. Biphosphonate therapy can be given to stop the bone loss, and perhaps reverse it somewhat. Biphosphonates such as alendronate inhibit osteoclast action. Raloxifene helps for women, and has an effect on reducing breast cancer as well. Raloxifene is a selective estrogen receptor modulator (SERM). Raloxifene is antiestrogenic in the breast but estrogen-like in the bones and reduces circulating cholesterol levels.

Some physicians (usually surgeons) think surgical repair is almost always indicated, and that not doing it is terrible painful. Other physicians (such as geriatricians) may say that the pain can be treated and the surgery itself is painful and requires rehabilitation, therefor it is not always indicated. What to recommend to an elderly patient should be the result of a good evidenced-based medicine (EBM) study taking into account parameters specific to that patient.

The elderly often may be placed into nursing homes against their will following a hip fracture, with the justification that it is for their safety--a paternalistic justification. If the patient has capacity, one should never make a nursing home against her or his will, regardless of the concerns of the family. If an elderly person is your patient, then you should be an advocate. It is similar to the situation faced by a pediatrician of a teenager whose parents are trying to get the physician to do something the teen doesn't want. Both adolescents and the elderly usually have capacity, and have the right to make their own decisions even when they aren't choosing safety as their highest priority. Both, in fact, are often more concerned to maintain their freedom and independence than their safety.