Grand Rounds Contributor: UT Southwestern Internal Medicine ConferenceEvaluation and Management of Hip Fracture Risk in the Aged
Section snippets
THE HIP FRACTURE SYNDROME: THE INTERACTION OF BONE AND FALL-RELATED FACTORS
Hip fractures occur when a force directed to the proximal femur exceeds the elastic properties of the bone. In osteoporosis research and clinical care, hip fracture prevention has largely focused on identifying patients with low bone mass and instituting therapies to increase bone density to improve bone strength. Accumulated fatigue damage, bone microarchitecture and mineralization10 also contribute to bone quality and strength but are not clinically measured. Although low bone density is a
NURSING HOME AND HOSPITAL STUDIES
The nursing home and hospital Cochrane review included 41 trials.27 The 30 nursing home studies found that interventions targeting single risk factors did not reduce falls, including exercise interventions. In fact, pooled data from 4 of 7 studies in nursing care facilities testing a combination of exercise types showed a significant increase in the rate of falls.
Overall, single exercise modality interventions did not reduce the rate of falls or risk of falling.27 Pooled data from 2 small
THE HOSPITAL SETTING
Eleven studies were reviewed that took place in what was categorized as a hospital.27 Most of these settings would not be applicable to the traditional U.S. acute care hospital. Patients were generally admitted for more than 6 weeks (1 acute setting, 6 subacute and 4 in both acute and subacute hospitals). The Cochrane reviewers emphasized the small number of hospital studies and variability of the studies limited the review.2., 27.
Multifactorial studies in hospitals with a length of stay of at
PREVENTING FALLS IN THE COMMUNITY
In a Cochrane review to assess interventions to reduce falls in community-dwelling older people, 111 trials (55,303 participants) were reviewed.28 The Cochrane investigators found that multicomponent exercise interventions reduced the rate and risk of falling. These programs contained at least 2 or more of the following: strength, balance, flexibility and endurance. The review did not find evidence for a difference between targeting at risk individuals or those enrolled without known risk.
TAI CHI
TC is a balance-oriented exercise program that has been growing widely as an exercise program to prevent falls in older people. Because the movements used in TC incorporate strengthening, balance, postural alignment and concentration, it may lead to reduced falls. Wolf et al55 published in 1996 the results of a 16-week TC intervention trial in older persons; it showed a 48% reduction in the risk of falls compared with a wellness education program. Subsequent studies have had inconsistent
COGNITIVE IMPAIRMENT AND DEMENTIA
Cognitive impairment is an independent risk for falls. Most studies of fall prevention and osteoporosis have excluded patients with dementia. Patients with Alzheimer’s and a history of falls are at increased risk of fracture and reduced survival compared with nonfallers with the disease. The efficacy of interventions that reduce fall risk in noncognitively impaired populations may not be applicable to those with dementia.63., 64., 65.
The mechanism underlying increased fall risk in patients with
HIP PROTECTORS
Hip protectors have been studied as an intervention to prevent hip fractures in frail institutionalized older patients. The mechanism of fracture prevention being the placement of a foam pad or plastic shield to redirect the force generated from the fall away from the proximal femur. Early studies were promising, with findings showing reductions in hip fractures in high-risk patients studied.70., 71. However, these studies were designed as cluster studies with inherent methodological concerns.
PHARMACOLOGIC INTERVENTIONS FOR OSTEOPOROSIS
A number of medications have been shown to reduce hip fractures in RCTs. Among bisphosphonates these include alendronate74., 75. (absolute risk reduction [ARR], 1.0%), risedronate12 (ARR, 1.0% without prevalent fracture between age 70 and 79 and 3.0% ARR in patients with baseline prevalent vertebral fracture) and zoledronic acid (1.1% ARR).76., 77., 78. Ibandronate has shown efficacy in reducing vertebral fractures but not in reducing hip fractures. Teriparatide,79., 80., 81., 82. raloxifene83
CALCIUM
Conflicting evidence88., 89., 90. exists regarding the efficacy of calcium in reducing hip fractures. Findings from studies with low adherence and inadequate documentation of baseline vitamin D status are common methodological concerns.89., 90. In a recent meta-analysis, vitamin D was reported to be effective in reducing fractures only when given with calcium.91 The beneficial effect of calcium on bone metabolism is related to the blunting or reversal of the age-related impairment of calcium
Fall Risk
All older patients should be asked if they have fallen during the past year and if so, the frequency, circumstances, symptoms, time of fall and consequences should be described (Table 2). All patients should have a gait and balance assessment. The Get-Up-And-Go Test is a practical test to perform in the clinical setting.93 Patients are asked to stand from the sitting position without use of arms (if possible), walk about 3 m and then turn and return to their chair and sit down. The ability to
CONCLUSION
Hip fractures are a complicated interaction of fall risks and bone strength (Figure 2). Because 90% of hip fractures occur in the setting of a fall before the fracture, identifying interventions that reduce fall risk factors is essential. Fall assessment and multicomponent exercise interventions that include strength, balance and flexibility seem to reduce fall and fracture rate. Although large clinical heterogeneity exists in fall trials, research methodology can be improved. Better
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This review was supported in part by the Margaret and Trammell Crow Distinguished Chair in Alzheimer’s and Geriatric Research and the Murrell Geriatric Research Fund.