A selection strategy was developed for fracture reduction programs in frail older people

Abstract

Objectives

The aims of this study were to develop and evaluate a simple index for assessing the risk of fractures after a fall and to propose a selection strategy for identifying elderly individuals at high risk of both falls and fall-related fractures.

Study Design and Setting

Two thousand five institutionalized older men and women were assessed for clinical risk factors and then followed up for falls and fall-related fractures for up to 2 years.

Results

Our fracture risk index is derived from seven previously identified significant independent risk factors: weight, lower leg length, balance, cognitive function, type of institution, fracture history, and falls in the past year. The fracture rate was 6.5 times greater in the one-sixth of the falls with the highest index (9.7/100 falls) than in the lowest sixth (1.5/100 falls). Our proposed approach (based on balance, risk of falls, and the fracture risk index) selected a group of older people with high risk of both falls and fall-related fracture. The fracture incidence rate was 144% higher, and the falls incidence rate was 31% higher in the selected residents than in the remainder.

Conclusion

The index could help rationalize fracture prevention programs for frail older people.

Introduction

What is new?

• Fracture risk index for people who fall is not available in the literature.

• Little is known about how to find very frail older people who are at high risk of both falls and fall-related fractures.

• The fracture risk index developed by this study was shown to be a good indicator of relative risk (RR) of fracture after a fall.

• Used in conjunction with a falls risk assessment tool, the selection strategy could identify individuals who are at high risk of falls and fall-related fractures and therefore help rationalize the provision of falls prevention and impact reduction programs in the population.

Frail older people are at extremely high risk of fractures [1], [2]. Most fractures in institutionalized older people are the result of falls [3]. Falling is a frequent event among this group, with up to 50% having at least one fall in a year [4]. We have previously developed a falls risk score to predict those who are at most risk of falling [4]. However, only about 1 in 20 falls results in a fracture [5]. It is therefore important to identify those older people whose falls are likely to lead to a fracture, so that cost-effective intervention programs may be implemented. To our knowledge, a fracture risk index for people who fall has not been published before.

In a cohort study of institutionalized older people who had a fall, we found that the significant independent risk factors for fracture were lower calcaneal broadband ultrasound attenuation (BUA), lower weight, longer lower leg length, better balance, lack of severe cognitive impairment, intermediate-care residence, a history of fracture since age 50 years, and lack of falls in the previous year [5]. A good fracture risk index should be based on follow-up of a large and randomly selected cohort and use an appropriate multivariate regression model to select a set of independent significant risk factors and to weight the selected factors according to their coefficients. A useful risk assessment tool should also include only those risk factors that can be easily assessed and accurately measured in a primary care setting.

The aims of this study were (1) to develop and evaluate a simple index for assessing the risk of fractures after a fall among institutionalized older people, and (2) to propose a strategy (by combining the simple index with our falls risk score) for selecting those residents who are at high risk of both falls and fall-related fractures and hence are most likely to benefit from fall prevention or fall impact attenuation programs for fracture reduction.