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All 512 patients who visited the hospital for treatment of a clinical fracture between April 2005 and September 2005 were invited to participate. Full analysis was possible in 277 patients. None of the patients involved in the study had dementia, nor had any received treatment for osteoporosis. Most of the participants were women (72.2 percent).After consenting to take part in the research study, each patient underwent a fall risk assessment and a bone mineral density test by dual-energy x-ray absorptiometry.

AAOS Now

Published 2/1/2008
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Carolyn Rogers

Patient safety: Preventing falls after a recent fracture

Fall risk factors predict patients at greatest risk

Healthcare providers can identify which patients are at greatest risk of falling after a fracture by examining activities of daily living (ADL) scores in all patients and polypharmacy (use of 5 or more pills per day) in women, according to a study published in the open-access journal BioMed Central (BMC) Musculoskeletal Disorders.

One third of people older than age 65 fall each year, and up to 5 percent of those falls result in a fracture. For postmenopausal women and the elderly, those fractures can have severe consequences in terms of mortality and morbidity.

“Patients with a history of a fracture have an increased risk for future fractures, even in the short term,” said Svenhjalmar van Helden, MD, the study’s lead author. “The prevention of new fractures should be an essential part of postfracture treatment.”

Prospective study
In 2005, the researchers undertook a prospective observational study at University Hospital Maastricht in The Netherlands—a large academic and regional hospital with a fracture and osteoporosis outpatient clinic.

Measuring fall risk factors
The investigators assessed fall risk by measuring balance, mobility, lower-limb muscle strength, handgrip strength, cognitive status, ADLs, visual impairment, and general measurements such as blood pressure. These factors were chosen based on their description in the Dutch guideline for prevention of falls in the elderly.

Patients were also asked about previous falls in the past 12 months, the use of psychoactive drugs, polypharmacy, osteoarthritis, urinary incontinence, difficulty reading the newspaper, depression, and difficulty with ADLs just before the fracture—including climbing stairs, walking outdoors, and taking care of their feet and toenails.

At least one fall risk factor was present in 84 percent of the patients; 76 (27 percent) had one fall risk factor, 62 (22 percent) had two, 47 (17 percent) three, and 49 (18 percent) had four or more fall risk factors.

Follow-up identified “fallers”
Follow-up information on falls and fractures was collected by telephone interview, performed monthly for 3 months after the fracture.

“The follow-up period was short, but was chosen to evaluate fall risk in the time patients were recovering from their fracture,” Dr. van Helden explained.

During the interviews, patients were asked if they had fallen, and if so, the number and timing of falls and whether the fall resulted in a fracture.

People who had fallen were classified as “fallers” (falling at least once within the 3-month follow-up period) or “recurrent fallers” (falling at least twice within that timeframe). Incidence of falls and odds ratios were also calculated.

Targeting risk factors
The study findings included the following:

  • Forty-two patients (15.2 percent) reported a new fall within 3 months of a recent clinical fracture; 10 of these patients had more than one fall.
  • Five patients sustained a new fracture within 3 months.
  • A greater percentage of women reported a new fall than men (18.5 percent and 6.5 percent, respectively).

The most significant fall risk factors were found to be sex (female), age, ADL problems, and polypharmacy. The incidence of falls was 35 percent in women with polypharmacy and low ADLs score—three times higher than in women without these risk factors. Of the total group, one out of two fallers had difficulties with ADL before the clinical fracture, compared with one in four patients who had no falls during the follow-up.

The mean age of female fallers was 69.9 years (range: 51–86 years), and 66.6 years in male fallers (range: 51–78 years) (P = 0.069).

Future research needed on men
One limitation of the study was that the male group was too small for separate analysis, Dr. van Helden said.

“Future studies should be large enough to include sufficient numbers of men and to perform subgroup analysis on different ages,” he said. “Eventually a very large cohort analysis with fracture risk as the endpoint would be most interesting.”

To view the complete study, visit: www.biomedcentral.com/1471-2474/8/55

Study authors include Dr. van Helden, Caroline E. Wyers, Pieter C. Dagnelie, Martien C. van Dongen, Gittie Willem, Peter R.G. Brink, and Piet P. Geusens.

Carolyn Rogers is a staff writer for AAOS Now. She can be reached at rogers@aaos.org