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Scientific Review
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ISFR Symposium Review: Preventing Falls and Fractures in Elderly
Written by M.Akmal
Monday, 24 January 2005
International Society for Fracture Repair (ISFR) Symposium: Preventing Falls and Fractures in Older Patients
Yokohama, Japan, June 29–July 1, 2004
Peter Augat
Institute of Orthopedic Research and Biomechanics, University of Ulm, Ulm, Germany
Fragility fractures in elderly people constitute a steadily escalating global health hazard. The increased morbidity and mortality following fractures in the elderly, added to the decrease in an individual's quality of living and the healthcare costs to society, make this an alarming burden. The rising incidence of fragility fractures with age can be explained by deteriorating bone quality and an increasing propensity to falls. On behalf of the International Society for Fracture Repair (ISFR), T Matsushita (Teikyo University School of Medicine, Tokyo, Japan) organized a unique international symposium entitled "Preventing Falls and Fractures in Older Persons". The meeting bought together experts from various research fields worldwide to discuss, from a interdisciplinary perspective, aspects that contribute to fragility fractures.
Risk for falling
Falls, defined by H Luukinen (University of Oulu, Oulu, Finland) as an unintentional change of position to a lower level without an overwhelming hazard, affect one third of home-dwelling older adults living in western societies; in Asian populations such as Japan the incidence of falls is approximately 50% lower. The incidence of falls is significantly higher in women compared with men, both sharing a steep increase in incidence with increasing age. In institutionalized elderly the incidence of falls is elevated to as many as 1500 falls per 1000 person years in certain institutions. In home–dwelling elderly, most of the falls occur indoors during the active hours of the day while for institutionalized persons there is little variation in timings. Approximately 15% of all falls result in a major injury that requires treatment; 3–5% of falls result in a fracture [1].
The increased propensity to falls in elderly people has a large variety of underlying causes. L Rubenstein (Greater Los Angeles VA GRECC, Los Angeles, CA, USA) provided an extensive overview on the risk factors clearly associated with fall propensity. Musculoskeletal condition has been identified to be of greatest importance for the prevention of falls. Muscle weakness, gait deficit, and arthritis rank highest among all the fall-related risk factors, with muscle weakness being the most reliable predictor of future falls. Of almost equal importance for fall prevention is the neurological condition of the patient, which is largely responsible for such risk factors as balance deficit or fear of falling. Furthermore, the likely deterioration of vision and cardiovascular health (i.e. syncope) both significantly contribute to the risk of falling. Although the use of psychotropic, antiarrhythmic, or diuretic medications have been identified as significant risk factors for falling, their contributions to overall risk is low. Environmental risk factors at home, in the hospital, or in the community also contribute to falls [2].
F Horak (Oregon Health and Science University, Portland, OR, USA) and B Maki (University of Toronto, Ont., Canada) elucidated on the role of postural orientation and equilibrium in falls. Postural orientation or alignment involves the active control of muscles forces and body part alignment in space, based on the interpretation of sensory information. Postural equilibrium or balance involves the coordination of sensorimotor systems to control the stabilization of the body's center of mass. Control of posture involves many parts of the nervous and musculoskeletal system. Therefore, many types of neurological and orthopedic constraints affect the different mechanisms underlying the control of posture. With advancing age it appears that people become more reliant on grasping and stepping reactions, but are less able to execute these reactions rapidly enough to prevent falling. A reduction in reaction time, slowed attention, and loss of plantar sensation are likely factors that increase the incidence of falls with advancing age.
Visual impairment has been identified as an important risk factor for falls in older people (S Lord, Prince of Wales Medical Research Institute, Sydney, NSW, Australia). While impaired visual acuity appears to have at least some association with falls, there significant evidence that poor contrast sensitivity is strongly associated with falling. The loss of edge contrast sensitivity predisposes older people to trips over obstacles, steps, and pavement cracks. The ability to perceive spatial relationships and judge distances is also important for negotiating environmental hazards. Visual impairment can be exacerbated by suboptimal visual correction; therefore, wearing glasses with optimally adjusted prescriptions is likely to reduce the number of falls [3].
For those people at an increased risk of falling it is important to identify the etiologicalfactors that contribute to their individual risk. Multiple factors may interact to predispose a person to falls caused by minor external perturbations. These potential fallers require interventional programs that decrease their risk of falling when carrying out activities of daily living. J Campbell (University of Otago, Dunedin, New Zealand) described how these subjects may benefit most from such programs. Multiple intervention programs are designed to combine a variety of etiological factors, most importantly those associated with the highest risk for falling (i.e. lower limb muscle strength, balance, and general health condition). Although previous multifactorial intervention studies have shown that the efficiency of intervention (cost versus benefit) is highest for those who are older than 80 years of age, more generalized public health approaches may also aid people above the age of 70 years.
Individuals at a high risk for falling may benefit from wearing hip protectors for direct injury site protection. P Kannus (University of Tampere, Tampere, Finland) noted that hip protectors worn by frail elderly people can reduce their risk for sustaining a hip fracture by as much as 80%.
D Marsh (Queen’s University of Belfast, Belfast, UK) highlighted the importance of adequate treatment for patients who have suffered a fragility fracture. Evidence from experimental studies suggests that osteoporotic bone heals in a similar way to young bone although at a slower rate. A stable fracture fixation at an early time allowing early mobilization is therefore exceptionally important in elderly individuals. Stable fracture fixation in osteoporotic bone with reduced holding capacities can be achieved by improved technology such as locking plates, hydroxyapatite coatings, or cement augmentation. Furthermore, there is an urgent need to explore the possibilities of fracture healing enhancement through physical or biological treatments. Low-intensity ultrasound, antiresorptive drugs such as bisphosphonates, or anti-inflammatory agents may be potential candidates.
Prediction of fracture risk
P Augat (University of Ulm, Ulm, Germany) pointed out the importance of considering cortical bone in the assessment of bone quality for the prediction of fracture risk. Although bone assessment technology provides an accepted tool for risk assessment, it largely neglects the contribution of structural properties such as bone geometry or measures of cortical bone quality. There is sufficient evidence that bone quality is strongly related to the presence of microcracks as well as architectural features of bone such as the cortical thickness. With improved imaging technology, some of these features might be accessible in the future to improve the assessment of the fracture risk in patients with reduced bone quality.
In addition to using pharmacological agents to improve bone quantity, it has been widely accepted that mechanical loading constitutes a critical regulatory signal to the skeleton that benefits bone quantity and quality. Mechanical signals in bone can be created by exercise but also by high-frequency stimulation using loading devices or ultrasound. C Rubin (State University of New York, NY, USA) presented evidence that mechanical loading at frequencies up to 50 Hz and at magnitudes of strain as low as several microstrains triggers an anabolic response. Low magnitude, high frequency signals have shown to effectively prevent postmenopausal bone loss, especially in lighter women [4]. Preliminary studies suggest that these stimuli may also be beneficial for the improvement of postural control, possibly due to their effect on the musculature.
Summary
This unique interdisciplinary meeting provided insight into multiple factors that lead to the steadily increasing number of osteoporotic fractures in the elderly population. Bone quality, postural control, and likelihood of falling can be influenced by targeted multifactorial intervention. There is a strong need for interdisciplinary action to identify people at risk for fracture at an early stage, and provide them with adequate treatment or intervention programs. Future research will identify on how to maximize the efficacy of intervention protocols in order to minimize the healthcare costs.
References
- Willig R, Luukinen H, Jalovaara P. Factors related to occurrence of hip fracture during a fall on the hip. Public Health 2003;117:25–30.
- Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. BMJ 2004;328:680.
- Lord SR, Dayhew J. Visual risk factors for falls in older people. J Am Geriatr Soc 2001;49:508–15.
- Rubin C, Recker R, Cullen D et al. Prevention of postmenopausal bone loss by a low-magnitude, high-frequency mechanical stimuli: A clinical trial assessing compliance, efficacy, and safety. J Bone Miner Res 2004;19:343–51.
Last Updated ( Wednesday, 26 July 2006 )
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