Preventing fractures in elderly people
Anthony D Woolf,
professor of rheumatology1,
Kristina Åkesson,
associate professor2
Institute of Health and Social Care, Peninsula
Medical School, Royal Cornwall Hospital, Truro
TR1 3LJ, Lund University, Department of
Orthopaedics, Malmö University Hospital,
S-20502, Malmö, Sweden
Preventing fractures in elderly people is a
priority, especially as it has been
predicted that in 20 years almost a quarter
of people in Europe will be aged over 65.
This article describes the factors
contributing to fracture, interventions to
prevent fracture, and the various
treatments.
Introduction
Fractures in elderly people are an important
public health issue, especially as incidence
increases with age, and the population
of elderly people is growing. Evidence
based interventions do exist to
prevent fractures, but they are not being
applied. The challenges are to identify those
most risk and to ensure that
treatment is cost effective. Elderly people
should be taught to improve their
bone health and to reduce the risk of
injury, but these measures are not restricted to
this age group, as prevention should
be throughout the life.
Sources
and methods
Recommendations are made following a
comprehensive review of the
literature, concentrating on systematic reviews
and evidence based guidelines on
fracture prevention that have been identified
by a standardised search strategy as part
of the European Bone and Joint Health
Strategies Project. Priority was given to
those systematic reviews and guidelines
that met quality criteria, including
criteria for guidelines from the Appraisal of
Guidelines Research and Evaluation (AGREE).
A universal problem
Around 310 000 fractures occur each year in
elderly people in the United Kingdom.
The cost of providing social care and support
for these patients is £1.7b ($2.8b;
€2.4b). Hip fractures place the
greatest demand on resources and have the
greatest impact on patients because of
increased mortality, long term
disability, and loss of independence. Although
less common, vertebral fractures are also
associated with long term morbidity
and increased mortality. By 2025 it has been
predicted that almost a quarter of
the population in Europe will be aged
over 65 years. The mean age of hip fracture in
women is 81 years, and as the
expected additional lifetime for an 80 year old
women in England is 8.7 years, there is
still a significant time for elderly
women to benefit from fracture prevention.
Summary points
-Prevention of fractures includes reducing the
number of falls, reducing the trauma
associated with falls, and maximising
bone strength at all ages
Pharmacological treatment is most
clinically effective and cost effective when
targeted at those who are at highest
risk
-Previous fracture and low bone
density are strong risk factors for future
fracture, and those at highest risk
can be identified by combining these with other
risk factors
-Reasons for previous falls and unsteadiness
in aged patients should be investigated
-Treatment of concomitant conditions
should be optimised
-Bone
fragility, falls, and people of high risk
Fractures occur in elderly people because of
skeletal fragility.
-Appendicular fractures are
usually precipitated by a fall. Falls
account for 90% of hip fractures, and the risk
of falling increases with age. Around
a third of people aged 65 or over fall at
least once a year, but only 1% of falls in
women result in hip fracture.
-Whether
fracture occurs depends on the impact
from the fall and bone strength. Bone strength
is related to mineral content, as
assessed by bone densitometry, with the
risk of fracture increasing
proportionately with decrease in bone
mineral density.
-Strategies to prevent fracture
in an elderly population must
therefore ensure maximum bone strength,
reduce the occurrence of falls, and reduce
the trauma associated with falls.
-Compared with a younger woman, a 70 year old
woman is five times more likely to
sustain a hip fracture and three times more
likely to incur any fracture during the
rest of her life.
- However, there are some
elderly people for whom the risk is
much greater, and for them specific treatments
to prevent fracture are more cost
effective.
Box 1:
Risk factors (excluding falls) for bone
loss, osteoporosis, and fracture in
elderly people (adapted from various sources)
Behavioural risk factors
-Low calcium intake (< 700 mg/d)
-Physical inactivity
-Vitamin D deficiency (low exposure to
sunlight)
-Smoking (current)
-Excessive alcohol consumption
-Factors can identify people most at risk of
fracture, principally because of low
-bone mass (osteoporosis) or falls (boxes 1 and
2).
-Other factors include bone turnover
and bone quality, assessed by bone
markers and quantitative ultrasound,
respectively.
-Frailty and comorbidity are also
risk factors for poor outcome. Such
factors could help determine whether bone
densitometry is needed and choice of
treatment.
-Bone density has the strongest relation to
fracture, but many fractures occur in
women without osteoporosis.
-The possibility
of fracture increases when low bone
density is combined with other
factors, but the exact interaction of these
factors is unclear.
- Efforts are being made to
describe the absolute risk for
patients over the comprehensible time period of
five to 10 years. This should help to
indicate whether intervention is
needed and to improve compliance.
Pharmacological
intervention
Pharmacological agents increase bone mass either
by decreasing bone resorption, with a
secondary gain in bone mass, or by a
direct anabolic effect. Preferably they also
increase bone strength and quality.
Randomised controlled trials of several
of these drugs show a decrease in
fractures within one to three years.
Drugs that specifically act on bone by
decreasing resorption are
bisphosphonates, calcitonin, selective oestrogen
receptor modulators, and oestrogen.
Combined calcium and vitamin D also
has an antiresorptive action, and parathyroid
hormone has become available as the
first anabolic agent for bone (see table A
on bmj.com).
Combined calcium and vitamin D
Combined calcium and vitamin D is the standard
treatment for osteoporosis as well as
a preventive measure, particularly in
frail elderly people. In elderly
institutionalised patients, further
hip and nonvertebral fractures were decreased
after three years' treatment with
1200 mg calcium and 20 µg (800 IU) vitamin D,
with significant benefit at 18 months.
A community based study found that vitamin
D given once every four months
decreased the overall risk of fracture by 39%,
and in another study 800 IU of vitamin D
given to elderly people (mean age 85)
over a 12 week period increased muscle strength
and decreased the number of falls by
almost a half.
Box 2:
Risk factors for falls in elderly people
Intrinsic factors
-General deterioration associated with agein
-Poor postural
control
-Defective proprioception
-Reduced walking speed
-Weakness
of legs
-Slow reaction time
-Various comorbidities
-Problems
with balance, gait, or
mobility
-Joint disease
-Cerebrovascular
disease
-Peripheral neuropathy
-Parkinson's disease
-Alcohol
-Various
drugs
-Visual impairment
-mpaired visual acuity
-Cataracts
-Glaucoma
-Retinal
degeneration
-Impaired cognition or depression
-Alzheimer's
disease
-Cerebrovascular disease
-"Blackouts"
-Hypoglycaemia
-Postural
hypotension
-Cardiac arrhythmia
-Transient ischaemic attack,
acute
onset cerebrovascular attack
-Epilepsy
-Drop attacks ?vertebrobasilar
insufficiency
-Carotid sinus syncope
-Neurocardiogenic (vasovagal)
syncope
-Extrinsic factors
-Personal hazards
-Inappropriate
footwear or clothing
-Multiple drug therapy
-Sedatives
-Hypotensive
drugs
-Environmental factors
-Hazards indoors or at home
-Bad
lighting
-Steep stairs, lack of grab rails
-Slippery floors,
loose rugs
-Pets, grandchildren's toys
-Cords for telephone
and electrical
appliances
-Hazards outdoors
-Uneven pavements,
streets, paths
-Lack of safety equipment
-Snowy and icy conditions
-Traffic
and public transportation
Bisphosphonates
Bisphosphonates are potent antiresorptive agents
that block osteoclast action with
little effect on other organ systems (see table B on
bmj.com). In large randomised controlled
trials, the bisphosphonate
alendronate reduced both vertebral and
non-vertebral fractures. It is most beneficial
in those at highest risk–women with
at least one prevalent vertebral fracture
or osteoporosis.
Symptomatic vertebral
fractures were decreased by 28-36%
over four years' treatment, whereas the risk of
hip fracture was reduced by just over
a half. Risedronate similarly reduces
the incidence of vertebral fractures. A study
of risedronate specifically designed to
evaluate its effect on hip fracture
showed that the incidence of hip fractures
was decreased only in elderly women
included because of a combination of
low bone mass and risk factors.
The effect was
not significant in women included
because of risk factors alone.
The daily dosing regimens of bisphosphonates are
complex, for reasons of absorption
and gastric side effects. To maximise uptake, tablets must be taken after an overnight
fast, with a full glass of water, and
food avoided for half an hour. The need for such measures may be overcome with the
new weekly dosing regimen for both agents.
Etidronate was the first available
bisphosphonate. It is used cyclically
to treat osteoporosis, as overdosage may cause
defects in mineralisation. No
randomised controlled trials have been
primarily powered to evaluate the effect
of this drug on fracture. New compounds based on
the primary bisphosphonate structure are being developed. The interval between doses
has been increased between two and 12
months, which would be beneficial, particularly
in elderly frail patients. At least two of
these compounds, zolendronate and
ibandronate, given intravenously or orally,
are undergoing clinical trials.
Selective oestrogen receptor modulators
Selective oestrogen receptor modulators
selectively block conformational changes of the
oestrogen receptor. In postmenopausal women
treated with raloxifene, vertebral
fractures were decreased by 30% over
three years, whereas no effect was seen on
non-vertebral fractures. A significant decrease
in the number of new cases of breast
cancer was also seen.
Oestrogen
Preventing fractures in women with osteoporosis
by giving oestrogen replacement therapy remains
controversial. Large size studies of
its effects on fracture have been lacking, and
the indication for efficacy has
relied on observational studies. The recent
report from the Women's Health Initiative
study on hormone replacement therapy
is the first large scale randomised controlled
trial in women aged 50-79. Hip and
vertebral fractures were decreased by 34%, and
the overall reduction in fracture risk
was 24%. However long term side effects,
particularly breast cancer, and
absence of benefits for cardiovascular events
limit the indications for use. The
primary target group for oestrogen replacement therapy is therefore not elderly
women with osteoporosis but women
soon after menopause, to eliminate climacteric
symptoms.
Calcitonin
Calcitonin is an endogenous inhibitor of bone
resorption, which acts by suppressing
osteoclasts. Salmon calcitonin is available
as subcutaneous injections or a nasal
spray. It is about 10 times more
potent than normally produced human calcitonin.
Although several studies have shown
effects on bone mineral density in
postmenopausal women, the effect on fracture has
been less well studied. When salmon
calcitonin 200 IU daily was, however,
given to postmenopausal women, new vertebral
fractures were decreased by 33% despite a
small effect on lumbar bone mineral
density. This has been interpreted as a quality
effect of antiresorptive agents beyond the
effect on bone mineral density.
Parathyroid hormone
Parathyroid hormone has a dual effect on bone.
Continuous dosing or increased
endogenous secretion leads to bone resorption,
whereas intermittent dosing has a
pronounced anabolic effect. Recombinant human parathyroid hormone given as
subcutaneous injections is promising,
decreasing vertebral and non-vertebral
fractures by 65-69% and 53-54%,
respectively, and markedly increasing bone mass
in under two years.
Impact and prevention of falls
Measures to prevent falls should be implemented
in elderly people. This has potential benefit
against appendicular fractures. It is
difficult to identify those at most risk;
a previous fall is a strong indicator, and
important determinants are weakness of the legs,
poor gait, and impaired balance and
coordination. Recommendations have been made for
assessing risk (box 3), although at
present there is no fully evaluated tool for this.
Effective prevention involves
identifying and modifying where
possible intrinsic, extrinsic, and environmental
risk factors (see box 2). Social service
staff and healthcare workers should
be aware of these factors. Individually tailored
programmes or Tai Chi can help improve
balance and steadiness. A meta-analysis of four
controlled trials of 1016 community dwelling women and men aged 65 to 97 years found
that individually prescribed
programmes of muscle strengthening and balance
retraining exercises reduced the
number of falls by 35%, benefiting most
those over 80. However, there is little
evidence as yet that fall prevention
reduces the risk of fracture.
Box 3: Assessment of elderly people for risk of
falls (adapted from guideline for the
prevention of falls in older persons with permission of Blackwell)
Approach as part of routine
care (not
presenting after falls)
·
Elderly people should be
asked at
least once a year about falls
·
Elderly people who
report a single
fall should be observed as they stand up from
a chair without using their arms, walk
several paces, and return (get up and go test).
Those showing no difficulty or unsteadiness
need no further assessment
Approach to those presenting
after
one or more falls, or with abnormalities of gait
or balance, or who report recurrent
falls
·
Elderly people who present because
of
a fall, report recurrent falls in past year, or
show abnormalities of gait or balance
should undergo a fall evaluation. This should
be performed by an experienced clinician,
which may necessitate referral to a
specialist
A fall evaluation includes a history
of circumstances around the fall, drugs, acute
or chronic medical problems, and
mobility levels; an examination of vision, gait
and balance, and function of the leg
joints; an examination of basic
neurological function, including mental status,
muscle strength, peripheral nerves of the legs,
proprioception, reflexes, and tests
of cortical, extrapyramidal and cerebellar
function; assessment of basic
cardiovascular status including heart rate
and rhythm, postural pulse and blood
pressure and, if appropriate, heart
rate and blood pressure responses to carotid
sinus stimulation
Externally applied devices can protect against
the impact of falls. External hip
protectors decreased hip fractures in
institutionalised patients, although
their role in frequent fallers in the community
is still being evaluated. The main
limitation is compliance.
Lifestyle
A sedentary lifestyle, poor diet, smoking, and
alcohol misuse are detrimental to
bone health. Maintaining a strong skeleton
at all ages relies on mechanical stimuli
from weight bearing and physical
activity. Programmes for physical exercise may
increase bone mass by only a marginal
amount, but loss of mobility results
in a rapid decrease in bone mass and loss of
physical fitness, particularly in elderly
people.
Poor nutrition is common in elderly people,
especially frail elderly people, and
several studies show low body weight and
body mass index associated with hip
fracture. Protein supplementation has
also improved outcome after hip fracture.
Adequate intake of all nutrients,
including calcium and vitamin D, is important.
Smoking carries a moderate and dose
dependent risk for osteoporosis and fracture,
which diminishes over time with cessation.
Selective
case finding
A selective case finding approach is recommended
to recognise and treat those elderly
people most at risk, ideally before the first fracture. High risk individuals may be
identified from risk factors for bone
fragility or susceptibility to trauma.
The key questions relate to previous
fragility fracture, previous falls or
unsteadiness, and risk factors for osteoporosis
or low bone mass
Positive responses
should lead to a full assessment to
confirm risk, provided the patient agrees to and
is able to follow instructions for
pharmacological treatment. Those at
risk of osteoporosis should be assessed by bone
mineral density measurement with dual
energy X ray absorptiometry at the
hip and spine if it will influence management.
Measurement of the calcaneus by ultrasonography
may be used as an intermediate
assessment method if dual energy X ray
absorptiometry is not feasible.
Patients with low values can then be referred
for full assessment.
Selection of treatment and monitoring response
Management of people at risk of fracture should
be tailored to their risks and needs.
Treatment should always couple any antiresorptive agent along with
non-pharmacological interventions (box 4).
The prevention of fracture can be measured only
at the population level. Measurement
of bone density or biochemical bone markers
can be used in the individual as an
indicator of treatment effect, but in
clinical practice lack of long term compliance
is the principal reason for poor response.
Good patient education with
re-enforcement is necessary to improve this.
If
bone density is measured again, it is
not meaningful until after two years because of the precision error of available bone
densitometers and the low rate of
change in bone mass. If the patient tolerates
treatment well, the second measurement can
be delayed for three or four years
providing there is a predetermined plan for
continued treatment.
Falls in the
last year can be asked about to review
effect of prevention. For those who have
sustained a fracture, the impact on
their quality of life can be monitored by a few
simple questions, which could be used on a
regular basis to provide a simple and
rapid evaluation (box 5). It is also important
to know if a local fracture prevention
strategy is making a difference, and
effectiveness can be measured by various
indicators such as the success of
case finding, numbers of fractures, and fracture outcome.
With our current state of knowledge it will be
possible to reduce the burden of
osteoporosis in elderly people. Unfortunately,
predicting and preventing all fractures is
still beyond our abilities, but there
has been progress in our understanding
of what was until recently a silent
epidemic.
Box 4: Recommendations for prevention of
fracture in elderly people based on
risk assessment (adapted from Royal College
of Physicians guidelines)
Indications
-Bone mineral density
T score* >1
(normal)
Advise on lifestyle
-Bone
mineral density T score -1 to
-2.5 (osteopenia)
Advise on lifestyle
Consider
combined calcium 1 g and
vitamin D 800 IU, depending on intake
-Bone mineral density T score 
2.5
(osteoporosis)
Investigate for causes of
osteoporosis
Advise on lifestyle and ensure adequate
intake of combined calcium and vitamin D
Consider pharmacological
treatment
Interpret result in context of age in frail
elderly people (Z score)
-Frail, biologically aged, or institutionalised
Consider
intake of combined calcium 1
g and vitamin D 800 IU
Perform falls assessment
Consider hip protectors
Low bone mineral
density and
additional risk factors
-Bone mineral density T
score -1 to
-2.5 plus fracture after low energy trauma or
high risk of falls or other risk
factors for fracture (checklist)
-Investigate for causes of fracture
Perform falls assessment
Advise
on lifestyle and ensure
adequate intake of combined calcium and vitamin D
Consider pharmacological treatment
-Bone mineral
density T score 2.5
plus fracture after low energy trauma
Investigate
for causes of fracture
Investigate for causes of osteoporosis
Perform
falls assessment
Advise on lifestyle and ensure adequate intake
of combined calcium and vitamin D
Consider pharmacological
treatment
*T
score compares bone mineral density
to peak bone mass.
Box 5: Simple questionnaire used to monitor
quality of life after fracture
(adapted from Doherty et al)
-Have your daily
activities been
limited by pain during the past week?
-Are you
able to wash and dress
yourself?
-Have you walked outside during
the
past week?
-Are you content with your current state of
health?
-Additional educational resources
Cochrane Musculoskeletal Group–the
group reviews science from an evidence based
perspective, using rigorous criteria
for evaluation of efficacy or risk
International
Osteoporosis
Foundation–this international organisation
assembles professionals, patient support groups,
and industry with an interest in
osteoporosis
International
Bone and Mineral
Society BoneKEy-Osteovision–this website
is a central repository of knowledge in
the field of bone, cartilage, and mineral
metabolism
American Society for Bone and Mineral
Research–this organisation focuses on research
in musculoskeletal, including both
basic and clinical science
Sambrook
P, Woolf AD. Osteoporosis.
Best Pract Res Clin Rheumatol
2001:335- 515–an update on diagnosis and
management of osteoporosis
nformation
for patients
International Osteoporosis Foundation–patient
support groups and national societies for
osteoporosis can be found through
this website for most countries
National
Osteoporosis Society–UK
national charity dedicated to eradicating
osteoporosis and promoting bone health in both
men and women. Website provides
useful information for the public, patients, and health professionals
National
Osteoporosis Foundation,
USA–the leading US voluntary health
organisation for osteoporosis, which provides
information for patients and health
professionals
NHS Direct–provides
a wide range of
information on osteoporosis, its prevention
and treatment
Ongoing research
-Defining absolute risk over 5-10 years for
different age groups in both women and men.
-Evaluation of
the effect of hip
protectors in non-institutionalised people,
including compliance.
-Development of simple fall prevention
strategies in the community and evaluation
of their effect on fracture.
-Long term studies evaluating the effect on
falls of long term balance and
coordination training in elderly and elderly frail people.
-Evaluation of annual vitamin D supplementation.
-Long term effectiveness of bisphosphonate
therapy.
-Development
of pharmacological
agents with more favourable dosing regimens,
particularly for frail elderly people.
-Understanding effects
of
pharmacological agents on bone quality to
understand better how drugs prevent
fracture.
Population based studies in men
to
define sex specific risk factors and
intervention levels for bone mineral
density.
