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Falls and Fracture in the Elderly

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The ageing of population. Percent of population aged 65 ABS and US Bureau of Census, 1996. ... medications, behavioral instructions, exercise programs aimed at ... – PowerPoint PPT presentation

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Title: Falls and Fracture in the Elderly


1
Falls and Fracture in the Elderly
  • Tuan V. Nguyen
  • Bone and Mineral Research Program
  • Garvan Institute of Medical Research

2
Overview
  • Osteoporosis
  • Magnitude of the problem
  • Bone mineral density (BMD) and fracture
  • Falls etiology and risk factors
  • Fracture and fall

3
Osteoporosis shift in thinking
  • Low bone mass, microarchitectural deterioration
    of bone tissue leading to enhanced bone fragility
    and a consequent increase in fracture risk
    (Consensus Development Conference, 1991)

compromised bone strength predisposing a
person to an increased risk of fracture. Bone
strength primarily reflects the integration of
bone density and bone quality (NIH Consensus
Development Panel on Osteoporosis JAMA
285785-95 2001)
4
Osteoporosis in risk-and-outcome view
RISK FACTOR
OUTCOME
Osteoporosis
Fracture
Bone Quality
Bone Mineral Density
Bone Strength
and
Architecture Turnover rate Damage
accumulation Degree of mineralization Properties
of the collagen/mineral matrix
5
Normal vs osteoporosis
6
Breaking bones
7
Incidence of all-limb fractures
8
Increase in life expectancy
WHO. Human Population Fundamentals of Growth
World Health, 2000.
9
The ageing of population
Percent of population aged 65
ABS and US Bureau of Census, 1996.
10
Annual fracture incidence in Australia 1996-2051
Projected annual number of all-limb fractures in
Australia aged 35 (Sanders et al, MJA 1999)
11
Hip, vertebrae, and Colles fractures
Projected annual number of all-limb fractures in
Australia aged 35(Sanders et al, MJA 1999)
12
Lifetime risk of some diseases - women
Any osteoporotic fracture Hip fracture Clinical
vertebral fracture Cancer (any site) Breast
cancer Lung/bronchus Coronary heart
diseases Diabetes Mellitus
, from birth
(from the age of 50)
13
Lifetime risk of some diseases - men
Any osteoporotic fracture Hip fracture Clinical
vertebral fracture Cancer (any site) Prostate
cancer Lung/bronchus Coronary heart
diseases Diabetes Mellitus
, from birth
(from the age of 50)
14
Consequences of fracture
  • Reduced mortality
  • Increased morbidity
  • Reduced quality of life
  • Incurred significant health care costs

15
Survival probability with and without fracture
Source Nguyen et al, 2005
16
Risk of death from hip fracture
50-year old women Lifetime risk of mortality
from Hip Fracture 2.8 Breast Cancer
2.8 Endometrial Cancer 0.7
Cummings et al. Arch Intern Med 1989 149 2445-8
17
Impact of hip fractures
  • 25 die within 6 months ()
  • 60 have restricted mobility ()
  • 25 remain functionally more dependent
  • Cardiac (8) and pumonary complication (4)
  • Transient heart attacks
  • Non-union and avancular necrosis

18
Impact of vertebral fractures
  • Symptomatic fx Lifetime risk 1/4 women, 1/8 men
  • Asymptomatic fx prevalence 20-30
  • Back pain, functional limitation
  • Rib-against-pelvis (RAP) syndrome
  • Costoiliac impingement syndrome
  • Decrease vital lung capacity

19
Asymptomatic vertebral fracture increases risk of
subsequent fractures
300 mw
234 No V
66 V
29 Fx
37 no fx
180 no fx
54 Fx
44
23
Pongchaiyakul C et al, J Bone Miner Res 2005
20
Asymptomatic vertebral fracture increases risk of
death
300 mw
234 No V
66 V
20 deaths
46 survived
209 survived
25 deaths
30
11
Pongchaiyakul C et al, J Bone Miner Res 2005
21
Impact of wrist fracture
  • More common in women in their 50s
  • Post-traumatic arthritis
  • Account for 39 of all physical therapy sessions
  • Reduced daily living activies

Melton LJ, J Bone Miner Res 2003
22
Fracture Prediction
23
A model for assessing fracture risk
Other factors (age, weight, structural factors)
Quadriceps weakness

Falls
Postural instability
Low bone mass
  • Interaction between BMD and fall-related factors
    in the prediction of hip fracture

24
BMD and age
25
Changes in BMD with age
Peak bone density
Menopause
Osteopenia
Puberty
Osteoporosis
Age
26
BMD and definition of osteoporosis
Gaussian distribution Constant standard
deviation Decrease with advancing age
T-scorei (BMDi Peak BMD) / SD
  • Define osteoporosis and osteopenia
  • T-score lt -2.5 osteoporosis
  • -2.5 lt T-scores lt -1 osteopenia

27
Prevalence of osteoporosis
Women
Men
28
Bone mineral density (BMD) and fracture risk
T lt 2.5 osteoporosis
Source Dubbo Osteoporosis Epidemiology Study
29
14-year predictive value of BMD - women
1287women
Osteoporosis 345 (27)
Non-osteoporosis 942 (73)
Fx 137 (40)
No Fx 208 (60)
No Fx 751 (80)
Fx 191 (20)
42
Source Dubbo Osteoporosis Epidemiology Study
30
14-year predictive value of BMD - men
821 men
Osteoporosis N 90 (11)
Non-osteoporosis 731 (89)
Fx 27 (30)
No Fx 63 (70)
No Fx 640 (88)
Fx 91 (12)
23
Source Dubbo Osteoporosis Epidemiology Study
31
Fracture and BMD summary of points
  • BMD is the primary predictor of fracture risk
  • Less than 50 of fractured individuals have low
    BMD (eg osteoporosis)
  • BMD alone does not accurately predict fracture

32
Falls etiology and risk factors
33
Falls
  • The second leading cause of accidental deaths
    (Rivara NEJM 1997)
  • 70 bil health care costs associated with falls
    and rehabilitation

34
Incidence of falls in the elderly
Source Dubbo Osteoporosis Epidemiology Study
35
Incidence of multiple falls in the elderly
Source Dubbo Osteoporosis Epidemiology Study
36
Why do falls occur ?
Intrinsic Factors
Extrinsic Factors
Medical conditions Impaired vision and
hearing Age related changes
Medications Improper use of assistive
devices Environment
FALLS
37
Etiology of falls
  • Accidents / environment 37
  • Weakness, balance, gait 12
  • Drop attack 11
  • Dizziness or vertigo 8
  • Orthostatic hypotension 5
  • Acute illness, medications, vision 18
  • Unknown 8

Rubenstein et al JAGS 1988
38
Risk factors for falls
  • Risk Factor OR
  • Sedative use 28
  • Cognitive Impairment 5
  • Lower extremity problem 4
  • Pathologic Reflex 3
  • Foot Problems 2
  • gt 3 balance/gait problems 1.4
  • gt5 balance/gait problems 1.9

Tinetti NEJM 1988
39
Measurement of postural sway
A non-fracture control
A hip fracture case
Postural sway test
40
Predictors of fall risk
Note Odds ratio and 95 confidence interval
Source Dubbo Osteoporosis Epidemiology Study
41
Falls and Fractures
42
Relationship between falls and fractures
Falls
Fx
  • 95 of hip fractures are caused by falls (Nyberg
    L, J Am Geriatr Soc 1996)
  • Only 5 of falls cause fractures

43
Falls and fracture risk
Source Dubbo Osteoporosis Epidemiology Study
44
Fall-related factors and hip fracture risk
Source Nguyen et al, JBMR 2005
45
Fall-related factors and hip fracture risk
BMD-and-gender-adjusted hazards ratio
Source Nguyen et al, JBMR 2005
46
Fall-related factors and hip fracture risk
BMD-independent risk factors for hip fracture
() gender specific ranges
Source Nguyen et al, JBMR 2005
47
Incidence of hip fracture by FNBMD (T-scores) and
number of risk factors
Source Nguyen et al, JBMR 2005
48
Predictor of fractures in non-osteoporotic men
and women
PARF Population attributable risk fraction
Source Dubbo Osteoporosis Epidemiology Study
49
Can we prevent fracture by reducing falls?
50
Hip protector
51
Hip protectors reduced hip fracture risk
  • Clinical trial 1801 frail elderly individuals
    (age 81 y) in Finland
  • 78 women
  • 63 assisted walking
  • Fracture incidence 2.1 vs 4.6/yr
  • 2.4 of falls resulted in hip fx when not wearing
    protector vs 0.4 when wearing protector (80
    reduction in risk)
  • Poor compliance

P Kannus et al NEJM 2001
52
Primary prevention
  • 301 community dwelling elders with 1 risk
    factors for falling
  • Intervention adjustment in medications,
    behavioral instructions, exercise programs aimed
    at modifying risk factors
  • One year follow up

Tinetti et al. 1994 NEJM
53
Primary prevention
Tinetti et al. 1994 NEJM
54
Tai Chi reduced falls
  • Atlanta FICSIT Trial
  • 200 community dwelling elders 70
  • Intervention 15 weeks of education, balance
    training, or Tai Chi
  • Outcomes at 4 months Strength, flexibility, CV
    endurance, composition, IADL, well being, falls
  • Falls reduced by 47 in Tai Chi group

Wolf JAGS 1996
55
Risk factor modifications for fracture
Cummings et al. Unpublished data
56
Falls and fractures summary
  • Fracture, particularly hip fracture, is a serious
    public health problem in the elderly
  • Although low bone mineral density is a primary
    predictor of fracture risk, it can not account
    for all fracture cases
  • Fall is highly prevalent in the community and is
    a major risk of fracture

57
Falls and fractures summary
  • Risk factors for fall also contribute to
    fractures
  • Preventing falls can theoretically reduce
    fracture incidence
  • A preventative program is required to reduce
    falls and fractures

58
Thank you!
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