How can you prevent falls and subsequent fractures?

What was the Epidemiology and Global Burden of Disease of Hip Fractures From 1990 to 2019? Results From and Additional Analysis of the Global Burden of Disease Study 2019

BACKGROUND

Hip fractures are associated with a high risk of death; among those who survive a hip fracture, many experience substantial decreases in quality of life. A comprehensive understanding of the epidemiology and burden of hip fractures by country, age, gender, and sociodemographic factors would provide valuable information for healthcare policymaking and clinical practice. The Global Burden of Disease (GBD) study 2019 was a global-level study estimating the burden of 369 diseases and injuries in 204 countries and territories. An exploration and additional analysis of the GBD 2019 would provide a clearer picture of the incidence and burden of hip fractures.

QUESTIONS/PURPOSES

Using data from the GBD 2019, we asked, (1) What are the global, regional, and national incidences of hip fractures, and how did they change over a recent 30-year span? (2) What is the global, regional, and national burden of hip fractures in terms of years lived with disability, and how did it change over that same period? (3) What is the leading cause of hip fractures? (4) How did the incidence and years lived with disability of patients with hip fractures change with age, gender, and sociodemographic factors?

METHODS

This was a cross-sectional study. Participant data were obtained from the GBD 2019 ( http://ghdx.healthdata.org/gbd-results-tool ). The GBD study is managed by the WHO, coordinated by the Institute of Health Metrics and Evaluation, and funded by the Bill and Melinda Gates Foundation. It estimates the burden of disease and injury for 204 countries by age, gender, and sociodemographic factors, and can serve as a valuable reference for health policymaking. All estimates and their 95% uncertainty interval (UI) were produced using DisMod-MR 2.1, a Bayesian meta-regression tool in the GBD 2019. In this study, we directly pulled the age-standardized incidence rate and years lived with disability rate of hip fractures by location, age, gender, and cause from the GBD 2019. Based on these data, we analyzed the association between the incidence rate and latitude of each country. Then, we calculated the estimated annual percentage change to represent trends from 1990 to 2019. We also used the Spearman rank-order correlation analysis to determine the correlation between the incidence or burden of hip fractures and the sociodemographic index, a composite index of the income per capita, average years of educational attainment, and fertility rates in a country.

RESULTS

Globally, hip fracture incidences were estimated to be 14.2 million (95% UI 11.1 to 18.1), and the associated years lived with disability were 2.9 million (95% UI 2.0 to 4.0) in 2019, with an incidence of 182 (95% UI 142 to 231) and 37 (95% UI 25 to 50) per 100,000, respectively. A strong, positive correlation was observed between the incidence rate and the latitude of each country (rho = 0.65; p < 0.001). From 1990 to 2019, the global incidence rate for both genders remained unchanged (estimated annual percentage change 0.01 [95% confidence interval -0.08 to 0.11]), but was slightly increased in men (estimated annual percentage change 0.11 [95% CI 0.01 to 0.2]). The years lived with disability rate decreased slightly (estimated annual percentage change 0.66 [95% CI -0.73 to -0.6]). These rates were standardized by age. Falls were the leading cause of hip fractures, accounting for 66% of all patients and 55% of the total years lived with disability. The incidence of hip fractures was tightly and positively correlated with the sociodemographic index (rho 0.624; p < 0.001), while the years lived with disability rate was slightly negatively correlated (rho -0.247; p < 0.001). Most hip fractures occurred in people older than 70 years, and women had higher incidence rate (189.7 [95% UI 144.2 to 247.2] versus 166.2 [95% UI 133.2 to 205.8] per 100,000) and years lived with disability (38.4 [95% UI 26.9 to 51.6] versus 33.7 [95% UI 23.1 to 45.5] per 100,000) than men.

CONCLUSION

Hip fractures are common, devastating to patients, and economically burdensome to healthcare systems globally, with falls being the leading cause. The age-standardized incidence rate has slightly increased in men. Many low-latitude countries have lower incidences, possibly because of prolonged sunlight exposure. Policies should be directed to promoting public health education about maintaining bone-protective lifestyles, enhancing the knowledge of osteoporosis management in young resident physicians and those in practice, increasing the awareness of osteoporosis screening and treatment in men, and developing more effective antiosteoporosis drugs for clinical use.

LEVEL OF EVIDENCE

Level III, prognostic study.

Insight into falls prevention programmes for people with visual impairments and intellectual disabilities: A scoping review

The aim of this study was to review the current literature on falls prevention in people with visual impairment and to estimate the applicability of methods of fall prevention for people with visual impairment and intellectual disability. A scoping review was performed according to the Arksey and O’Malley framework. Relevant studies were collected from PubMed, Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL). All records covering the time span from January 1980 until November 2017 were collected. Studies were included if the participants had a visual impairment according to objective ophthalmic assessments, the article described interventions to reduce falls or risk factors for falls, and the study was written in English and published in a peer-reviewed journal. The methodological quality of the studies were determined by consensus of the authors on the PEDro scale. Fifteen articles were included in this scoping review. Three articles focused on screening and intervention programmes, five articles addressed the effectiveness of environmental adjustments, and seven articles involved training programmes for physical improvement. Environmental adjustments emerged as having the best evidence for falls prevention for people with a visual impairment. Physical training programmes improved balance in those with a visual impairment but could not reduce the number of falls. Environmental adjustments also may be effective for persons with a visual impairment and intellectual disability. In addition, multifactorial screening and intervention programmes are recommended as an important new research direction with important clinical implications.

Orthogeriatrics in Hip Fracture

Orthogeriatrics is a system of care for complex elderly patients who have suffered fragility fractures. This has resulted in demonstrable improvements in care for patients with hip fracture. The article includes a review of the early history of orthogeriatrics as well as current concepts in orthogeriatric care including the use of national databases, audit and important aspects of clinical care such as analgesia, perioperative decision making, ceilings of care and rehabilitation.

[Co-management in geriatric traumatology]

BACKGROUND

Fragility fractures are becoming more common and are leading to significantly increased morbidity and mortality rates.

METHOD

In order to improve the outcome of these patients, they are increasingly being treated from the beginning interdisciplinarily and interprofessionally as part of co-management models. The main contents of these systems are rapid surgical stabilization for rapid remobilization, treatment with standardized paths and regular communication within the team and a well-functioning discharge management. Furthermore, the organization is a key ingredient in secondary prevention of geriatric traumatology.

CONCLUSION

If this system can be implemented as a whole, this will lead to an improvement of the functional outcomes for the patient as well as to cost savings.

Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossébo randomised controlled trial

OBJECTIVE

To assess the effectiveness of a two year exercise programme of progressive balance retraining in reducing injurious falls among women aged 75-85 at increased risk of falls and injuries and living in the community.

DESIGN

Pragmatic multicentre, two arm, parallel group, randomised controlled trial.

SETTING

20 study sites in 16 medium to large cities throughout France.

PARTICIPANTS

706 women aged 75-85, living in their own home, and with diminished balance and gait capacities, randomly allocated to the experimental intervention group (exercise programme, n=352) or the control group (no intervention, n=354).

INTERVENTION

Weekly supervised group sessions of progressive balance training offered in community based premises for two years, supplemented by individually prescribed home exercises.

OUTCOME MEASURES

A geriatrician blinded to group assignment classified falls into one of three categories (no consequence, moderate, severe) based on physical damage and medical care. The primary outcome was the rate of injurious falls (moderate and severe). The two groups were compared for rates of injurious falls with a "shared frailty" model. Other outcomes included the rates of all falls, physical functional capacities (balance and motor function test results), fear of falling (FES-I), physical activity level, and perceived health related quality of life (SF-36). Analysis was by intention to treat.

RESULTS

There were 305 injurious falls in the intervention group and 397 in the control group (hazard ratio 0.81, 95% confidence interval 0.67 to 0.99). The difference in severe injuries (68 in intervention group v 87 in control group) was of the same order of magnitude (0.83, 0.60 to 1.16). At two years, women in the intervention group performed significantly better on all physical tests and had significantly better perception of their overall physical function than women in the control group. Among women who started the intervention (n=294), the median number of group sessions attended was 53 (interquartile range 16-71). Five injurious falls related to the intervention were recorded.

CONCLUSION

A two year progressive balance retraining programme combining weekly group and individual sessions was effective in reducing injurious falls and in improving measured and perceived physical function in women aged 75-85 at risk of falling.Trial registration ClinicalTrials.gov (NCT00545350).

Vision and Relevant Risk Factor Interventions for Preventing Falls among Older People: A Network Meta-analysis

Our study objective was to determine the effect of vision intervention and combinations of different intervention components on preventing falls and fall-related injuries among older people. Six electronic databases were searched to identify seven articles published before May, 2014. We conducted a systematic review of data from seven randomized controlled trails and identified eight regimens: vision intervention alone (V), vision plus exercise (referred to as physical exercise) interventions (V + E), vision plus home hazard interventions (V + HH), vision plus exercise plus home hazard interventions (V + E + HH), vision plus exercise plus sensation interventions (V + E + S), vision plus hearing interventions (V + H), vision plus various risk factor assessment and interventions (V + VRF), and the control group (C, no intervention group). The main outcome was the incidence of falls during the follow-up period. Seven papers included 2723 participants. Network meta-analysis of seven trials, using pairwise comparisons between each intervention, indicated there was no significant difference. However, there was a trend in which intervention incorporating V + VRF had more advantages than any other combination of interventions. In conclusion, V + VRF proves to be more effective than other V combination interventions in preventing falls in older people (≥65 years of age). V alone appears less effective in our network meta-analysis.