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Falls and Hip Fractures

by Benjamin W. Pearce

How serious is the problem?

Ninety percent of the more than 352,000 hip fractures in the U.S. each year are the result of a fall. The remaining 10 percent of the hip fractures occur spontaneously due to low bone density or osteoporosis. Spontaneous fractures can then precipitate the fall. Women have two to three times as many hip fractures as men, and white post menopausal women have a 1 in 7 chance of a hip fracture during their lifetime. The hip fracture rate increases at age 50, doubling every five to six years. More than one-third of adults ages 65 years and older fall each year (Hornbrook 1994; Hausdorff 2001). Nearly one half of the women who reach 90 will have suffered a hip fracture.

Among older adults, falls are the leading cause of injury deaths (Murphy 2000) and the most common cause of nonfatal injuries and hospital admissions for trauma (Alexander 1992). In 2003 more than 1.8 million seniors age 65 and older were treated in emergency departments for fall-related injuries and more than 421,000 were hospitalized (CDC 2005).

What outcomes are linked to falls?

In 2002, nearly 13,000 people ages 65 and older died from fall-related injuries (CDC 2004). More than 60% of people who die from falls are 75 and older (Murphy 2000). Of those who fall, 20% to 30% suffer moderate to severe injuries such as hip fractures or head traumas that reduce mobility and independence, and increase the risk of premature death (Sterling 2001). Only 25 percent of hip fracture patients will make a full recovery; 40 percent will require nursing home care; 50 percent will need a cane or walker; and 24 percent of those over the age of 50 will die within 12 months.

Falls are a leading cause of traumatic brain injuries (Jager 2000). Among older adults, the majority of fractures are caused by falls (Bell 2000). Approximately 3% to 5% of older adult falls cause fractures (Cooper 1992; Wilkins 1999). Based on the 2000 census, this translates to 360,000 to 480,000 fall-related fractures each year. The most common fractures are of the vertebrae, hip, forearm, leg, ankle, pelvis, upper arm, and hand (Scott 1990).

How can seniors reduce their risk of falling?

Through careful scientific studies, researchers have identified a number of modifiable risk factors:

Lower body weakness (Graafmans 1996)
Problems with walking and balance (Graafmans 1996; AGS 2001)
Taking four or more medications or any psychoactive medications (Tinetti 1989; Ray 1990; Lord 1993; Cumming 1998).

Seniors can modify these risk factors by:

Increasing lower body strength and improving balance through regular physical activity can help to reduce the incidence of falls (Judge 1993; Lord 1993; Campbell 1999). Seniors who are mobile and walk regularly can keep their joints and muscles limber which reduce their risk of falling. People who are sedentary and allow their muscles to atrophy are highly at risk of falling.

Proper nutrition can also help reduce the risk of falling. Seniors who are undernourished are often unsteady on their feet and can even feel dizzy when they stand up. Inadequate nutrition can also lead to a number of other health failures and diseases that further destabilizes the body. Proper diet and exercise can significantly improve strength and endurance which mitigates fall risk.

Asking their doctor or pharmacist to review all their medicines (both prescription and over-the-counter) to reduce side effects and interactions can also help. It may be possible to reduce the number of medications used, particularly tranquilizers, sleeping pills, and anti-anxiety drugs (Ray 1990). Medicines effect gait and balance for most adults. Limiting the number of different medicines that one is taking can help to stabilize and reduce fall risk.

Studies have shown that some other important fall risk factors are Parkinson's Disease, history of stroke, arthritis (Dolinis 1997), dementia and cognitive impairment (Tromp 2001), and visual impairments (Dolinis 1997; Ivers 1998; Lord 2001). To reduce these risks, seniors should see a health care provider regularly for chronic conditions and have an eye doctor check their vision at least once a year. Seniors with dementia tend to be less careful ambulating than their non-demented counterparts who are constantly aware of and fear the consequences of a fall.

Randomized trials have demonstrated that calcium supplementation and estrogen are effective in preserving bone density in postmenopausal women. In a randomized trial in healthy postmenopausal women, calcium supplementation slowed bone loss and significantly reduced symptomatic fractures. Numerous observational and nonrandomized experimental studies suggest that risk of fracture can be reduced 25-50% by estrogen replacement therapy as well (Chaupy 1994). All women should also receive counseling regarding universal preventive measures related to fracture risk, such as dietary calcium and vitamin D intake, weight-bearing exercise, and smoking cessation from their physician.

What other things may help reduce fall risk?

Because seniors spend most of their time at home, one-half to two-thirds of all falls occur in or around the home (Wilkins 1999). Most fall injuries are caused by falls on the same level (not from falling down stairs) and from a standing height (for example, by tripping while walking) (Ellis 2001). Therefore, it makes sense to reduce home hazards and make living areas safer. Researchers have found that simply modifying the home does not reduce falls. Common environmental fall hazards include tripping hazards, lack of stair railings or grab bars, slippery surfaces, unstable furniture, and poor lighting (Northridge 1995; Connell 1996; Gill 1999).

To make living areas safer, seniors should:

Remove tripping hazards such as throw rugs and clutter in walkways;
Use non-slip mats in the bathtub and on shower floors;
Have grab bars put in next to the toilet and in the tub or shower;
Have handrails put in on both sides of stairways;
Improve lighting throughout the home.
Diagnosis and Treatment

The doctor will x-ray the hip to determine exactly where the bone is broken and how far out of place the pieces have moved. Most hip fractures are one of two types: Femoral neck fractures are 1-2 inches from the joint or; Intertrochanteric fractures are 3-4 inches from the joint. Modern treatment for hip fractures aims to get you back on your feet again as soon as possible. The doctor will reposition the fracture and hold it in place with an internal device. Femoral neck fractures are usually stabilized with surgical screws or pins. These are used if you are younger, or if your broken bone has not moved much out of place. If you are older and less active, you may need a high strength metal device that fits into your hip socket, replacing the head of your femur (hemiarthroplasty). For Intertrochanteric fractures a metallic device (compression screw and side plate) holds the broken bone in place while it allows the head of the femur to move normally in the hip socket.

Recovery depends largely on the extent of the injury and the overall health and fitness of the patient. Some patients respond readily to physical therapy and rehabilitation, especially those with positive attitudes and cognitive awareness. Others who are less cooperative are more at risk for a prolonged recovery, or further decline. Ample research has demonstrated the mind's ability to influence our health and recovery. People who suffer a hip fracture often experience a sense of helplessness and despair which can lead to depression. Helping victims through their rehabilitation and recovery through positive reinforcement can often dramatically influence the results. Returning them to their home and familiar routine promptly will also enable them to focus on healing allowing them to feel more in control of their future rather than fearing what may be to come which is beyond their control.

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References and Further Reading

Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992;82(7):1020-3.

American Geriatrics Society, et al. Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society 2001;49:664-672.

Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. Medical Journal of Australia 2000;173(4):176-7.

Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Falls prevention over 2 years: a randomized controlled trial in women 80 years and older. Age and Aging 1999;28:513-18.

Centers for Disease Control and Prevention. Incidence and costs to Medicare of fractures among Medicare beneficiaries aged >65 years--United States, July 1991-June 1992. MMWR 1996;45(41):877-83.

Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2005). National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer). Available from: URL: www.cdc.gov/ncipc/wisqars. [Cited 7 Aug 2005].

Chapuy MC, Arlot ME, Delmas PD, et al. Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women. BMJ 1994;308:1081-1082. a. Reid IR, Ames RW, Evans MC, et al. Long-term effects of calcium supplementation on bone loss and fractures in postmenopausal women: a randomized controlled trial. Am J Med 1995;98:331-335.

Connell BR. Role of the environment in falls prevention. Clinics in Geriatric Medicine 1996;12(4):859-80.

Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: a world-wide projection. Osteoporosis International 1992;2(6):285-9.

Cumming RG. Epidemiology of medication-related falls and fractures in the elderly. Drugs and Aging 1998;12(1):43-53.

Dolinis J, Harrison JE, Andrews GR. Factors associated with falling in older Adelaide residents. Australian and New Zealand Journal of Public Health 1997;21(5):462-8.

Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age and Ageing 1999;28:121-5.

Ellis AA, Trent RB. Do the risks and consequences of hospitalized fall injuries among older adults in California vary by type of fall? Journal of Gerontology: Medial Sciences 2001:56A(11):M686-92.

Gill TM, Williams CS, Robison JT, Tinetti ME. A population-based study of environmental hazards in the homes of older persons. American Journal of Public Health 1999;89(4):553-6.

Graafmans WC, Ooms ME, Hofstee HMA, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: a prospective study of risk factors and risk profiles. American Journal of Epidemiology 1996;143:1129-36.

Hall SE, Williams JA, Senior JA, Goldswain PR, Criddle RA. Hip fracture outcomes: quality of life and functional status in older adults living in the community. Australian and New Zealand Journal of Medicine 2000;30(3):327-32.

>Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050-6.

Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community-dwelling older persons: Results from a randomized trial. The Gerontologist 1994:34(1):16-23.

Ivers RQ, Optom B, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains eye study. Journal of the American Geriatrics Society 1998;46:58-64.

Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992-1994. Academic Emergency Medicine 2000;7(2):134-40.

>Judge JO, Lindsey C, Underwood M, Winsemius D. Balance improvements in older women: effects of exercise training. Physical Therapy 1993;73(4):254-65.

Lord SR, Caplan GA, Ward JA. Balance, reaction time, and muscle strength in exercising older women: a pilot study. Archives of Physical and Medical Rehabilitation 1993;74(8):837-9.

Lord SR, Dayhew J. Visual risk factors for falls in older people. Journal of the American Geriatrics Society 2001;49:508-15.

Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports, vol. 48, no. 11. Hyattsville (MD): National Center for Health Statistics; 2000.

Northridge ME, Nevitt MC, Kelsey JL, Link B. Home hazards and falls in the elderly--the role of health and functional status. American Journal of Public Health 1995;85(4):509-15.

Ray W, Griffin MR. Prescribed medications and the risk of falling. Topics in Geriatric Rehabilitation 1990;5:12-20.

Samelson EJ, Zhang Y, Kiel DP, Hannan MT, Felson DT. Effect of birth cohort on risk of hip fracture: age-specific incidence rates in the Framingham Study. American Journal of Public Health 2002;92(5):858-62.

Sterling DA, O'Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma-Injury Infection and Critical Care 2001;50(1):116-9.

Stevens, JA, Olson S. Reducing falls and resulting hip fractures among older women. In: CDC Recommendations Regarding Selected Conditions Affecting Women's Health. MMWR 2000;49(RR-2):3-12.

Tinetti ME, Speechley M. Prevention of falls among the elderly. New England Journal of Medicine 1989;320(16):1055-9.

Tromp AM, Pluijm SMF, Smit JH, Deeg DJH, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. Journal of Clinical Epidemiology 2001;54:837-44.

U.S. Bureau of the Census. Population Projections Program, Population Division, Washington, D.C. Available: www.census.gov/population/www/projections/popproj.html, 2002.

Wilkins K. Health care consequences of falls for seniors. Health Reports 1999;10(4):47-55.

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