Letters

Hip protectors

Carpets can be used to reduce injury from falls

Integrated approach to care of older people is necessary

Acceptability of hip protectors was 35% at six months in the community

Rate of adherence is 42% at three months in residential homes

Carpets can be used to reduce injury from falls

EDITORIt takes about 40 years of wearing hip protectors to prevent one fracture, according to the editorial by Cameron,¹ so other strategies may be helpful. Hip protectors look like institutional underwearwhite, plain, and unfashionable. Making them more attractive might improve their acceptability. The alternative approach is to pad the floor. Carpet improves gait in older people² and in a small observational study dramatically reduced serious injury from falls.³ Perhaps it's time for the Axminster trial of hip protection.

Jed Rowe, consultant geriatrician. 
Well Balanced Clinic, Moseley Hall Hospital, Birmingham B13 8JL jedrowe{at}geriatrickery.freeserve.co.uk

Integrated approach to care of older people is necessary

EDITORWe wish to raise the contentious issue of funding in the context of the management of falls in care homes. Critical success factors for the use of hip protectors are accurate fitting and compliance, as mentioned in the editorial by Cameron¹; these can be difficult in care homes now that the prevalence of dementia is increasing. Furthermore, wearing hip protectors may be a confounding factor in continence and an impediment to the promotion of continence. A more environmental approach in care homes might be as effective and less intrusive.

The mechanical assault on a hip from a fall will depend on the properties of the flooring. Floor coverings in institutional settings are inevitably a compromise between homeliness, clinical appropriateness (largely the maintenance of cleanliness), and cost. Floor coverings are available with cushioning, as has been used for reducing head injury in children's playgrounds. Environmental design and technology have much unexploited potential for unobtrusive risk management.

People will certainly need three sets of protectors, with an estimated initial outlay of £120 per person, and several replacements will be required over time; that, together with the added care to ensure appropriate placement and compliance, greatly adds to the cost. Although this may be justified, the question of who pays remains unclear. Presently, we are occasionally obliged to provide hip protectors from social care money; investment by health services is sporadic.

In the United Kingdom the justification for and funding of hip protectors and environmental protection cuts across health technology assessment and the work of the National Institute for Clinical Excellence. Perhaps eventually funding will be withdrawn from orthopaedic trauma and rehabilitation programmes to facilitate this preventive care.

Hip protectors show that an integrated approach to the health and care of older people is necessary to yield outcome improvement.

Clive Bowman, medical director. 
Ian Ireland, head of quality. 
BUPA Care Services, Horsforth, Leeds LS18 4UP bowmanc{at}bupa.com

Acceptability of hip protectors was 35% at six months in the community

EDITORCameron identifies the low use of hip protectors as one of the main drawbacks to their more general use.¹ Initial compliance rates of 50-60% have been reported, but, as Cameron points out, little research has been done into the acceptability of the protectors among patients living in the community. ^{2 3} We carried out a small study to assess acceptability in such a group.

Forty nine patients with osteoporosis living in inner city Belfast were provided with hip protectors (Safehip). After six months the project nurse completed a questionnaire to assess the rate of use and the factors influencing this. The acceptance rate was initially 53% (26/49) and fell to 35% (17/49) at six months. The patients rated the protectors poorly on bulkiness, heat, and the tightness of the waistband; these were also the factors that most strongly influenced their decisions on wearing them. They also disliked the plastic cover and the noise made on movement when the protectors were in place. Overall appearance, appearance under tight clothes, and looking after the protectors were rated more favourably.

Many patients said that it was difficult to get the hip protectors on and off (19 rated it generally difficult or very difficult, and 20 commented that it was difficult or very difficult to get them on and off to go to the toilet). Similar factors have been noted in other studies.^2-4 Few of the patients were prepared to wear the hip protectors at night.

Those who wore the hip protectors were almost three times more likely than those who did not to believe that they offered protection from hip fractures (86% (25/29) v 30% (6/20)). Two thirds of patients wearing the protectors felt more confident about going out. Most patients (46) stated that they would be likely or very likely to recommend the protectors to a friend.

Some problems were identified in patients who forgot the hip protectors in a nursing home, so forgetting them is likely to be more of a problem with patients living at home. Compliance may be improved in this group if primary care workers in contact with the patients remind them that hip protectors should be used every day.

Jeni M McAughey, general practitioner. 
Skegoneill Health Centre, 195 Skegoneill Avenue, Belfast BT15 3LL jmmcaughey{at}doctors.org

Margaret McAdoo, project nurse, North and West Belfast Locality Consortium. 
Springfield Road Surgery, Springfield Road, Belfast BT12 7AH

Rate of adherence is 42% at three months in residential homes

EDITORWith reference to Cameron's editorial, we have previously shown that patients' adherence with hip protectors is achievable at a level that is likely to result in reduction of hip fractures but were unable to assess usage in subjects with cognitive dysfunction, confusion, or incontinence because of ethical issues in a controlled trial. ^{1 2} The establishment of a hip protector service in Dorset has allowed us to study these factors in an observational study.

Residential homes in Poole were approached, offering their residents hip protectors. Assessments were made of falls risk (modified STRATIFY score), cognitive function, confusion, and urinary continence. Residents were offered hip protectors free of charge. Assessment of adherence was made after 1 week and 3, 6, and 12 months. Forty seven residential homes with 783 beds are taking part. Over 880 residents have been identified, mean age 88 (SD 7) years; the female:male ratio is 4.6:1. Of the 873 residents who were offered protectors, 645 expressed an interest and 612 were wearing them at one week. Of the 753 residents so far assessed at three months, 340 were wearing protectors. At three months 180 out of 292 incontinent residents compared with 158 out of 369 (43%) residents who were continent were wearing protectors, as well as 170 out of 291 (58%) residents with dementia compared with 169 out of 474 (35%) without dementia, and 89 out of 141 (63%) residents who were always confused compared with 150 out of 292 (51%) of residents who were sometimes confused and 95 out of 227 (42%) who were never confused (P<0.001, Mann-Whitney test). There was correlation between the risk of falling and adherence (STRATIFY score 0=33%, 1=45%, 2=52%, 3=49%, 4=73%, and 5=82%).

Extrapolating the results to all residents suggests 42% adherence at three months, a rate greater than in our previous study and likely to result in a reduced incidence of hip fracture. The higher adherence among cognitively impaired subjects, confused subjects, and subjects at high risk of falling supports our concept that hip protectors are worn by subjects at greatest risk of fracture.³

Paul W Thompson, consultant rheumatologist. 
Poole Hospital, Poole, Dorset BH15 2JB pwt{at}dial.pipex.com

Carol Jones, osteoporosis prevention officer. 
Osteoporosis Dorset, Bournemouth, Dorset BH1 4JQ

Tracy Villar, consultant physician, care of the elderly. 
Poole Hospital NHS Trust, Poole, Dorset BH15 2JB

   This work is administered by Osteoporosis Dorset (Registered Charity No 1023507) and funded by Dorset Health Authority and Poole Social Services).