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ANALYSIS: Teppo L N Järvinen, Harri Sievänen, Karim M Khan, Ari Heinonen, and Pekka Kannus Shifting the focus in fracture prevention from osteoporosis to falls BMJ 2008; 336: 124-126 [Full text]

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Don't forget simple preventions

Tom Sargent   (19 January 2008)

Vision assessment and fall prevention in the elderly

Peter D Cackett   (20 January 2008)

More focus on falls but not at the expense of osteoporosis care

Jonathan R Bayly, Tahir Masud   (21 January 2008)

Occupational Therapy has a primary preventative role

Anita Atwal, Christine Craik. Director of Occupational Therapy. Associate Director Centre for Professional Practice Research, Deputy Head (Learning and Teaching). Anne Mcintyre Lecturer in Occuaptional Therapy   (21 January 2008)

Don't forget simple preventions: Baffiectomy!

Reinhard Wentz   (21 January 2008)

Falls Prevention: The Stork Challenge – A Simple Balance Test Helps Motivate People to Exercise

Lyn Williamson   (22 January 2008)

Home Safety - helping prevent falls

Dafydd Pugh Jones   (22 January 2008)

Falls and the designs of our standard homes

Roohi Afshan, H. Khan ( My mother)   (23 January 2008)

Reducing the number of falls will also help

Joseph R. Herr   (24 January 2008)

Home environment dangers

Vinu Raj   (25 January 2008)

Re: Home environment dangers

John W Myles   (25 January 2008)

“Falls and Osteoporosis; the alarming couple”

A Michael   (29 January 2008)

Preventing Falls – clinically and cost effective

Karim M Mahawish, James A. Barrett   (13 February 2008)

Authors' reply: Focusing fracture prevention on falls!

Teppo L Järvinen, Karim M Khan, Harri Sievänen, Ari Heinonen, and Pekka Kannus   (17 February 2008)

Don't forget simple preventions 19 January 2008
Tom Sargent, Retired GP Bo'ness, West Lothian EH51 0DH Send response to journal: Re: Don't forget simple preventions	Editor The illustration on the front of the 19th January 2008 BMJ hints at a simple and very effective means of fall prevention. The Baffiectomy. There was a publication on this in the BMJ a few years ago but I cannot find the term in your search engine. Many patients in their 80s have very ancient slippers which have long lost supportive elements especially around the heel. This greatly increases the risk of falls especially on bends in the stairs. Slippers can be removed and replaced with safer, newer ones with considerable reduction in risk. It can be a relatively simple procedure but there is a risk of trauma to those removing the Baffies from the elderly person without permission. A glance is enough to make the diagnosis. A home visit to the patient or other persons in the household can be of benefit in the making of the diagnosis as the evidence is often removed before surgery attendance. Explanation to the patient or relatives may produce the appropriate treatment (with no charge to the NHS) in the form of a Christmas or Birthday present. As with many simple diagnoses the awareness of this problem may be lifesaving and no specific tests are necessary. Competing interests: None declared
Vision assessment and fall prevention in the elderly 20 January 2008
Peter D Cackett, Clinical Research Fellow Singapore Eye Research Institute, Singapore 168751 Send response to journal: Re: Vision assessment and fall prevention in the elderly	Dear editor I read with interest the article by Järvinen et al. and would like to highlight the importance of assessment of visual function in the elderly in the general practice setting as an important method of identifying those patients at high risk of falls. In a recent Scottish study by Cox et al. of 537 patients admitted with hip fracture, 46% patients were found to have bilateral visual impairment (binocular visual acuity worse than 6/12) and in the majority of cases the cause of this visual defect such as cataract and uncorrected refractive error was potentially remediable.1,2 They further demonstrated that a significant proportion of these patients had not accessed optometric and ophthalmic care pathways and social deprivation appeared to be an underlying cause of this. Therefore simple visual acuity screening in a general practice setting and appropriate referral for visually impaired patients may be a simple cost effective way of fall and subsequent fracture prevention in the elderly. 1. Cox A, Blaikie A, MacEwen CJ, Jones D, Thompson K, Holding D, Sharma T, Miller S, Dobson S, Sanders R. Visual impairment in elderly patients with hip fracture: causes and associations. Eye. 2005 Jun;19(6):652-6. 2. Cox A, Blaikie A, Macewen CJ, Jones D, Thompson K, Holding D, Sharma T, Miller S, Dobson S, Sanders R. Optometric and ophthalmic contact in elderly hip fracture patients with visual impairment. Ophthalmic Physiol Opt. 2005 Jul;25(4):357-62. Competing interests: None declared
More focus on falls but not at the expense of osteoporosis care 21 January 2008
Jonathan R Bayly, Lecturer, osteoporosis and falls University of Derby, Keddleston Road, Derby, DE22 1GB, UK, Tahir Masud Send response to journal: Re: More focus on falls but not at the expense of osteoporosis care	The article by Järvinen and colleagues (1) is correct in reminding us that falls are important determinants of fracture risk. This aspect is too often ignored by clinicians who manage patients with low trauma fractures as suggested by the low level of documented falls assessments in a recent study in over 3 million patients registered with UK general practitioners (2). The opportunity to diagnose and treat conditions which increase the risk of falls is often missed in these patients. However, rather than shifting the emphasis from bone strengthening pharmacotherapy towards interventions designed to reduce falls, as suggested by Järvinen and colleagues, we believe that the better message should be to add falls assessment and interventions to osteoporosis treatments, in the prevention of fractures. In the UK the strategy is most definitely not screening and treatment of those with osteoporosis as inferred in this paper but risk factor based selective case-finding and the review by Poole and colleagues (3) referenced in the same article endorses that approach. The highest risk patients are those with poor bone health and a prior low trauma fracture, almost always as a result of a fall. Their identification, assessment and management by both pharmacological treatment and falls risk reduction is strongly advocated in guidance recently issued by the British Orthopaedic Association and the British Geriatric Association and endorsed by many other relevant national organisations in the UK (4). A systematic approach to both secondary fracture prevention and the identification of high risk fallers was the subject of separate submissions by the National Osteoporosis Society and the British Geriatric Society respectively to the Expert Review Group for inclusion within the Quality Outcomes Framework of the new general practitioners’ contract in the UK. The pharmacological approach suggested to fracture in the former is notably endorsed as cost effective by the National Institute for Health and Clinical Effectiveness (5) One of the problems with attempting to reduce fracture incidence by prioritising falls interventions is that there is no evidence base for community dwelling older people and the studies listed by Järvinen and colleagues do not support claims for a statistically significant 50% reduction in fracture rates in this setting through falls interventions. This is the thrust of the systematic review by Gates and colleagues in the same edition of the BMJ (6). It is essential that health care planning does not skate over this gap and that national policy is not put ahead of the evidence base. Individual falls studies, as opposed to systematic review, may indeed suggest that the number of falls or fallers may be reduced, but not fractures. We do not know the ones that we can stop falling were the ones who were going to fracture and we know little about the ‘offset of effect’ and therefore need to be cautious. The first line treatment for osteoporosis in clinical practice, generic alendronate, is now £4.12 ($8.05, €5.5) per month in the UK and hardly expensive at nearly one third of the mean of all prescription item costs and is shortly to ‘go generic’ in the US market as well. This affords the opportunity for economical treatment for the majority who will be able to tolerate alendronic acid and for whom it is appropriate. A multi-disciplinary falls intervention costs of the order of £600 ($1175, €794) based upon estimations in the Service Development Organisation report (7) that underpins the Gates paper and the known throughput of 1.7 new patients per 100,000 population per week (8). We are unlikely therefore to see a significant impact on the almost 70,000 hip fractures (9) we will expect to occur in England this year through integrated falls services alone and probably evidence-based falls interventions of any kind. A risk factor for fracture may be important but has to be shown not only to be associated and causative but that its modification will impact upon the desired outcome of fracture reduction. Likewise, though the global conspiracy argument may be over-stated, the main point made by Alonso-Coello and colleagues (10) also in the same edition is correct. Therapies, however effective, will not be well directed if they are aimed at those with low absolute risk, such as an arbitrary classification group like those with osteopenia. The priority should be fragility fracture prevention in those with poor bone health and a prior low trauma fracture where even those with the much derided label of ‘osteopenia’ have a four-fold likelihood of fracture compared to those with neither risk factor (11). Here we sincerely hope an absolute fracture risk tool will help us to identify those who will benefit from therapy. The challenge remains as to what is the most effective way to reduce the more than 10% annual increase in falls admissions in England over the last two years (9). The evidence is clear though that the priority for fracture rate reduction currently lies with secondary fracture prevention. Nearly 50% of hip fracture patients have had a prior low trauma fracture (12) and only 10-20% will have received optimal care (13,14). Far from shifting the balance away from osteoporosis treatments for fracture prevention we need to face up to the challenge of delivering interventions that have been robustly shown to link closely to vertebral and hip fracture rate reduction. Currently falls interventions do not fall in to that category. Delivering this is also a challenge for health care planners, commissioners and providers but could be achieved by the adoption of recommendations made in two recent government funded reports (2,14) for the universal adoption of fracture liaison services and a domain for osteoporosis within the QOF. The latter sadly appears to have lost out to an increase in GP surgery opening hours which has no solid evidence base for fracture reduction or indeed any health outcome at all. 1. Jarvinen TLN, Sievanen H, Khan KM, Heinonen A, Kannus P. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ. 2008 January 19, 2008;336(7636):124-6. 2. Hippisley-Cox J, Bayly J, Potter J, Fenty J, Parker C. Evaluation of standards of care for osteoporosis and falls in primary care: The Health and Social Care Information Centre; 2007. 3. Poole KES, Compston JE. Osteoporosis and its management. BMJ. 2006 December 16, 2006;333(7581):1251-6. 4. British Orthopaedics Association. The Care of Fragility Fracture Patients. London; 2007. 5. National Institute for Health and Clinical Excellence. Bisphosphonates (alendronate, etidronate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Technology appraisal guidance 87; 2005. 6. Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ. 2008 January 19, 2008;336(7636):130-3. 7. Lamb S, Gates S, Fisher J, Cooke M, Carter Y, McCabe C. Scoping Exercise on Fallers’ Clinics: Report to the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO); 2007. 8. The Clinical Effectiveness and Evaluation Unit RCoPL. National Audit of the Organisation of Services for Falls and Bone Health for Older People. Available from: http://www.rcplondon.ac.uk/college/ceeu/fbhop/NationalAuditReportFinal30Jan2006.PDF [Accessed 30 March 2006]. 2006. 9. Department of Health. Hospital Episode Statistics (England). Available from : http://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=192 [Accessed 30 December 2007]. 2006. 10. Alonso-Coello P, Garcia-Franco AL, Guyatt G, Moynihan R. Drugs for pre-osteoporosis: prevention or disease mongering? BMJ. 2008 January 19, 2008;336(7636):126-9. 11. Pasco J, Seeman E, Henry M, Merriman E, Nicholson G, Kotowicz M. The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporosis International. 2006;17(9):1404-9. 12. Edwards BJ, Bunta AD, Simonelli C, Bolander M, Fitzpatrick LA. Prior Fractures Are Common in Patients With Subsequent Hip Fractures. Clinical Orthopaedics & Related Research. 2007;461:226-30. 13. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility Fractures and the Osteoporosis Care Gap: An International Phenomenon. Seminars in Arthritis and Rheumatism. 2006;35(5):293-305. 14. Clinical Effectiveness and Evaluation Unit. National Clinical Audit of Falls and Bone Health. London; 2007 November 2007. Competing interests: J Bayly was the lead author for the recent osteoporosis submission to the QOF review process on behalf of the National Osteoporosis Society and a joint author for the British Geriatric Society's submission on falls. Both he and T Masud have received educational support, honoraria and travel expenses for lectures on falls and bone health and advisory board work from a number of pharmaceutical companies with an interest in these disease areas
Occupational Therapy has a primary preventative role 21 January 2008
Anita Atwal, Lecturer in occupational therapy. Director Centre for Professional Practice Research Brunel University . School of Health Science and Social Care. Uxbridge, Middlesex. UB8 3PH, Christine Craik. Director of Occupational Therapy. Associate Director Centre for Professional Practice Research, Deputy Head (Learning and Teaching). Anne Mcintyre Lecturer in Occuaptional Therapy Send response to journal: Re: Occupational Therapy has a primary preventative role	We welcome and support measures to prevent factures in older adults. Occupational Therapists are in fact best placed to assess older adults in general practice to identify and solve factors relating to falls prevention. For example occupational therapists can not only can assess and solve environmental risk factors but assess function and gait, complete psychological assessments and implement out individual occupation based programs to enable older adults to maintain and enhance independence. Occupational therapists, therefore, might add a positive dimension to health promotion because of their unique understanding of the impact of occupation on health. We acknowledge the need to demonstrate the efficacy of occupational therapy within a health promotion framework, although evidence is emerging to suggest the effective when engaged in primary preventative roles. One piece of research by Clark et al (1997) used a randomised-controlled trial to evaluate the effectiveness of preventative occupational therapy services specially tailored for multiethnic independent living older adults. The findings from this study suggest that preventive health programmes based on occupational therapy may improve the health of older adults . Clark C, Azen SP, Jackson J, Carison M, Mandel D, Hay J, Josephson K, Cherry B, Hessel C, Palmer J, Lipson J (1997) Occupational Therapy for Independent-Living Older Adults. Journal of American Association 278(16), 1321-1326. Competing interests: None declared
Don't forget simple preventions: Baffiectomy! 21 January 2008
Reinhard Wentz, Retired Medical Librarian TW2 7PS Send response to journal: Re: Don't forget simple preventions: Baffiectomy!	Dear Dr Sargent, While the delightful term ‘baffiectomy’ doesn’t seem to appear anywhere in the BMJ in recent years, the concept of ‘removing unsuitable slippers’ has been mentioned in a BMJ News item in 2007 by Owen Dyer ‘Simple precautionary measures can reduce numbers of falls in hospital’ [doi:10.1136/bmj.39139.641875.DB] It contains the note that ‘The key measures of [this] programme were replacing unsuitable slippers, correcting poor vision, reducing symptoms of incontinence to minimise toilet visits, clearly marking the records of patients who had already fallen, and ensuring that walking aids were easily accessible.’ The programme was described in the journal Age and Ageing (2004;33:390-5) and can be seen here (pdf file): http://ageing.oxfordjournals.org/cgi/reprint/33/4/390 One of the study's authors, Angela Cockram, matron for elderly services at York Health Services NHS Trust [is quoted as saying]: "It wasn't rocket science—it was about doing the basic things properly and consistently." With kind regards, Reinhard Wentz, Dipl. Bibl. London Competing interests: None declared
Falls Prevention: The Stork Challenge – A Simple Balance Test Helps Motivate People to Exercise 22 January 2008
Lyn Williamson, Consultant Rheumatologist Rheumatology Department, Great Western Hospital, Swindon SN6 3BB Send response to journal: Re: Falls Prevention: The Stork Challenge – A Simple Balance Test Helps Motivate People to Exercise	Jarvinen and colleagues highlight the fact that the strongest single risk factor for fracture is falling rather than osteoporosis. They also comment that falls risk remains largely overlooked in clinical practice because it is difficult to assess (1). We should like to share with readers an inexpensive falls prevention strategy which incorporates a simple measure of balance that can be modified for use in any healthcare or public waiting area. We developed an exercise walkway for patients to use during outpatient visits. This consists of a series of 10 balance, breathing and stretching exercises. Each exercise is illustrated by a collage of attractive photographs of patients, relatives, friends and staff performing the exercise. The exercises are chosen to be simple; feasible to perform when sitting or standing; concentrating on breathing and core stability; and involving the whole spine, arms and legs. (Neck Stretches; Shoulder Release; Upper Body Stretch; Hip Glide; Hand Stretch; Sitting Quads; Ankle Swivel; Leg Lift; Shuttle Walk). Brief, encouraging instructions accompany the photographs and the information is reinforced by an illustrated leaflet. The walkway starts and finishes with the ‘Stork Test’: a static one-leg balance test with closed eyes. The length of time a person can stand on one leg, with eyes closed is a direct measure of their balance and hence falls risk (2). We introduced the ‘Stork Test’ as a method of engaging and motivating people to continue exercising. We piloted the walkway with 108 people (57 patients, 16 relatives, 35 staff), 28 male, mean age 55 (13-85). With the help of a trained volunteer, they completed the walkway exercises and answered an anonymous questionnaire, documenting the Stork Test measurements and asking about demographics, previous exercise and motivation to further exercise. The Stork Test time decreased with age and improved after the exercises, with a strong correlation between right and left leg. The overall mean times improved from 13.2 seconds to 18.4 seconds (p<0.001). The number with Stork Test times of less than 4 seconds decreased from 25 (24% before exercise to 10 (9.4%) after exercise (p<.001). 78% thought they would continue the exercises at home and 65% said the Stork Test had influenced this decision. The exercise walkway is safely run by trained volunteers. The volunteers themselves benefit from helping with the exercises and feel relaxed after each session. Relatives and friends are invited to take part with patients as this helps overcome the embarrassment of exercising in a public place, and encourages them to continue the exercises together at home. The exercise walkway demystifies core stability exercises, and involves and engages people in a way that simple information giving does not. The Stork test is a clinically relevant, reproducible test of balance and falls risk, which can be used by patients and practitioners to monitor improvement. Whilst we accept there is a need to study the long term effects of these brief interventions, in the short term we feel the exercise walkway allows people to make best use of precious outpatient time. In the current climate of health prevention, this kind of walkway could be used to change the culture of doctors’ waiting rooms from patients passively sitting to them actively improving their own health. References: 1. Jarvinen T, Sievanen H, Khan KM et al BMJ 2008; 336: 124-126 Shifting the focus in fracture prevention from osteoporosis to falls 2. Vellas BJ, Wayne S, Romero L et al J Am Geriatr Soc 1997; 45: 735- 738 One-leg balance is an important predictor of injurious falls in older patients Competing interests: None declared
Home Safety - helping prevent falls 22 January 2008
Dafydd Pugh Jones, Ceredigion Care and Repair Ceredigion, Wales, SY23 Send response to journal: Re: Home Safety - helping prevent falls	Ceredigon Care and Repair developed an innovative new service in 2004, to ensure that falls due to the home environment are reduced. This service was to complement falls prevention work carried out at Bronglais Hospital, which included strength and balance, and medical reviews. We developed our own Home Safety - Risk Assessment tool, which is undertaken by our HS Officer (not an OT). It assesses the home, not the client, and concentrates on access, stairs and passage ways. It also covers Fire Prevention, Security and Energy Efficiency. Advice is given and followed up in writing, and any adaptations are carried out by our own HS Craftsman -e.g. Handrails, stairails, grab rails, tacking down carpets, steps. We receive referrals from Falls teams(led by Dr Hugh Chadderton), Osteoporosis Nurses, District nurses, discharge teams and directly from clients. The scheme is supported by Local Health Board, NHS Trust, Local Authority and Welsh Assembly Government. The service won a Care and Repair Cymru Award for challenging dependence in 2007, and was used as a best practice toolkit by Health Challenge Wales in 2006. Last year 280 older people received the service. Competing interests: None declared
Falls and the designs of our standard homes 23 January 2008
Roohi Afshan, SpR Psychiatry Springfield university hospital SW17 7DJ, H. Khan ( My mother) Send response to journal: Re: Falls and the designs of our standard homes	I read with interest the article " Shifting the focus in fall prevention from osteoporosis to falls" and the comments in the Editors choice regarding strategies for prevention of falls in the recent BMJ . As a SpR(Specialist Registrar) in Old Age Psychiatry, the major portion of my job entails assessment of the elderly patients at their homes. I have been acutely aware of the risks to fall which our home designs pose to this vulnerable group of patients. A fall may mean the difference between continuing to live independently in the community to being forced to give up their loved homes of last 40- 50 years and to go and live among strangers in a completely align environment which is no doubt very distressing . I had the first hand experience of unfriendliness of our home designs to our elders when my mother who is 75 years old recently visited me from overseas and stayed for 2 weeks with me. She has arthritis of knee and mild heart failure and uses diuretics (not uncommon in this age group). Her basic requirement was a bedroom and a toilet downstairs. I have a standard four bed room house which I was very proud of. I hastily converted the tiny study into a bed room for her and was embarrassed by the discomfort she faced during her stay due to the lack of storage space and the risk of falls this narrow room caused. I have come to despise the concept of cloak rooms, the limited space in them limits the mobility of the elderly people and the question of bathing remained unresolved. I had to be with her each time she climbed stairs to have a bath as the arthritis of her knees not only made it difficult but risky to climb stairs. I wonder if most of you had similar experiences when you dared to invite your parents. I now can understand very well when even loving families are unable to take their parents to stay with them for few days on occasions such as Christmas from residential or nursing homes ,and the sadness which it can cause to the parents and the guilt which their children experience from it. When my mother left, I had a good look at my beloved home and asked myself “Will I be able to live with safety and dignity in this house when I eighty?” I am afraid I could not say yes to it, no matter how much I wish to live and die with dignity in my own home, just like most of my patients I wonder why the professionals who are involved in the designing of our standard homes and not just the elderly home, don’t realise that most of us would like the design of our homes to enable us to continue to live in our own homes as we grow old and perhaps be able to invite our parents to come and stay with us occasionally, rather than creating ghastly alterations and adding chair lifts with their inherent risks. After all we are the elders of the future. References: 1.Godlee F. Absolute risk please. Editors choice. BMJ 2008(19th January)Volume 336 2..Teppo L N Jarvinen et al . Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 2008(19th January),124- 126,Volume 336. Competing interests: My mother was the one to suggest thinking about the designs of the standard houses in UK
Reducing the number of falls will also help 24 January 2008
Joseph R. Herr, Retired 94507-1602 Send response to journal: Re: Reducing the number of falls will also help	Reducing the number of exposure to situations during which the senior can fall is an additional approach to fractures with added benefits for the senior. Reducing the number of trips the senior makes to the bathroom at night will drastically reduce exposure to falling. Nocturia is a symptom of obstructive sleep apnea (OSA). By treating OSA the nightly exposure to falling will be reduced. There have been anecdotal reports that treating OSA also treats ulcerative colitis and irritable bowel syndrome with the implication that OSA causes both ulcerative colitis and irritable bowel syndrome. [1,2] During apneas the diaphragm exerts extra effort to overcome the obstruction. The effort can be 10 to 15 times the normal effort by the diaphragm.[3] It seems that the diaphragm's effort could be analogous to the handling the intestines during abdominal surgery. The injury to the intestines and degradation of intestinal performance in sleep apnea patients occurs nightly, while the surgical trauma is a one time affair. There are a number of treatments used with OSA patients with varying results. References: 1) Herr JR. Medical literature implies continuous positive airway pressure might be appropriate treatment for irritable bowel syndrome. Chest. 2002 Sep;122(3):1107. 2) Herr, Joseph R. Measles (MMR) to inflammatory bowel disease (12 November 2003) http://www.bmj.com/cgi/eletters/327/7423/1069-c 3)Guileminault, C. (1985) Obstructive sleep apnea. The clinical syndrome and historical perspective. Medical Clinics of North America 69(6) 1187-1203 Competing interests: The author has been treated for both ulcerative colitis and obstructive sleep apnea.
Home environment dangers 25 January 2008
Vinu Raj, Locum Registrar, Trauma & Orthopaedics Robert Jones & Agnes Hunt Orthopaedic Hospital, SY10 7AG Send response to journal: Re: Home environment dangers	It was interesting to read the responses to the article "Shifting the focus in fracture prevention from osteoporosis to falls", with quite a few concentrating on the home environment. Having worked as the coal face of various surgical departments ( A & E and Trauma & Orthopaedics), one of the most common responses to the question 'How did you fall?' would be 'Fell over in the house' either by tripping on the carpet or due a piece of equipment that was placed in the wrong place. conferring with my colleagues, this seems to be a general occurance, which seems to elude our stringent observations. Usually the case of being obvious after someone pointing it out! Many of the elderly populations do not have family coming down regularly to clean up or to do regular maintanence work at home, which leaves many loose ends dangling, literally and figuratively. This usually ends up as a disaster. We are all aware of how disabling a fracture neck of femur can be to someone who is managing to mobilise within the house and how this can push them over the edge, leading to various hospital acquired infections due long durations of stay. We have all learnt 'Prevention is better than cure'. This is applicable here in no small measure, as prevention of falls will have a multipronged effect on reducing the morbidity & mortality of these elderly patients not forgetting the cost savings. So is it time to ensure that there is adequate preventive maintanence in the houses of the elderly in which more often they live alone? or will it take the health and safety executive into the residences creating more paper work for people dealing with their daily care? Competing interests: None declared
Re: Home environment dangers 25 January 2008
John W Myles, Retired Orthopaedic Surgeon Peterborough Send response to journal: Re: Re: Home environment dangers	Gates and Coleagues have done the elderly a good turn by drawing attention to the importance of falls in the etiology of fractures. As a 77year old - and retired Orthopaedic Surgeon with a long-term interest in hip fractures I would like to emphasise the role of proprioception in steadying one at awkward moments. The lightest touch on wall or banister when, for example, descending the stairs makes a surprising difference to one's feeling of stability. Competing interests: None declared
“Falls and Osteoporosis; the alarming couple” 29 January 2008
A Michael, Consultant Orthogeriatrician Russells Hall Hospital, Dudley DY1 2HQ Send response to journal: Re: “Falls and Osteoporosis; the alarming couple”	Dr Järvinen and colleagues’ concept of shifting the focus in fracture prevention from osteoporosis to falls seems logical; especially that if patients do not fall they will not break bones. However one can argue that if bones are not osteoporotic they are unlikely to break from low trauma. For every one standard deviation that bone mineral density decreases, the risk of all future osteoporotic fractures increases by about 50%. Fractures are the product of two interactive components, falls and bone mineral density, the contribution of each is variable in different clinical scenarios. Our approach to preventing fractures should be multidimensional and holistic, as in other areas of geriatric medicine when pathology is multifactorial. So we should try our best to reduce falls and also prevent bone mineral density decline especially in high risk group, mainly those with low bone mineral density who had previous fractures. Interestingly in one study nearly half of the patients attending Falls Clinic were osteoporotic and one third were osteopenic (1). It seems that there are many links between osteoporosis and falls, and they should be approached concurrently. (1) Michael A, Obiechina N, James R, Tiwary A. “Bone Mineral Density (BMD) In Patients With Falls”. Abstract. Osteoporosis International. 2007; 18 (supplement 3): 8269. Competing interests: None declared
Preventing Falls – clinically and cost effective 13 February 2008
Karim M Mahawish, SpR Geriatrics Arrowe Park Hospital, Upton, Wirral. CH49 5PE, James A. Barrett Send response to journal: Re: Preventing Falls – clinically and cost effective	Approximately 30 per cent of people aged over 65 years fall each year (1) one-tenth of whom sustain a fracture including fracture neck of femur which is associated with significant mortality and loss of independence (2). The high social and health care costs associated with falls should encourage routine screening of elderly patients as highlighted by Järvinen et al (3). The assessment of a person after a fall should take account of appropriate footwear, visual impairment, postural hypotension, continence, the timed ‘get up and go’ test and medication review. The meta-analysis by Gates et al (4) provides less than helpful conclusions. There was considerable heterogeneity in the trials included and the number of participants was small. The results contradict those of SIGN (5), NICE (6), the Cochrane reviews (1,7) and guidance from the National Service Framework for Older People (2). These conclude that multi -factorial interventions are successful in reducing falls, even in a population-based approach. Additionally, recent studies demonstrate that single targeted interventions are as effective in people at risk (8) and a benefit to cost ratio of multi-targeted community intervention programs of 20:1 (9). With an annual cost to the NHS of around £1.7 billion (6), it would make more sense to implement preventative care, conduct nationwide studies on cost effectiveness and campaign for rehabilitation, to prevent further unbundling of services. 1. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews 2003, Issue 4. 2. Implementing the NSF for Older People Falls Standard – Support for commissioning good services. Department of Health, 2003. 3. Järvinen TLN, Sievänen H, Khan KM, Heinonen A, Kannus P. Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 2008; 336:124-126 4. Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: a systematic review and meta-analysis. BMJ 2008; 336: 130-133 5. Scottish Intercollegiate Guidelines Network. SIGN 56. Prevention and management of hip fracture in older people. SIGN, 2002 6. NICE. Falls: The assessment and prevention of falls in older people. National Institute for Health and Clinical Excellence (NICE). National Clinical Guideline 21, November, 2004 7. McClure R, Turner C, PeelN, Spinks A, Eakin E,Hughes K. Population-based interventions for the prevention of fall-related injuries in older people. Cochrane Database of Systematic Reviews 2005, Issue 1 8. Campbell AJ, Robertson MC. Rethinking individual and community fall prevention strategies: a meta-regression comparing single and multifactorial interventions. Age and Ageing 2007; 36: 656–662 9. Beard J, Rowell D, Scott D, Beurden E, Barnett L, et al. Economic analysis of a community-based falls prevention program. Public Health 2006; 120: 742–751 Competing interests: None declared
Authors' reply: Focusing fracture prevention on falls! 17 February 2008
Teppo L Järvinen, Orthopaedic resident Tampere University Hospital, P.O. Box 2000, 33520 Tampere, Finland, Karim M Khan, Harri Sievänen, Ari Heinonen, and Pekka Kannus Send response to journal: Re: Authors' reply: Focusing fracture prevention on falls!	We welcome the numerous responses to our paper entitled “Shifting the Focus in Fracture Prevention from Osteoporosis to Falls” (1). There appears to be a broad consensus on one of the most important issues put forward in our paper – population-wide fracture-preventing interventions should be simple and feasible. As already suggested in 1991 by Law et al. (2), primary prevention of any aging-related public health problem must rely on improving the health-related lifestyle of the entire population. In the case of age-related fractures, strength and balance training, sufficient intake of vitamin D and calcium, and smoking cessation are appropriate measures (2, 3). Falls, the single most important risk factor for fractures in elderly adults, have a multifactorial aetiology; therefore possible preventive measures are protean. We agree with the responses that suggested population-level interventions to reduce the burden of fractures including home visits accompanied with possible safety-enhancing alterations, the assessment of visual function (which in fact, is included in the physiological profile assessment instrument (4) mentioned in our paper), the “baffiectomy”, and treating conditions such as nocturia or obstructive sleep apnea. We also want to thank Drs. Bayly and Masud for encouraging discussion of the role of bone-targeted pharmacotherapy. We share the authors’ view that theoretically an optimal strategy for prevention of fractures in elderly people would include interventions targeted at reducing falls and improving bone strength. However, the continuing rise in health care costs means that health care is under strict economic scrutiny. Although our duty as doctors is clearly to serve our patients, there is increasing recognition that, particularly in publicly-funded health care systems, it is important to consider both the cost and the benefit of treatment. Patients, therapists and those paying for the treatment have a right to know how many older adults needed treatment (the number needed to treat, NNT) to prevent one (hip) fracture and at what cost. In many countries, large-scale fracture prevention with medication is not economically viable. Bearing this in mind, we add the following to Drs. Bayly and Masud’s response: 1) Bayly and Masud infer that our claim that “the risk of falling still remains overlooked in clinical practice as well as in important publications on prevention of fractures” would be flawed. We are happy to learn that numerous agencies in UK have adopted falls prevention along with bone-targeted pharmacotherapy as a means to prevent fractures. Whether this is true in everyday practice in UK and other countries requires audit-type evidence (5). Nevertheless, as evidenced by the title of our paper, we seriously question whether the relative emphasis afforded to falls and drugs in fracture prevention publications is correct. We respectfully reiterate that the focus of these communications does not do justice to the importance of falling as the primary risk factor for fractures. Many fracture prevention papers merely provide a token ‘nod’ to falls in a perfunctory paragraph. Prospective studies indicate that fall events put the patient at greater risk of fracture than does relative bone fragility. 2) Bayly and Masud point to absence of evidence that falls preventions would prevent fractures in community dwelling older people. They argue that the falls-prevention interventions we listed do not support claims for a 50% reduction in fracture rates. In fact, these interventions point to the right direction or fracture reduction, but as we noted in our paper, “Unfortunately, no study into preventing falls has had sufficient power to use fractures as a primary outcome”. In this respect, one should also recall that absence of evidence is not a proof of absence of an effect (rather absence of evidence, only). Bayly and Masud emphasise Gates and colleagues’ systematic review (6) to argue that multifactorial falls prevention interventions do not work. However, there are limitations in the studies that were available for review (the quality, content and implementation-intensity of the intervention studies varied considerably resulting in considerable heterogeneity in the results), and therefore, it cannot be used as strong evidence against any single falls prevention intervention. Our main arguments for advocating fall prevention’s primacy over treatment of osteoporosis to prevent fractures are; (i) falling is a strong and very common risk factor of fracture in elderly populations (as opposed to moderate role of low BMD or osteoporosis), (ii) screening for propensity to falls (by simple questionnaires) is valid, cheap, and readily available in every health-care setting (unlike DXA scanning), and (iii) falls can be prevented (level 1 evidence, especially for exercise). Importantly, we also emphasise that, (iv) many of the strategies to prevent falls in the elderly populations, such as strength and balance training, provide additional health benefits beyond fracture prevention (7). 3) We agree with Bayly and Masud that generic alendronate will reduce the cost of treating osteoporosis, but it must be kept in mind that for the total cost calculation, we must also take into account the costs of the clinic visits, DXA scanning, and possible laboratory examinations. Also, treatment of possible adverse effects should be included. In fact, the National Institute of Health and Clinical Excellence (NICE) in the UK has recently issued health economic appraisals for the primary and secondary prevention of osteoporotic fracture that are more restrictive than previous guidelines for the management of osteoporosis. Thus, we still have concerns about the prices of many of the bone- specific drugs and the subsequent total costs, and especially the alleged effectiveness of bone-targeted pharmacotherapy. As our colleagues appreciate, before one can enter into discussion on the possible cost- effectiveness of any preventive pharmacotherapy (or any other health measure), a specific hierarchy of evidence has to be obtained. First, it needs to be shown that the given health measure can work under idealized circumstances: Drugs are tested in carefully selected populations in so called efficacy trials. Although there is evidence of the efficacy of bisphosphonates on hip fractures in women aged 65-80 years of age (relative risk [RR] 0.58; 95% credible interval [CrI], 0.42-0.80) (8), there is yet no evidence that such approach actually works: the effectiveness of bone-targeted pharmacotherapy given to individuals with health states that would have led to their exclusion from the pivotal RCTs is still completely lacking. We iterate that in clinical trials that approached the design of an effectiveness study (drugs given to less selected, high-risk population), there was no significant effect of bisphoshonates in preventing hip fracture (9, 10). Also, it is important for readers to recall that the alleged cost- effectiveness of bone-targeted pharmacotherapy is based on calculations that have assumed an unrealistic 100% compliance with therapy. The clinical reality is that at least 50% of patients discontinue therapy within 1 year and the decline seems to continue thereafter (11). Also cost studies have extrapolated the magnitude of the anti-fracture efficacy from younger populations to those aged +80 years (12). Such flaws invalidate the estimates. 4) Drs. Bayly and Masud also pose great expectations for the new fracture prediction model called Absolute Fracture Risk (13). They suggest that this would overcome the flaws in the prevailing tool for identifying those at increased risk of fracture, and thus, help identify those who likely benefit from pharmacotherapy. However, as discussed in our Analysis, we claim that even the theoretical basis for such enthusiasm fails under scrutiny (See paragraph “Absolute fracture risk” and Figure 2 of our paper, www.bmj.com). In brief, there are two fundamental flaws: i) In agreement with our notions, a recent commentary by Browner (14) specifically assessed the new concept (Absolute Fracture Risk algorithm) and showed that the addition of clinical risk factors to BMD did not greatly improve risk prediction, particularly among those aged 70 and older, in whom the vast majority of hip fractures occur. Similar to the BMD-based fracture prediction it is supposed to replace, the Absolute Fracture Risk-algorithm undeniably works at the population level - essentially showing that the set of risk factors have a statistically significant association with fractures. However, in clinical practice (at the individual level), a tool should have excellent discriminative ability, i.e., to be able to predict with high sensitivity and specificity who is going to have a fracture and who is not. Unfortunately, it does not (14). The difficulty in developing a clinically useful and viable prediction tool was elegantly exemplified by Browner as follows: Being able to predict a coin toss 51% of the time can make one rich in the long run, but won’t impress someone who watches your performance for “only” a few hundred flips (14). ii) Before such a completely new algorithm could even theoretically be advocated for wide use, one should have actual RCT-derived evidence to show that bone- targeted pharmacotherapy indeed reduces the incidence of hip fractures in the “high-fracture risk” people classified according to the new criteria. At present, there is no data to suggest this would be the case (9, 10, 15). 5) Finally, Drs. Bayly and Masud call attention to the importance of secondary prevention to reduce fracture rates. Although we share their view on the importance of secondary prevention, we must respectfully disagree with their proposition that “an optimal care” would comprise of treatment with bone-targeted pharmacotherapy. Although it is true that those with a previous fracture have about 2-2.5 times increased relative risk of future fracture (for example, according to a recent population- based study in Finland, the absolute risk of secondary hip fracture is 5% and 8% in the first two years after hip fracture (16)), this approach has problems. First, many fractures in the elderly population occur without BMD- defined osteoporosis and recent previous fracture. The notion that up to 50% of hip fracture patients have had a fracture before is misleading since many of these previous fractures (such as radius fracture) occurred as long as 30 years before the index hip fracture; it would not be appropriate to treat such patients with bone-specific drugs for decades. As only about 10% of hip fracture patients have had a previous hip fracture, treatment of hip fracture patients with bone-specific drugs, no matter how effective, will not address the entire problem. Second, and even more importantly, the increased risk of secondary fracture seems to be mostly attributable to extraskeletal risk factors, not osteoporosis (1). Thus, a policy of initiating pharmacotherapy on all patients with a prior “fragility” fracture would - at best - have a negligible effect on the population burden of fractures. It would, however, be associated with astronomical costs. In a recent BMJ Analysis paper, Mangin et al. (17) called for fresh, broad-minded thinking into preventive health care in elderly people. They reminded us that preventive treatments do not relieve suffering directly but reduce the risk of future suffering. Prevention has side effects other than the hazards of the treatment - in particular, the shadow cast over a currently healthy life by the threat of disease, which might be magnified in elderly people for whom mortality looms larger. When we convey risk to any patient we should be cautious - it is like putting a drop of ink into the clear water of the patient’s identity, which can never be quite clear again (17). The interventions that have been shown to reduce falls, and injurious falls, meet Mangin et al.’s criteria as being both fresh and feasible. We feel that it is time to shift the focus in fracture prevention research and interventions from bone-specific agents to efforts to reduce falls and related injuries. 1. Jarvinen TL, Sievanen H, Khan KM, Heinonen A, Kannus P. Shifting the focus in fracture prevention from osteoporosis to falls. Bmj 2008;336(7636):124-6. 2. Law MR, Wald NJ, Meade TW. Strategies for prevention of osteoporosis and hip fracture. Bmj 1991;303(6800):453-9. 3. Osteoporosis prevention, diagnosis, and therapy. Jama 2001;285(6):785-95. 4. Lord SR, Menz HB, Tiedemann A. A physiological profile approach to falls risk assessment and prevention. Phys Ther 2003;83(3):237-52. 5. Salter AE, Khan KM, Donaldson MG, Davis JC, Buchanan J, Abu-Laban RB, et al. Community-dwelling seniors who present to the emergency department with a fall do not receive Guideline care and their fall risk profile worsens significantly: a 6-month prospective study. Osteoporos Int 2006;17(5):672-83. 6. Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. Bmj 2008;336(7636):130-3. 7. Pedersen BK, Saltin B. Evidence for prescribing exercise as therapy in chronic disease. Scand J Med Sci Sports 2006;16 Suppl 1:3-63. 8. Nguyen ND, Eisman JA, Nguyen TV. Anti-hip fracture efficacy of biophosphonates: a Bayesian analysis of clinical trials. J Bone Miner Res 2006;21(2):340-9. 9. McCloskey EV, Beneton M, Charlesworth D, Kayan K, deTakats D, Dey A, et al. Clodronate reduces the incidence of fractures in community- dwelling elderly women unselected for osteoporosis: results of a double- blind, placebo-controlled randomized study. J Bone Miner Res 2007;22(1):135-41. 10. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, et al. Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 2001;344(5):333-40. 11. Compston JE, Seeman E. Compliance with osteoporosis therapy is the weakest link. Lancet 2006;368(9540):973-4. 12. Jarvinen TL, Kannus P. Re: "Half the burden of fragility fractures in the community occur in women without osteoporosis. When is fracture prevention cost effective?" by Sanders et al. Bone 2006;39(6):1390-1; author reply 1391-2. 13. Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J, et al. The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 2007;18(8):1033-46. 14. Browner WS. Predicting Fracture Risk: Tougher Than It Looks. BoneKEy 2007;4(8):226-230. 15. Lyles KW, Colon-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007;357(18):1799-809. 16. Lonnroos E, Kautiainen H, Karppi P, Hartikainen S, Kiviranta I, Sulkava R. Incidence of second hip fractures. A population-based study. Osteoporos Int 2007;18(9):1279-85. 17. Mangin D, Sweeney K, Heath I. Preventive health care in elderly people needs rethinking. Bmj 2007;335(7614):285-7. Competing interests: None declared