Shifting the focus in fracture prevention from osteoporosis to falls
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39428.470752.AD (Published 17 January 2008) Cite this as: BMJ 2008;336:124All rapid responses
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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
Competing interests: No competing interests
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/NationalAuditReportFinal30... [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&categ... [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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests