Circumstances of Falls Resulting in Hip Fractures Among Older People
ABSTRACT & COMMENTARY
Synopsis: It is probable that all older patients would benefit from targeted training in balance and selective use of hip protectors.
Source: Norton R, et al. J Am Geriatr Soc 1997;45:1108-1112.
The injury prevention research centre in new Zealand is conducting a large case-control study to identify potentially modifiable risk factors for hip fractures. They have collected information on 1832 hip fractures in persons aged 60 and older admitted to Auckland region hospitals between July 1991 and February 1994. The investigators have also conducted personal interviews in a random sample of 911 patients or their caregivers. Extensive information has been collected and analyzed about the circumstances leading to the fractures and pre-existing medical conditions.
Only 2% of the fractures were reported to have occurred spontaneously without a preceding fall; 96% were clearly associated with falls, emphasizing the importance of the events contributing to falls in the elderly. Although 85% of the falls took place at home, only 25% were associated with some kind of object such as stairs, steps, chairs, electric cords, or loose carpets. Of the falls that occurred away from home, pathway irregularities, stairs, steps, and pets were more common. Wet or slippery surfaces were fairly equally distributed between falls at home and outdoors. The majority of all falls occurred indoors, either in private residences or institutions. Only 13% had a medical condition (such as dizziness, blackouts, or seizures) that contributed to the fall.
For a large proportion of falls where no environmental hazard was identified, patients were not even engaged in any forward motion. (Patients were standing, sitting, turning, reaching, etc.) These situations were most common in the oldest patients (age 80 and older) and in institutionalized residents, suggesting that these groups especially, and probably all older patients, would benefit from targeted training in balance and selective use of hip protectors.
COMMENT BY MARY ELINA FERRIS, MD
This study adds to a growing body of medical literature on falls in geriatric patients, which are estimated to occur in 30% of those older than age 65 annually. The incidence of falls rises to 50% in those over age 80. Approximately half of these falls result in some kind of injury, and 1% result in hip fractures, with significant mortality and association with nursing home placement. All these statistics have led to great interest in understanding the mechanisms of serious falls and how they might be prevented.
The low number of self-reported spontaneous fractures leading to falls found here contradicts past thinking on hip fractures, but this has been supported by other studies.1 The large number of fractures studied demonstrated interesting differences in fall characteristics based on age, with younger patients more likely to have a specific object associated with falls when no contributing medical condition was present. Conversely, older patients had more falls attributed to gait and balance difficulties.
These differences have led the authors to conclude that activities focused on increased physical exercise and correction of medical conditions may be more worthwhile in preventing hip fractures than trying to modify hazards in the home environment. Although their research did not test this hypothesis, another study that used gait and balance training did show an effectiveness in reducing falls.2 Further support comes from a recent article studying mobility after hip fractures, demonstrating that poor balance at two months post-fracture was a key predictor of further hospitalizations, nursing home placement, and even mortality.3
These studies support the importance of careful medical investigation of falls in the elderly population for any correctable conditions, which includes assessment of gait and balance and ordering physical therapy when abnormalities are found. Future studies will follow outcomes to track our effectiveness, but, in the meantime, there are good indications that hip fractures may be reduced by this approach.
References
1. Nyberg L, et al. J Am Geriatr Soc 1996;44:156-160.
2. Tinetti ME, et al. N Engl J Med 1994;331:821-827.
3. Fox KM, et al. J Am Geriatr Soc 1998;46:169-173.
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