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Reducing the incidence of osteoporotic hip fractures: 2

Carol Jones
SRN SCM HV HealthEdCert
Osteoporosis Prevention Officer
Osteoporosis Dorset
E:mail@osteodorset.org.uk

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The factors that govern whether a femoral neck fracture occurs during a fall include: the impact directly on the greater trochanter; protective reflexes (putting your hand out to break the fall); local soft tissue energy absorption (amount of adipose tissue, ie, your own inbuilt hip protectors); and bone strength (osteoporosis) (see Figure 1).(1,2 )

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Preventive strategies therefore include increasing bone strength (prevention and treatment of osteoporosis), avoiding falls, and methods that modify the impact on the hip during a fall (external hip protectors [EHPs]).

Bone fragility
Ninety per cent of all hip fractures in the over-75s are due to osteoporosis.(4) Osteoporosis is defined as "a progressive systemic skeletal disease characterized by low bone mass and architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture".(5) Osteoporosis affects most skeletal sites. Loss of bone mass and structure are important because they are associated with increased fracture risk. The clinical burden of the disease both to the individual and the NHS are fractures, especially hip fractures.

Bone densitometry
The most common way of measuring the density of bone is by dual-energy X-ray absorptiometry (DXA), although local availability will also determine the bone scanning technique used (see Further Reading section).

Treatments
The physician now has a choice of preparations to choose from that retard bone loss, reduce fracture risk and are licensed for the prevention and/or treatment of osteoporosis (see Table 1).

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However, the majority of the evidence is for the prevention and treatment of osteoporosis in postmenopausal women despite a steep exponential rise in osteoporotic fractures in older men, especially hip fractures.
"Although the drugs are effective in reducing fracture risk, they do not provide a woman with any visible signs that they are working, nor do they reduce acute pain following fracture or directly improve psychological well-being."(7) Therefore, in order for long-term therapy to be successful, the patient must be involved in the decision-making, which needs to take into account their beliefs, perception of risks and personal preferences as well as their medical history and current situation. Concordance with therapy is best facilitated through a multidisciplinary approach to management and shared care involving the community pharmacist and nurse.

Falls
A total of 95% of all hip fractures occur as a result of a fall.(1,2) One definition of a fall is: "… an event which results in a person coming to rest inadvertently on the ground".(8) The two key words in this definition are "inadvertently" and "ground"; the majority of us have experienced the embarrassment of falling to the ground; in youth we might cover our dignity with bruises but we can usually pick ourselves up and dust ourselves off, but not so in old age. Falls are common - 30% of the over 65s living in the community will fall each year. Falls injury hospitalisation increases exponentially in the over-65s,(9,10) rates being higher in women than men. Seventy-five percent of falls-related deaths occur in the home.(11) Table 2 illustrates the two different types of fall risk.(12)

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Strategies to reduce the frequency of falls in elderly people need to be aimed at either the entire population or at individuals at the greatest risk. Examples of approaches can be found in Primary Care Strategy for Osteoporosis and Falls,(13) Falls, Fragility and Fractures(12) and Physical Activity and the Prevention and Management of Falls and Accidents among Older People.(8)

Modifying the force of a fall
Only 1% of falls result in a hip fracture.(10) Given the frequency of falls in the population of over-65s it is not surprising that the immediate effect of falling is not the risk of fracture but the "overriding fear of the consequences and indignity of suffering a further fall".(9) Therefore you would think that an intervention which has been demonstrated to reduce the incidence of hip fracture,(14-16) improve the self-confidence, function and independence of the client in the community,(17) has included men in its trials,(18) is cost-effective,(19) works immediately, is without gastrointestinal side-effects and has a track record of over 10 years of evidence-based research(20) would be widely available. However, in the UK the provision of EHPs is entirely dependent on your postcode.

What are EHPs?
EHPs are designed to divert impact away from the greater trochanter to the surrounding soft tissues. There are two types of EHP: soft pads and hard, semi-rigid plastic shields. From this briefest of description it is not difficult to come to the conclusion that one sort doesn't suit all circumstances! Approximately 10 different EHPs are marketed around the world.(21) The delivery/positioning system for the two types of EHPs varies from pockets sewn into the inner surfaces of tracksuit pants or trousers to specially designed underwear. (21) Some are even worn externally in a belt over clothing.(21) The delivery/positioning system has to be effective, functional, aesthetically pleasing and comfortable to wear, as initial acceptance and long-term continuing use are the major issues.
Practical problems with using hip protectors are related to activities such as dressing and using the toilet, especially in frail elderly patients.(21) Community nurses are in an excellent position to lead on the development, implementation and evaluation of user instruction/ education and follow-up care plans. Osteoporosis Dorset has independently produced a booklet, How to Prevent Breaking Your Hip, which provides practical solutions to hip fracture prevention based on our work in Poole residential homes using the Lauritzen hip protector. Demand was so great for this publication that Robinson Care kindly agreed to reprint it. Free copies can be obtained from Robinson Care on 01909 735001.

Moving the agenda forward
Preventive strategies for reducing the incidence of falls and osteoporotic fractures in primary care need to include measures that target the whole population by promoting bone health. This can be achieved through increasing the level of physical activity undertaken at all ages, reducing the prevalence of smoking and increasing dietary calcium,(22,23) as well as targeting individuals at high risk of fracture (selective case-finding).(5,24)
Forty-five percent of the annual £1.7 billion cost of treating hip fractures in England and Wales is for acute care, and 50% is for social care and long-term hospitalisation.(25) Primary care trusts (PCTs) with links to their local communities, secondary care and social services are ideally placed to integrate the population (health promotion) and selective case-finding approach.
Nurses, with their diverse roles in primary care, armed with the scientific evidence, knowledge of what works elsewhere and supporting publications from voluntary care organisations, are uniquely placed to help their PCTs reduce the incidence of osteoporotic hip fractures and improve the health and social care of their populations of older people.

A note on EHPs
Not all EHPs are the same Healthcare ­professionals need to know which EHP/­delivery system applies to which research. For example, a study carried out in Poole in 1998 (Age Ageing 1998;27:195-8) used the "Mark 1" of a particular hip protector ­underwear with very tight-fitting Scandinavian- designed pants. This study is still discussed in other articles (eg, Geriatr Med 2003;33(5):63-9), even though the "Mark 1" has not been available for the last 5 years and has been discontinued in favour of a more research-based comfortable protector.
A multiagency, multidisciplinary group brought together by the Surgical Dressing Manufacturers Association (SDMA) and supported by the National Patient Safety Agency are developing ­standards which will clarify some of these issues.

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References

  1. Grisso JA, Kelsey JL, Strom BL, et al. Risk factors for falls as a cause of hip fracture in women. N Engl J Med 1991;324:1326-31.
  2. Hedlund R, Lindgren U. Trauma type, age and gender as determinants of hip fracture. J Orthop Res 1987;5:242-6.
  3. National Institute of Health. Osteoporosis and Related Bone Disease National Resource Centre. Falls and fracture prevention. NIH ORBO-NRC 1999;2(1).
  4. Phillips S, Fox N, Jacobs J, Wright WE. The direct medical costs of ­osteoporosis for American women aged 45 and older. Bone 1988;9:217-9.
  5. World Health Organization. Assessment of fracture risk and its ­application to screening for postmenopausal osteoporosis. Technical report series 843. Geneva: WHO; 1994.
  6. Royal College of Physicians. Osteoporosis: clinical guidelines for prevention and treatment. London: RCP; 1999. Available from URL: http://www. rcplondon.ac.uk/pubs/wp_osteo_update.htm
  7. NOS submission to NICE. Available from URL:http://www.nos.org.uk/influence.asp
  8. Health Education Authority. Physical activity and the prevention and ­management of falls and accidents among older people. London: HEA; 1999.
  9. Stalenhoef PA, Crebolder HFJM, Knottnerus A, Van der Horst FGEM. Incidence, risk factors and ­consequences of falls among elderly subjects living in the community. A criteria- based analysis. Eur J Public Health 1997;7:328-34.
  10. Tinetti ME, Speechley M, Ginster SF, et al. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7.
  11. OPCS. The health of elderly people. An epidemiological overview. London: HMSO; 1992.
  12. Cryer C, Patel S. Falls, fragility and fractures. Proctor and Gamble; 2001. p. 6.
  13. National Osteoporosis Society. Primary care strategy for osteoporosis and falls. London: NOS; 2002.
  14. Cameron ID, Cumming RG, Kurrle SE, et al. Prevention of hip fracture with use of hip protector. N Engl J Med 2001;344:855-7.
  15. Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip fractures in older people (Cochrane review). In: The Cochrane Library. Oxford: Update Software; 2000.
  16. Kannus P, Parkkari J, Niemi S, et al. Prevention of hip fracture in elderly people with the use of a hip protector. N Engl J Med 2000;343:1506-13.
  17. Cameron ID, Stafford B, Cumming RG, et al. Hip protectors improve falls self-efficacy. Age Ageing 2000;29:57-62.
  18. Meyer G, Warnke A, Bender R, Mulhauser I. Effect on hip fractures of increased use of hip protectors in ­nursing homes: cluster randomised trial. BMJ 2003;326:76-8.
  19. Kumar BA, Parker MJ. Are hip ­protectors cost effective? Injury 2000;31:693-5.
  20. Lauritzen JB, Petersen MM, Lund B. Effect of external hip protectors on hip fractures. Lancet 1993;341:11-13.
  21. Myint P, Woodhouse PR, Munim F. Prevention of hip fracture: the role of hip protectors. Geriatr Med 2003;33(5):63-9.
  22. Department of Health. National Service Framework for older people. London: Department of Health; 2001.
  23. Department of Health. Saving lives: our healthier nation. London: Department of Health; 1999.
  24. Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D. Guidelines for diagnosis and management of ­osteoporosis. The European Foundation for Osteoporosis and Bone Disease. Osteoporos Int 1997;7:390-406.
  25. Torgerson DJ, Dolan P. The cost of treating osteoporosis fractures in the UK female population [letter]. Osteoporos Int 2000;11:551-2.
  26. Torgerson DJ, Iglesias CP, Reid DM. The economics of fracture ­prevention. In: Barlow D, Francis R, Miles A, editors. The effective management of osteoporosis. London: Aesculapius Medical Press; 2001. p. 111-21
  27. Cooper C. Epidemiology of ­osteoporosis. Osteoporos Int 1999;Suppl 2:S2-8.
  28. UK Government Actuary's Department. Variant population ­projections for the United Kingdom and its constituent countries. London: UK Government Actuary's Department; 2002.
  29. Marshall D, Johnell O, Wedel H, et al. Meta-analysis of how well measures of BMD predict occurrence of osteoporotic fractures. BMJ 1996;312:1254-9.
  30. International Osteoporosis Foundation. Available from URL: http://www.osteofound.org/index.php
  31. Kanis JA, Gluer CC for the Committee of Scientific Advisors, International Osteoporosis Foundation. An update on the diagnosis and ­assessment of osteoporosis with ­densitometry. Osteoporos Int 2000;11:192-202.

Resource
The National Osteoporosis Society
Provides a ­telephone helpline for patients, specific drug/
therapy ­information sheets and an invaluable network of ­osteoporosis peer support groups
T:01761 472721
W:www.nos.org.uk

Further ­reading
Position Statement on the Use of Quantitative Ultrasound in the Management of Osteoporosis NOS; 2001
Primary Care Strategy for Osteoporosis and Falls
NOS; 2002 W:www.nos.org.uk/healthprof_info.asp
Section 4, Table 4.
Referral criteria for bone density measurement
Physical Activity and the Prevention and Management of Falls and Accidents among Older People
HEA; 1999