Fractures in the elderly

Background: Fractures in elderly are an important public health issue, especially as incidence increases with age, and the population of elderly people is growing. Elderly are more likely to have fractures due to many factors as frequent falls, impaired protective reflexes during falls, osteoporosis, many medical illnesses and drugs. Fracture incidence in institutionalized elderly people is generally higher than the general population. Function and quality of life may deteriorate drastically after a fracture. Detecting the most prevalent risk factors of fractures may help preventing further fractures and decrease their functional and economic burden.

Objective: to assess fracture risk among elderly living in geriatric homes.

Methods: Study design: a Cross sectional study. 100 elderly (≥ 60 years) subjects including both males and females living in four nursing homes in Cairo were recruited.

Fracture risk calculators to estimate the absolute risk of fractures were done for each participant including; Fracture Risk Assessment Tool (FRAX), which estimates the 10-year probability of hip fracture and major osteoporotic fracture (hip, clinical spine, proximal humerus, or forearm), Q fracture, which calculates the risk of developing any osteoporotic (i.e. hip, wrist, shoulder or spine) fracture or hip fracture alone by answering some simple questions and Garvan tool, developed by the Garvan Institute of Medical Research (one of Australia’s largest medical research institutions).

Results: According to presence of positive history of fractures our study concluded that the prevalence of fractures in the included nursing homes was 21%. The most prevalent risk factor of fractures in the current study is recurrent falls (49%) and the least prevalent risk factor is CKD (2 %). Other prevalent risk factors were Functional impairment in IADL (35%), prolonged Timed Up & Go Test (34%), functional impairment in ADL (32%), and depression by GDS (26%). There was a statistically significant difference between subjects with history of fractures and subjects without as regards history of recurrent falls in the last year, prolonged Timed Up & Go Test and functional impairment in ADL and IADL (P<0.05). However there was no statistically significant difference between both groups as regards diabetes mellitus, dementia, epilepsy, history of parent osteoporotic fracture, visual and hearing impairment, liver cirrhosis, cancer, COPD and Depression. Those who sustained fractures (Group I) had the higher mean of estimated 10 year fracture risk according to the three risk assessment tools (FRAX, Q fracture and Garvan) than those who didn’t sustain fractures (Group II) with high statistically significant difference between the two groups (P<0.001). According to the current study the cutoff of significant 10 year major osteoporotic fracture risk according to FRAX, Q fracture and Garvan is 7.1%; 17.5%and 19% respectively. And the cutoff of significant 10 year hip fracture risk according to FRAX, Q fracture and Garvan is 3%; 5.7% and 2 % respectively. Garvan tool has the highest sensitivity to calculate the estimated 10 year risk of hip and major osteoporotic fracture according to the current study with accuracy 85.2% and 93.9% respectively. FRAX tool has the highest specificity to calculate the estimated 10 year risk of hip and major osteoporotic fracture according to the current study with accuracy 87% and 90.3% respectively. Conclusion: According to the current study the prevalence of fractures in geriatric homes in Cairo is 21%.The most prevalent risk factor for fractures is recurrent falls (49%), while the least prevalent risk factor is chronic kidney disease (2%). Garvan tool is considered the most sensitive in predicting the 10 year risk of hip and major osteoporotic fractures, while FRAX is considered the most specific tool to calculate such risk. Key words: Fracture risk calculators, Osteoporotic fracture, Hip fracture, Geriatric homes   Introduction: Elderly are more prone to develop fractures due to many risk factors as decreased bone mineral density(BMD) (osteoporosis) and many other independent clinical risk factors as frequent falls, visual impairment, slow gait, functional impairment, many medical illnesses and drugs (James, 2008). Osteoporosis is a common disease characterized by low bone mass with microarchitectural disruption and skeletal fragility that result in an increased risk of fracture, particularly at the spine, hip, wrist, humerus, and pelvis (Riggs & Melton, 1995). Drugs as; Glucocorticoids, synthetic retinoids, antidepressants, heparin, and androgen deprivation therapy and Medical conditions as; Rheumatoid arthritis, diabetes mellitus, celiac disease, thyroid diseases, inflammatory bowel disease, cystic fibrosis, and chronic kidney disease are all considered as risk factors for secondary osteoporosis and osteoporotic fractures(Bloster, 2012). Osteoporotic fractures (fragility fractures, low-trauma fractures) are those occurring from a fall from a standing height or less, without major trauma such as a motor vehicle accident (Johnell and Kanis, 2006). Hip fracture has been recognized as the most serious consequence of osteoporosis because of its complications, which include chronic pain, disability, diminished quality of life and premature death (Mithal and Dhingra, 2009). Regarding falls, every year, 30 to 40% of elderly people living in the community and 50% of nursing home residents fall, falls contribute to >40% of nursing home admissions and are the 7th cause of death in people ≥65 (Laurence, 2013).

Many studies stated that fracture incidence in institutionalized elderly people is generally higher than the general population; residents are generally frailer than seniors living in the community. They tend to be older, and have greater limitations in their activities of daily living. They also have more chronic illnesses, are physically dependent, and have a higher prevalence of gait problems (Nakamura et al., 2010).

Function and so quality of life deteriorate dramatically after a fracture; at least 50% of elderly people who were ambulant before fracturing a hip do not return to their previous level of function. After falling, elderly people may fear of falling again, that`s why mobility is reduced because confidence is lost. Some people even avoid certain activities as shopping and cleaning because of this fear. Decreased activity can increase joint stiffness and weakness, further reducing mobility (Laurence, 2013).

Moreover, most fractures occur in patients with T-scores better than -2.5, so treatment strategies relying solely on BMD testing will miss many patients who are at risk of fractures and who might benefit from interventions to reduce fracture risk (Cranney et al., 2007).

Thus assessment of clinical conditions or risk factors independent of BMD measurement is important for the prediction of fracture (Kanis et al., 2005).

Many risk assessment tools have been developed to predict probability of fractures and the need of drug therapy accordingly (Bolland et al., 2011).

One of the most famous tools is the WHO Fracture Risk Assessment Tool (FRAX) which predicts the 10-year probability of a major osteoporotic (hip, spine, forearm, or humerus) and hip fracture using clinical risk factors for fractures alone or with femoral neck bone mineral density(Sandhu et al., 2010).

Other fracture risk assessment tools as the Q fracture tool, a risk prediction algorithm designed to estimate absolute risk of osteoporotic fracture and hip fracture in primary care (Hippisley-Cox and Coupland, 2009) and the Garvan fracture risk calculator developed by the Garvan Institute of Medical Research which is valid and useful in identifying individuals at high risk of fracture (Luai et al., 2014).

Methods

Study design: a Cross sectional study. 100 elderly (≥ 60 years) subjects including men and women living in four nursing homes in Cairo were recruited.

At first, medical history was obtained by questionnaire, weight and height were measured then fracture risk calculators to estimate the absolute risk of fractures were done for each participant including;

a- Fracture Risk Assessment Tool (FRAX), which estimates the 10-year probability of hip fracture and major osteoporotic fracture (hip, clinical spine, proximal humerus, or forearm), using easily obtainable clinical risk factors for fracture (age, gender, BMI, history of personal fracture, history of parental hip fracture, smoking status, glucocorticoids use, alcohol intake, and presence of rheumatoid arthritis or secondary osteoporosis) alone or in combination with femoral neck BMD (g/cm2, using dual energy x-ray absorptiometry [DXA]), in the current study the FRAX score used was FRAX without BMD we used [FRAX-body mass index (BMI)].

b- Q fracture, which calculates the risk of developing any osteoporotic (i.e. hip, wrist, shoulder or spine) fracture or hip fracture alone by entering some simple clinical data. An updated version was developed in 2012 to improve the use of QFracture, such as extending the age range to patients older than 85 years and including additional variables as previous fragility fracture, ethnic group, epilepsy and use of anticonvulsants, care home residency, additional inflammatory arthropathies, chronic obstructive airways disease, type 1 diabetes, and other causes of immobility (such as Parkinson’s disease or dementia).

c- Garvan tool, developed by the Garvan Institute of Medical Research allows individuals to make informed judgments about their actual risk of having an osteoporotic fracture by entering risk factors as age, gender, number of falls in the past year, and number of fractures since age 50 years. As with FRAX, Garvan was calculated with BMI and not BMD.

Ethical considerations

Informed consent was taken from every elder participating in this study. The study methodology was reviewed and approved by the Research Review Board of the Geriatrics and Gerontology Department, Faculty of medicine, Ain Shams University.

Statistical methods:

Analysis of data was performed by using version 20 of the Statistical Package for Social Science (SPSS). Data were expressed as mean and standard deviation (SD) for all quantitative variables. Frequency and percentage for all qualitative variables was calculated. Comparison between quantitative variables was done using t-tests to compare 2 groups. Comparison of qualitative variables was carried out using the Chi-square test. A P < 0.05 (two sided) was considered significant. Receiver operating characteristic (ROC) curve analysis was used to assess the ability of each calculator to discriminate between individuals who sustained any fracture and those who did not. Results: According to presence of positive history of fractures our study concluded that the prevalence of fractures in the included nursing homes was 21%. The mean age of our study population is 72.15 years with standard deviation ±8.78 with 49 male and 51female patients The most prevalent risk factor of fractures in geriatric homes according to the current study is recurrent falls (49%) [Falls ≤ 2 last year (28%) and falls >2 last year (21%)] and the least prevalent risk factor is CKD (2 %). Other prevalent risk factors are Functional impairment in IADL (35%), TUGT >14 seconds (34%), functional impairment in ADL (32%), depression by GDS (26%). (Table 1)

We divided the subjects recruited in this study into 2 groups; Group I, includes subjects with history of fractures and Group II, includes subjects without history of fractures.

There was a statistically significant difference between subjects with history of fractures (Group I) and subjects without (Group II) as regards history of recurrent falls in the last year, prolonged Timed Up & Go Test and functional impairment in ADL and IADL (P<0.05). However there was no statistically significant difference between both groups as regards diabetes mellitus, dementia, epilepsy, history of parent osteoporotic fracture, visual and hearing impairment, liver cirrhosis, cancer, COPD and Depression. (Table 2)

Group I had the higher mean of estimated 10 year fracture risk according to the three risk assessment tools (FRAX, Q fracture and Garvan) than Group II with high statistically significant difference between the two groups (P<0.001). (Table 3) Table (4) and Figures (1-6) show that the cutoff for significant 10 year risk of hip fracture by the FRAX tool is >3% with specificity 89.9% and sensitivity 66.7% and accuracy87%, and the cutoff of 10 year major osteoporotic fracture risk according to FRAX is >7, with sensitivity 76.2% and specificity 87.3% with accuracy 90.3%.

Also, the cutoff of 10 year hip fracture risk according to Garvan is >2, with sensitivity 85.7% and specificity 73.4% with accuracy 85.2%, and the cutoff of 10 year major osteoporotic fracture risk according to Garvan tool is >19, with sensitivity 95.2% and specificity78.5% and accuracy 93.9%

Moreover, the cutoff of 10 year hip fracture risk according to Q fracture tool is >5.7, with sensitivity 71.4% and specificity 85.9% and accuracy 80.9%, and the cutoff of 10 year major osteoporotic risk according to Q fracture tool is >17.5%, with specificity 97.5% and sensitivity 61.9% and accuracy 85.1%.

According to the current study Garvan tool has the highest sensitivity to calculate the estimated 10 year risk of hip and major osteoporotic fracture with accuracy 85.2 and 93.9 respectively. And FRAX tool has the highest specificity to calculate the estimated 10 year risk of hip and major osteoporotic fracture according to the current study with accuracy 87 and 90.3 respectively.

Source: Essay UK - https://www.essay.uk.com/essays/medicine/fractures-in-the-elderly/


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