|Abstract / Summary
PURPOSE: To give a) a description of health status and causes of admittance of orthopaedic patients older than 74 years of age and b) a description of falls causing admittance to an orthopaedic department. c) To find risk factors for falls, hip fractures and mortality; d) to assess the primary acceptance and later compliance of hip protectors; and e) to evaluate the effect of hip protectors on the risk of hip fractures and on the fear of falling.
METHOD: Baseline data were collected during a structured interview for 1,684 patients admitted to two orthopaedic departments. The 1,006 patients admitted to one of the departments (intervention group) were offered three pairs of energy dispersing hip protectors (Safehip®), whereas the 678 patients admitted to the other department were controls. All patients were followed for 1 – 2.5 years, and the number of new hip fractures was registered for both groups. Compliance of hip protectors was evaluated through questionnaires mailed to the users every third month.
RESULTS: a) Median age was 83 years, women accounted for 81%, and 92% lived in their own home. A fall preceded the admittance in 1,170 (69%) of the cases, and 543 (32%) had sustained a hip fracture. Significant medical conditions and dementia were present in 27% and 32% of the subjects respectively. b) Most of the falls occurred in the morning or afternoon (72%), and only 10% of all falls occurred during the night – and in this case typically in relation to toilet visits. Nearly 25% of the subjects could not recall the reason of their fall, 22% stated they had fainted, and nearly every second had stumbled. Concerning time of the day, place, and reason for the fall no differences were observed whether the fall resulted in a hip fracture or not. c) Risk factors for falling were: being a women (adjusted odds ratio: 1.8), dementia (2.1), self- reported tendency for falling (2.5), and dizziness (1.7). Reduced risk for falls was observed in patients with impaired mobility (0.28) and in patients with a previous hip fracture (0.50). Risk factors for hip fracture at inclusion were se X(adjusted OR for men: 0.80), age (1.5 for every 5th year), dementia (2.6), significant medical condition (1.8), dizziness (1.4) and tobacco (1.6). Increased risk of a new hip fracture in the follow up period was observed in demented (adjusted incidence ratio: 2.1), in patients admitted after a fall at inclusion (5.8), and in smokers (3.3). Overall mortality was 22% per year (standardised mortality rate 2.0), and for hip fracture patients the mortality rate was 31% (SMR 2.6). The increased mortality observed after a hip fracture was related to se X(adjusted mortality ratio for males: 1.8), older age (1.3 for every 5th year), dementia (2.5), significant medical condition (1.8), and living in nursing homes (1.8). Adjusted for these variables no increase in mortality was related to hip fracture. d) Primary acceptance of hip protectors was 57%. The acceptance was increased in men (64%) and in patients admitted after a hip fracture (65%). In addition, self-reported tendency for falling and fear of falling was positively related to primary acceptance. At 6 and 12 months following inclusion in this study 77% and 58% were still registered as users. Tendency for stopping the use of hip protectors was increased in patients admitted after a fall at inclusion and in patients with need for personal assistance when walking outdoors. The highest compliance was observed in patients indicating fear of falling. e) Comparing the risk for new hip fractures in the intervention- and in the control group (intention-to-treat analysis) no effect of the hip protectors was observed (adjusted incidence ratio: 1.1 [95% CI: 0.70 – 1.8]). Adjusted for receipt of the hip protectors still no effect was observed (1.0 [0.61 – 1.7]). Finally, adjusting for the use (treatment-received-analysis) a statistically non-significant reduction of hip fracture risk could be related to the use of hip protectors (0.88 [0.50 – 1.5]). In patients complaining of impaired distant vision hip protectors reduced the risk of hip fractures to 0.25 [0.08 – 0.85] (treatment-received-analysis), and in several high-risk groups the same tendency was observed, however this study had not the power to give statistically significant estimates of the effect in these subgroup analyses. The users reported 143 falls with impact on the hip protector. Only two hip fractures occurred while the hip protectors were worn, and in none of these cases an impact on the hip protector was observed. Nearly one half of the patients reported fear of falling, and 40 – 60% of these patients stayed in some instances indoors because of the risk of falling. At the first questionnaire following inclusion 30% and 33% of the users indicated, that the hip protectors gave more confidence when walking in- and outdoors respectively; and 15% had spent more times being outdoors because of the use of hip protectors.
CONCLUSION: a) Admittance of elderly patients to an orthopaedic department was most often caused by a fall, and the prevalence of dementia and significant medical conditions was high. b) Only one half of all falls were related to stumbling whereas the rest were related to the patient fainting or unknown. Concerning time of the day, place, and reason for the fall no differences were observed whether the fall resulted in a hip fracture or not. c) The increased mortality following a hip fracture was not related to the hip fracture itself but to factors related to health prior to the incidence. d) The primary acceptance of hip protectors in this population was 57%, and 58% of these were still users one year later. e) Hip protectors offers an effective protection against hip fractures – but only when used. In the light of the described compliance no effect of hip protectors on intention-to-treat-basis could be observed in this population of elderly subjects, predominantly coming from their own home. There seemed to be effect in several high-risk groups, but this study had not the power to give statistically valid estimates in these subgroup analyses. Fear of falling is prevalent in old people, and it could be relevant to offer hip protectors to these patients with high risk of hip fracture, when falling tendency is also present.