More than 350,000 hospital admissions and 60,000 nursing home admissions annually are due to hip fractures. Incidence of hip fracture is expected to rise to an estimated 650,000 annually by 2050. Prognosis for older adults after a hip fracture is grim, more than 28% die within the first year.
More than 350,000 hospital admissions and 60,000 nursing home admissions annually are due to hip fractures. Incidence of hip fracture is expected to rise to an estimated 650,000 annually by 2050. Prognosis for older adults after a hip fracture is grim, more than 28% die within the first year.
More than 350,000 hospital admissions and 60,000 nursing home admissions annually are due to hip fractures. Incidence of hip fracture is expected to rise to an estimated 650,000 annually by 2050. Prognosis for older adults after a hip fracture is grim, more than 28% die within the first year.
tures is a serious concern to both the residents and the interdisciplinary staff of assisted liv- ing (AL) facilities. According to the American Academy of Orthopedic Surgeons, more than 350,000 hospi- tal admissions and 60,000 nursing home admissions annually are due to hip fractures.1 Moreover, the inci- dence of hip fracture is expected to rise to an estimated 650,000 annual- ly by the year 2050 because of the increasing age of the US population. Women account for approximately 80% of all hip fractures. However, despite gender, the rate increases exponentially with age. Compared with their younger counterparts ages 60 to 65, people 85 years and older are 10 to 15 times more likely to Fall Prevention factors is not enough. Investigation sustain a hip fracture. The risk for hip fractures can be re- of the circumstances after the occur- The prognosis for older adults af- duced by preventing falls. In the AL rence of a fall and the resulting in- ter a hip fracture is grim. More than and LTC settings, a fall prevention terventions are also essential com- 28% die within the first year. Fifty and management program is para- ponents of a fall management percent lose the ability to walk inde- mount. In June 2007, The Joint program. Therefore, it is vital to pendently, resulting in the need for Commission released the 2008 Na- perform regular analysis and pro- an assistive device for safe mobility. tional Patient Safety Goals for As- gram modification to effectively im- Loss of functional independence can sisted Living Facilities, which in- pact fall statistics. Utilization of all be life altering. There is often an cluded (1) “reduce the risk of members of the interdisciplinary increased reliance on caregivers, resident harm resulting from falls” medical team and facility staff is re- which may necessitate altered living and (2) “implement a fall reduction quired for effective and thorough arrangements. Long-term care (LTC) program including an evaluation of management of the multifaceted as- admissions account for 40% of sus- the effectiveness of the program.”2 pects of fall prevention. tained hip fractures. To be effective, a fall prevention Extrinsic fall risk factors in the fa- Successful resident retention re- program must be comprehensive. cility environment that are easily re- quires an effective approach that is The first step requires identification solved may include clutter or obsta- both multifaceted and individualized of the environmental and individual cles in the hallways; waxed, wet, or to minimize the incidence of hip fall risk factors of each resident. slippery floors; and excessive furni- fractures. Strategies include reduc- Once risk factors are identified, an ture in the common areas that limit tion of fall risk factors, prevention action plan can be implemented to space for a clear path to ambulate. and management of osteoporosis, reduce the risk of falls and reduce In the resident’s room, inappropriate and encouragement of consistent ex- the potential for hip fractures. bed and chair heights, excessive ercise at therapeutic levels. However, initial reduction of risk clutter, throw rugs, and limited walk-
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ing space are common contributing factors to falls. Poor or inadequate One- or Two-Sided Hip Protectors? lighting, particularly lack of night- lights in the bedroom and bathroom Research continues on the use of one- or two-sided hip protectors. is another significant environmental Kannus and colleagues1 found that the risk of hip fracture can be reduced fall risk factor. All staff, including in frail elderly adults by the use of an anatomically designed bilateral external housekeeping and direct caregivers, hip protector. The study included 1801 ambulatory but frail elderly adults should be educated about how to (mean age 82 years). In the hip-protector group, 4 people had a hip fracture identify and resolve environmental (among 1034 falls) compared with 9 control patients (among 370 falls). risk factors for falls. Assessment of Kiel and colleagues2 more recently reported results of the HIP PRO the facility and resident rooms study, designed to determine efficacy of an energy-absorbing and energy- should be a frequent and consistent dispersing unilateral hip protector in 1042 elderly nursing home patients part of the fall prevention program. (mean age 85 years; 79% women) to reduce the risk of falls. Residents Another considerable extrinsic fall were randomly assigned to a 1-sided hip protector on the left or right hip. risk factor is polypharmacy. The dai- The study was terminated at 20 months for failure to show efficacy of the ly use of 4 or more medications hip protector despite good adherence to the treatment. The efficacy of doubles a resident’s risk for falls. Ad- bilateral versus unilateral hip protectors is still being researched. ditionally, commonly used medica- tions can increase the risk of falling Reference 1. Kannus P, Parkkari J, Niemi S. Prevention of hip fracture in elderly people with use of a hip by causing dizziness and drowsiness. protector. New Engl J Med. 2000; 343(21):1506-1513. The physician, nursing staff, and 2. Kiel DP, Magaziner J, Zimmerman S, Ball L, Barton BA, Brown KM, Stone JP, Dewkett D, Birge SJ. consultant pharmacist should regu- Efficacy of a hip protector to prevent hip fracture in nursing home residents. The HIP PRO larly perform a review of medica- randomized controlled trial. JAMA. 2007;298:413-422.
tions to rule out potential side ef-
fects and negative interactions. Each resident should be thorough- in and out of the bathtub. In addi- fragility and fracture risk. Osteoporo- ly screened for intrinsic fall risk fac- tion, an occupational therapist as- sis is referred to as a silent disease tors. To maintain proper posture and sesses residents’ needs for adaptive because symptoms are often absent balance, many systems must be equipment such as an elevated toilet until a fracture occurs. Women ac- working. A change in medical status seat, tub bench, or grab bars. Direct count for 80% of the 25 million or progression of chronic diseases, caregivers should be knowledgeable Americans who have reached the including neurological, musculoskele- about proper footwear that is appro- defined threshold for osteoporosis. tal, and cardiovascular conditions, priate for each resident, including Millions more suffer from osteope- should be addressed by a physician shoes with nonskid soles and cloth- nia, a precursor to osteoporosis. and monitored by the nursing staff. ing that fits properly and is easy to Type I osteoporosis primarily af- Yearly eye examinations are impor- take on and off for toileting. fects women 10 to 15 years post- tant to screen for visual deficits such According to a study by Kannus menopause, with the greatest loss as diminished depth perception and and colleagues in the New England of bone mass in the initial 5 years. visual field limitations, which may Journal of Medicine,3 the risk of hip Fracture risk is highest in the wrist limit safe mobility. fracture can be reduced in frail eld- and the vertebral bodies. Type II os- Physical therapists can perform a erly adults by the use of an ana- teoporosis is referred to as age-relat- complete strength, balance, and gait tomically designed external hip ed or senile osteoporosis because it evaluation to assess safety and fall protector. The FDA has approved affects both men and women with risk during daily activities. The phys- hip protector garments for the use onset after age 70. It is caused by a ical therapist may identify a need for of reducing hip fractures. Hip pro- decrease in calcium absorption and an assistive device or further training tectors are worn over undergar- production of active vitamin D. Type on the appropriate and proper use ments but under clothing and are II osteoporosis affects both trabecu- of the current assistive device for readily available through a medical lar and cortical bone, resulting in an safe ambulation. Physical therapists supply company (see also One- or increased risk for fractures of the hip are also skilled in the treatment of Two-sided Hip Protectors?). and the vertebral bodies. gait and balance disorders. Identification of those residents Occupational therapists are con- Osteoporosis Prevention at risk for or diagnosed with osteo- sulted for training in functional ac- and Management porosis is a good step in identifying tivities of daily living (ADLs) to max- Osteoporosis is a skeletal disease those who are more likely to have a imize safety and independence with characterized by a decrease in bone hip fracture. Screening for osteo- dressing, toileting, and transferring mass that causes increased bone porosis includes identification of
26 Assisted Living Consult November/December 2007
primary risk factors including age, ample of this is bedrest, which class can offer companionship and female gender, small bone structure, causes a 1% loss of bone mass per motivation for a consistent flexibili- and low body weight (less than 127 week. It is important to realize that ty and strengthening program. With lb), sedentary lifestyle, smoking, basic ADLs do not prevent or man- the same focus in mind, walking poor diet, and use of certain med- age osteoporosis. Consistent weight- programs are becoming more prev- ications. Medications used to treat bearing exercise, such as standing alent in residential and community rheumatoid arthritis, depression, or walking, is required to prevent living. Despite the exercise program seizure disorders, and disorders of bone loss in the lower extremities. chosen, to effectively reduce falls the endocrine and gastrointestinal and hip fractures, consistent weight- systems may have side effects that Therapeutic Exercise bearing and moderate-intensity ex- can damage bone and lead to os- The benefits of exercise are well doc- ercise is required. teoporosis. It is also important to umented in the research literature. consider that certain medications For exercise to be effective in improv- Final Thoughts such as glucocorticoids, loop diuret- ing bone density, muscle strength, The most effective approach to ics, and antiseizure medications can and balance, the appropriate type, in- lessening the incidence of hip frac- reduce the amount of calcium in tensity, frequency, and duration must ture is multifaceted and individual- the bone. Diagnosis of osteopenia be performed. The Centers for Dis- ized. Strategies to reduce the risk of and osteoporosis is confirmed with ease Control and Prevention (CDC) hip fracture include reduction of bone mineral densitometry (BMD) recommends that adults should en- fall risk factors, prevention and tests such as dual-photon absorp- gage in 30 minutes or more of mod- management of osteoporosis, and tiometry (DPA) and dual-energy ra- erate-intensity physical activity on encouragement of a consistent ex- diograph absorptiometry (DEXA). most, if not all, days of the week.4 ercise program at therapeutic levels. Preventative strategies to manage An approach that includes all mem- osteoporosis should include education bers of the interdisciplinary medical about proper diet, lifestyle modifica- team and facility staff members is tion, and the impact of smoking and Declining physical an effective and thorough way to excessive alcohol use on bone health. manage the multifaceted aspects of The typical diet of elderly Ameri- activity level has direct hip fracture prevention. ALC cans is deficient in calcium and vita- consequences on min D, which are necessary for bone Mimi Jacobs, PT, OCS, is the founding Exec- bone stability. health. The recommended intake of utive Director of Fox GERI: Geriatric Educa- tion and Research Institute and a physical 1500 mg or more of calcium and 400 therapist for Fox Rehabilitation, providing IU/day or more of vitamin D can re- rehabilitation services to multiple AL facili- duce fracture risk by up to 30% in Resistance exercises use weights ties in NY, NJ, and PA. some populations. The healthcare or exercise bands for resistance and Jaime Bellace, PT, GCS, is a board-certified team members can work together to are essential for increasing bone and specialist in geriatric physical therapy and develop a diet that meets the require- muscle strength. Research continues is the Clinical Coordinator of Physical Ther- ments. In addition to calcium and vi- to demonstrate its effectiveness in the apy for Fox Rehabilitation, providing geri- tamin D, pharmaceutical agents such elderly population. Numerous re- atric therapy at home and at multiple AL as bisphosphonates and calcitonin search studies have also demonstrat- facilities in NJ. can assist in bone resorption. ed the positive impact of balance ex- Hip fractures related to osteo- ercise training on reducing the risk of References 1. The American Academy of Orthopaedic porosis can occur because of the falls. Tai Chi is one popular type of Surgeons (AAOS). Falls and hip fractures. extent of bone fragility combined low-intensity weight-bearing, dynam- AAOS Web site. http://orthoinfo.aaos.org. Ac- with poor body mechanics during ic-balance exercise program that has cessed June 30, 2007. ADLs. People at risk for osteoporot- been shown to directly impact fall 2. Joint Commission.. 2008 National Patient Safety Goals for Assisted Living Facilities. Joint ic hip fractures should be educated statistics in older adults. Commission Web site. www.jointcommission.org/ about posture and proper body me- Physical and occupational thera- patientsafety/nationalpatientsafetygoals/08_asl_ chanics to avoid excessive strain. pists can work with other members npsgs.htm. Accessed July 9, 2007. Physical activity is required to of the interdisciplinary team to de- 3. Kannus P, Parkkari J, Niemi S. Prevention of hip fracture in elderly people with use of a maintain proper bone development velop and implement an individual- hip protector. New Engl J Med. 2000; 343(21): and growth. Declining activity level ized exercise program for at-risk 1506-1513. has direct consequences on bone residents to improve bone density, 4. Centers for Disease Prevention and Control stability. A sedentary lifestyle in- strength, flexibility, and balance for (CDC). How active do adults need to be to gain some benefit? CDC Web site. www.cdc.gov/ creases the risk of osteoporosis and hip-fracture reduction. nccdphp/dnpa/physical/recommendations/ hip fracture. The most extreme ex- In addition, a group exercise adults.htm. Accessed July 12, 2007.
Treatment of Low Bone Density or Osteoporosis To Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From The American College of Physicians