The population enrolled in this study is one of the biggest present in literature and shows the characteristics of patients with recent hip fracture, and how this event occurs.
Median age of this population is comparable with what present in literature, and confirms that extra-skeletal risk factors play an important role, and that generally this population is not involved in densitometric screening and preventive approaches.
Despite overweight patients (35% of our population) have an higher risk of falling, those underweight have an higher risk of hip fracture, maybe because of a reduced adipose panniculus.
More than 50% of these patients has severe disability before the fracture. In particular there were an insufficiency in staying upstanding and in walking with a significant deficit in daily activities. It was recently demonstrated that even subclinical disability is a risk factor for falling (39
). These defects usually worsen after fracture leading to irreversible effects especially in disability. In this study we found frequent coexistence of a visual (more than 33% of patients) and hearing (1 patient out 7 patients) deficit and that may increase risk of falling and than fracture.
25% of patients had an important cognitive deficit. This value is underestimated because of the exclusion of patients (15% in this study) with severe cognitive impairment that were not able to perform questionnaires. It must be considered that cognitive impairment, even not severe, may reduce patient’s collaboration for diagnostic exams and therapeutic compliance.
Co-morbidities are another important characteristic of patients with hip fracture: 90% of patients had one pathology and 50% at least two. These values are in line with data recently published in BMJ (40
) and confirm frailty of elderly patients with hip fracture and high mortality risk. Most frequent co-morbidity is cardiovascular disease. This may be explained by the reported association between cardiovascular disease, osteoporosis and hip fracture (41
), that may have a genetic or pathogenic common background.
Only 16% of patients was taking no drugs, while 40% was taking at least 4 drugs. Most frequent medications were anti-hypertensive drugs. Recent studies demonstrated higher risk of falling in patients taking anti-hypertensive drugs (OR 1.24; CI 1.01–1.5) and diuretics (OR 1.07; IC 1.01–1.14), but not beta-blockers (42
). In this population proton pump inhibitors are frequently taken, and their use has recently been correlated with increased risks of fracture (43
), maybe caused by a reduced intestinal absorption of calcium, although this problem seems to decrease with chronic use. In our population more than one elderly patients with hip fracture out three takes hypnotics or anti-depressant drugs, and these drugs have been recently proved to increase risk of falling (42
). These effects may be caused by sedation, insomnia or sleep problems, nycturia, decreased postural reflex or increased reaction time, orthostatic hypotension, equilibrium disorders, heart rhythm and conduction disorders and altered motility, all of whom caused by anti-depressant drugs.
Daytime sleepiness is an important risk factor for falling, both in not-treated depression and in patients suffering from depression and treated with anti-depressant drugs (44
); risk of falling is the same in patients suffering from depression treated with anti-depressant and those not treated with such drugs (44
Anti-depressant are also used, for long time and without periodic revaluation, in patients suffering from other pathologies than depression (urinary incontinence, chronic and neuropathic pain, anxiety disorders, irritable bowel syndrome, sedation).
In our opinion it’s noteworthy that patients with hip fracture often assume non-steroidal anti-inflammatory drugs (NSAIDs) twice a week, or more; some studies have demonstrated an increased risk of falling in patients with chronic pain or that chronically use NSAIDs (45
). Few reports have investigated the correlation between chronic pain and risk of falling in elderly people. Pain is involved in functional defects and muscular weakness and is associated with mobility limitations that may facilitate falling. In addition there are similar neurocognitive defects in patients with frequent falling and in those suffering from chronic back pain, supporting the role of neuropathic pain in falling. Chronic pain may be an important risk factor for falling in elderly patients, and this may be explained by the high prevalence of chronic pain, often under-treated, in such patients.
Our study confirms that hip fractures are often caused by falling, and this highlights the importance of preventing falling in order to reduce hip fracture. It’s important to note that 1 patient out of 3 has a positive history of falling in the last year and this is the most relevant risk factor for falling (27
) and fracture (46
), although most relatives and general practitioners underestimate this factor. In our opinion it’s noteworthy that more than 1 fracture out 10 happens during the night-time, often in bedroom, and this demonstrates the role of insufficient lighting or problems in standing up from the bed, in falling. Those factors were present in more than 10% of our patients.
Frequently (more than 1 case out of 3) some objects played a role in causing falling. Most dangerous were carpets. In more than 10% of our patients, loose flooring were involved in falling.
Our patients were often at risk of malnutrition, and this increases the risk of osteoporosis and sarcopenia, and than of falling. 4 patients out of 5 have had an insufficient calcium intake (lower than 800 mg\die) that may cause secondary hyperparathyroidism. It’s urgent to organize a program for nutritional education in elderly people.
Family history of hip fractures and smoking are less important risk factors for osteoporosis, falling and fractures than a previous fragility fracture that was present in 1 patient out of 3.
Only 18% of patients with recent hip fracture were previously screened by densitometry and only 17% were treated with drugs for osteoporosis.
Most of our patients had medium T-score of femoral neck of −2,4 and Z-score of −0,4 and this confirm that patients with hip fracture are often osteopenic (47
) with bone mineral density comparable to people of the same age. This stresses that hip fractures have different causes, not only osteoporosis, and so we must use different approaches to prevent them.
Our study gives important informations both about the prevalence of hypovitaminosis D, that have known negative effects on bone and muscle, and about preventive strategies thus applied. We found that in patients without vitamin D supplementation mean serum levels of 25OHD were very low, and that in cities of our region, except Verona, only 12% takes vitamin D supplementation.
In Verona the prevalence of patients with hypovitaminosis D is lower thanks to preventive strategies applied during the last years and based on the use of vitamin D bolus during winter months (37
). Moreover vitamin D has been recently correlated with time for functional recovery from hip fracture (48
). All those data support preventive strategies with vitamin D supplementation in elderly people and in patients with hip fracture.
In conclusion, elderly people with hip fracture have often pre-existing disability, comorbidities with polypharmacy, individual and ambiental risk factors for falling, and low calcium and vitamin D intake. Community and personalized preventive strategies are feasible and urgent.