It is of great clinical importance to be able to predict falls, secondary fractures, hospitalizations, and death after rehabilitation in the elderly with hip fractures. Overall, 32%–56% of patients report one or more falls following hospital discharge for hip fracture surgery,1
3%–14% sustain a secondary fracture,4
and 15% die within a year.7
The incidence of falls, the incidence of fractures, and death rates in our study have all been consistent with these observations. Hence, our cohort represents the elderly with hip fractures well. In this study, we have shown for the first time that the Norton scoring system may be used for predicting falls long after rehabilitation in the elderly with hip fractures.
Pressure ulcers are a major problem associated with morbidity and mortality in elderly immobile patients. Risk assessment scales, such as the Norton scoring system, have been available for more than 50 years for assessing the risk of pressure ulcers, but their usefulness in preventing these ulcers remains uncertain.13
The current study adds to the evidence showing that it is too early to abandon the Norton scoring system, given that it can be used for purposes other than predicting the risk of pressure ulcers, including predicting postoperative complications and inhospital mortality in elderly patients following hip fracture surgery,10
predicting postoperative complications in elderly patients following spine fracture surgery,15
and predicting the duration and outcome of rehabilitation in elderly patients following any type of hip surgery,11
or hospital-associated deconditioning.17
Age, congestive heart failure, poor quality of life, poor nutritional status,3
fear of falling,18
use of a gait device, and slow walking during rehabilitation2
are all associated with falls in the elderly following hip fracture surgery. Except for age, most of these risk factors are difficult to measure. On the other hand, Norton scale scores are simple to measure and, accordingly, can be used as a geriatric screening assessment tool by nurses and physicians who are not familiar with traditional geriatric and rehabilitation scales. There are few well-studied scales used for assessing the risk of falls in the elderly, including the falls risk assessment tool,19
Berg balance scale,20
and timed up and go test.21
Relative to these scales, the Norton scoring system is not time-consuming. Most importantly, it is already being used successfully throughout the world right now.
In a recently published study, we have shown that the Norton scoring system may be used for predicting mortality in the elderly long after rehabilitation following any type of hip surgery, stroke, and hospital-associated deconditioning.22
In the current study, ANSS and low ANSS were not associated with death long after rehabilitation in the elderly with hip fractures. This discrepancy may be explained in two ways, ie, the current study included elderly patients with a history of hip fractures, while the other study included elderly patients with a history of hip fractures as well as elderly patients with a history of elective total hip replacement, stroke, and hospital-associated deconditioning. Moreover, the follow-up period in the current study was more than a year longer than that in the previous study. There is a place to study the predictive value of the Norton scoring system in terms of mortality long after rehabilitation separately for elderly patients following total hip replacement, stroke, and hospital-associated deconditioning.
One may claim that it should be no surprise that a low ANSS is independently associated with falls in the elderly with hip fractures, given that patients who develop pressure ulcers are more likely to fall, being partially immobile in the first place. However, regression analysis showed that ANSS as well as a low ANSS are independently associated with falls in the elderly with hip fractures, regardless of the appearance of pressure ulcers.
Another limitation is the sample size being too small for making population-based conclusions regarding lower ANSS cutoffs. Although an ANSS of 14 represents a high risk for pressure ulcer,8
it is possible that a lower ANSS is more sensitive and specific in predicting falls. Accordingly, it would be valuable to study the association between a lower ANSS and falls in the future in large-scale populations. In the meantime, in order to overcome this limitation, the regression analysis in has included low ANSS as a nonparametric variable as well as ANSS as a parametric variable.
Another limitation is the observational nature of this study. Future studies should include interventional measures used to prevent falls and fractures in elderly patients with a low ANSS, ie, bisphosphonates and vitamin D supplementation.23