Position Development Paper
Official Positions for FRAX® Clinical Regarding Falls and Frailty: Can Falls and Frailty be Used in FRAX®?: From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

https://doi.org/10.1016/j.jocd.2011.05.010Get rights and content

Abstract

Risk factors for fracture can be purely skeletal, e.g., bone mass, microarchitecture or geometry, or a combination of bone and falls risk related factors such as age and functional status. The remit of this Task Force was to review the evidence and consider if falls should be incorporated into the FRAX® model or, alternatively, to provide guidance to assist clinicians in clinical decision-making for patients with a falls history. It is clear that falls are a risk factor for fracture. Fracture probability may be underestimated by FRAX® in individuals with a history of frequent falls. The substantial evidence that various interventions are effective in reducing falls risk was reviewed. Targeting falls risk reduction strategies towards frail older people at high risk for indoor falls is appropriate. This Task Force believes that further fracture reduction requires measures to reduce falls risk in addition to bone directed therapy. Clinicians should recognize that patients with frequent falls are at higher fracture risk than currently estimated by FRAX® and include this in decision-making. However, quantitative adjustment of the FRAX® estimated risk based on falls history is not currently possible. In the long term, incorporation of falls as a risk factor in the FRAX® model would be ideal.

Introduction

The World Health Organization fracture risk assessment tool (FRAX®) algorithm has been developed to estimate the 10-year risk of hip and major fractures based on clinical risk factors, with or without bone mineral density (BMD). The risk factors included in FRAX are: age, sex, body mass index (BMI), personal history of fracture, parental history of hip fracture, current smoking, alcohol intake, glucocorticoid use, rheumatoid arthritis, other causes of secondary osteoporosis and with the option of including femoral neck BMD. Risk factors identified for hip fractures can either be purely skeletal related such as bone mass, bone geometry, bone microarchitecture, bone turnover, or be fall related such as neuromuscular function, cognitive impairment, visual acuity, certain medications, or can be both skeletal and fall related such as age, genetic factors, family history of fracture, weight, weight change and mobility (1). One criticism of the FRAX model by some users has been the lack of consideration of falls or falls risk in predicting fractures.

The remit of this FRAX Clinical Task Force Sub-Committee is to review the evidence and consider if falls should be incorporated into the FRAX model or alternatively provide guidance to clinicians on how a history of falls should be used in conjunction with FRAX in their clinical decision-making.

Section snippets

Methodology & Data sources

A Medline search was conducted using “falls” and “fractures” and “fracture prediction” as search terms. This search was limited to the English language. Relevant citations were included at the discretion of the task force members.

Statements

Question: Should a falls history be incorporated into FRAX?

Official Position: Falls are a risk factor for fractures but are not accommodated as an entry variable in the current FRAX model. Fracture probability may be underestimated in individuals with a history of frequent falls, but quantification of this risk is not currently possible.

Grade: Good, A, W

Ad hoc Task Force Opinion not Approved by the Expert Panel: Existing data are not of adequate quality to incorporate quantitative adjustment to

Rationales

In the future, a falls history should be incorporated into FRAX. At this time, it is recommended that FRAX users be made aware that FRAX currently underestimates fracture risk in patients with falls. As an example, an accompanying statement could be added to FRAX as follows: “Data from the Study of Osteoporotic Fractures suggest that in comparison to individuals without a fall in the previous year, a history of each fall (up to 5 falls or more) in the previous year increases the 10 year hip

Epidemiology of Falls and Relationship Between Falls and Fractures

Falls are common amongst older people and a major public health concern in terms of morbidity/quality of life, mortality and cost to the health and social services. The prevalence has been estimated as 28–35% in community dwelling older people aged 65 years and up to 42% in those aged over 75 years (2).

Around 40–60% of falls in older adults lead to injuries, with 30–50% resulting in minor trauma, 10–15% lead to serious injuries with around 5–10% resulting in fracture, 1–2% of these being hip

Additional Question for Future Research

It is suggested that future studies evaluate whether combining standard bone directed osteoporosis treatment strategies, (e.g., bisphosphonates) with strategies to assess and reduce falls risk will have an additive effect on fracture risk reduction. Though it is intuitive that combination therapy directed at bone and falls risk would further reduce fractures; demonstration of this in properly designed clinical trials and subsequently identifying optimal combination approaches is necessary. An

In Summary

The FRAX tool is an established method, used worldwide, to estimate 10-year fracture risk that can aid discussion with patients and help in decisions regarding treatment for osteoporosis and in fracture prevention. A number of limitations have recently been identified including the lack of incorporation of a falls history. There is some evidence that, in comparison to some other fracture prediction tools, FRAX may underestimate fracture risk in individuals with a history of falls. This

Acknowledgements

We thank Dr Emma Clark and Dr Morten Frost / Professor Bo Abrahamsen for permission to use data which is not yet published from the COSHIBA and SOMA cohorts respectively.

References (63)

  • J. Close et al.

    Prevention of falls in the elderly trial (PROFET): a randomised controlled trial

    Lancet

    (1999)
  • B. Allolio

    Risk factors for hip fracture not related to bone mass and their therapeutic implications

    Osteoporos Int

    (1999)
  • T. Masud et al.

    Epidemiology of falls

    Age Ageing

    (2001)
  • N. Austin et al.

    Fear of falling in older women: a longitudinal study of incidence, persistence, and predictors

    J Am Geriatr Soc

    (2007)
  • N. Deshpande et al.

    Activity restriction induced by fear of falling and objective and subjective measures of physical function: a prospective cohort study

    J Am Geriatr Soc

    (2008)
  • G. Salkeld et al.

    Quality of life related to fear of falling and hip fracture in older women: a time trade off study

    BMJ

    (2000)
  • S.D. Berry et al.

    Falls: epidemiology, pathophysiology, and relationship to fracture

    Current Osteoporosis Reports

    (2008)
  • M.E. Tinetti et al.

    The patient who falls: “It's always a trade-off”

    JAMA

    (2010)
  • J.C. Woolcott et al.

    Meta-analysis of the impact of 9 medication classes on falls in elderly persons

    Arch Intern Med

    (2009)
  • S.G. Leveille et al.

    Chronic musculoskeletal pain and the occurrence of falls in an older population

    JAMA

    (2009)
  • American Geriatrics Society BGS. AGS/BGS Clinical Practice Guideline: Prevention of falls in older persons. 2010...
  • J.L. Kelsey et al.

    Indoor and outdoor falls in older adults are different: the maintenance of balance, independent living, intellect, and Zest in the Elderly of Boston Study

    J Am Geriatr Soc

    (2010)
  • M.C. Nevitt et al.

    Risk factors for recurrent nonsyncopal falls. A prospective study

    JAMA

    (1989)
  • M.E. Tinetti et al.

    Identifying mobility dysfunctions in elderly patients. Standard neuromuscular examination or direct assessment?

    JAMA

    (1988)
  • A.M. Schott et al.

    How hip and whole-body bone mineral density predict hip fracture in elderly women: the EPIDOS Prospective Study

    Osteoporos Int

    (1998)
  • D.M. Black et al.

    An assessment tool for predicting fracture risk in postmenopausal women

    Osteoporos Int

    (2001)
  • K.W. Lyles et al.

    Zoledronic acid and clinical fractures and mortality after hip fracture

    N Engl J Med

    (2007)
  • P. Geusens et al.

    Can hip fracture prediction in women be estimated beyond bone mineral density measurement alone

    Therapeutic Advances in Musculoskeletal Disease

    (2010)
  • S.R. Cummings et al.

    Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group

    N Engl J Med

    (1995)
  • S.A. Wainwright et al.

    Hip fracture in women without osteoporosis

    J Clin Endocrinol Metab

    (2005)
  • P. Gardsell et al.

    The predictive value of fracture, disease, and falling tendency for fragility fractures in women

    Calcif Tissue Int

    (1989)

    • Cited by (95)

    View all citing articles on Scopus
    a

    Position Conference Members: See appendix 1.

    View full text
    Copyright © 2011 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.