Position Development PaperOfficial 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®
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.
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Position Conference Members: See appendix 1.