INJURY PREVENTION

Health Evidence Bulletins - Wales
Team Leader: Dr. Ronan Lyons

Date of Completion: 02.04.98

2:Older People

This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation

The Statements The Evidence
2.1 General Fall Prevention Measures  
2.1a. Home assessment and surveillance can reduce falls in frail elderly people. This can be carried out by a variety of health care workers or volunteers (reduction in risk = 20-30%)i,ii..
(Health Gain Notation - 1 "beneficial")
i. Preventing falls and subsequent injury in older people. Effective Health Care Bulletin. Vol. 2 No.4. University of York: NHS Centre for Reviews and Dissemination, 1996 http://www.york.ac.uk/inst/crd/ehc25.htm
(Type I evidence - systematic review)
ii. Gillespie LD, Gillespie WJ, Cummings R, Lamb SE, Rowe BH. Interventions to reduce the incidence of falling in the elderly. Cochrane Database of Systematic Reviews Cochrane Library 1998 Issue 2.
http://www.update-software.com/ccweb
cochrane/revabstr/ab000340.htm

(Type 1 evidence- systematic review)
2.1b. The role of exercise alone in preventing falls in the elderly is uncertain. The positive results from an initial systematic review have been challenged by a more recent review i,ii
(Health Gain Notation - 4 "unknown")
There is some evidence that balance training, such as Tai Chi, can reduce falls in older people by around one third iii, iv
(Health Gain Notation - 1"beneficial")
i. Preventing falls and subsequent injury in older people. Effective Health Care Bulletin. Vol. 2 No.4. University of York: NHS Centre for Reviews and Dissemination, 1996.
(Type I evidence - systematic review)
http://www.york.ac.uk/inst/crd/ehc24.htm
ii. Province M, Hadley E, Hornbrook M et al, for the FICSIT Group. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of FICSIT trials. Journal of the American Medical Association 1995; 273: 1371-1347.
(Type II evidence - randomised controlled trial)
iii. Wolf SL, Kutner NG, Green RC et al, The Atlanta FICSIT study: two exercise interventions to reduce frailty in elders. Journal of the American Geriatrics 1993; 41: 329-32.
(Type II evidence - randomised controlled trial)
iv. Cambell AJ, Robertson MC, Gardener MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of general practice programme of home based exercise to prevent falls in elderly women. British Medical Journal 1997; 315 : 1065-69.
http://www.bmj.com/cgi/content/full/315/7115/1065
(Type II evidence - randomised controlled trial)

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2.2 Osteoporosis and related factors
2.2a. There is observational evidence that taking regular weight bearing exercise plays a substantial part in preventing osteoporosis
(risk reduction for regular exercise = 50%) i.
(Health Gain Notation - 2 "likely to be beneficial")
caveat: Risk based on observational studies may be incorrect due to selection biases and confounding variables. This has not been tested by intervention trials.
i. Law MR, Wald NJ, Meade TW. Strategies for preventing osteoporosis and hip fracture. British Medical Journal 1991; 303: 453-459.
(Type IV evidence - observational studies)
2.2b. Stopping smoking may reduce osteoporotic fractures. A meta-analysis of observational studies showed a strong risk between smoking, osteoporosis and fractures. Persistent smoking increases the risk of a hip fracture by about half. However, no interventional studies were foundi.
(Health Gain Notation - 2 "likely to be beneficial")
i. Law MR, Hackshaw AK. A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. British Medical Journal 1997; 315: 814-816.
http://www.bmj.com/cgi/content/full/315/7112/841
(Type IV evidence - observational studies)
2.2c. Evidence from observational studies suggests that lower intakes of vitamin D and calcium are risk factors for osteoporosis. It is likely that a dietary increase in calcium and vitamin D will result in fewer fractures but the effectiveness of interventions have not been tested in the general populationi.
(Health Gain Notation - 2 "likely to be beneficial")
i. Allison S. Cost benefits of nutritional support. Paper presented to a scientific workshop: A positive contribution to NHS cost containment. London: Medical Society of London, October 1993.
(Type IV evidence - observational studies)

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2.2d. Calcium and Vitamin D supplements can reduce fractures in high risk individuals. High dose oral vitamin D plus calcium supplements reduce the number of fractures in elderly women in nursing homes (reduction in risk = 20%)i,ii. Vitamin D and calcium supplements in the elderly living in the community result in reduced bone loss and less fracturesiii
(Health Gain Notation - 1 "beneficial")
The effectiveness of an annual injection of vitamin D in reducing fractures needs further studyiv as the only study found was not properly randomised. Calcium and vitamin D supplements improve bone mineral density in people with corticostroid induced osteoporosis but studies so far have been too small/short to evaluate potential effects on fracture incidence.
(Health Gain Notation- 2 "likely to be beneficial")
i. Gillespie WJ, Henry DA, O’Connell DL, Robertson J. Vitamin D, vitamin D analogues and calcium in prevention of fractures in involutional and post-menopausal osteoporosis. Cochrane Database of Systematic Reviews. Cochrane Library 1998, Issue 3 http://www.update-software.com/ccweb
cochrane/revabstr/ab000227.htm

(Type I evidence - systematic review)
ii. Chapuy MC, Arlot ME, Ou Boeunt F et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. New England Journal of Medicine 1992; 327: 1637-1642.
(Type II evidence - randomised controlled trial )
iii. Dawson-Hughes B, Harris SS, Krall EA et al Effect of calcium and vitamin D supplementation on bone chemistry in menopausal women 65 years of age or older. New England Journal of Medicine 1997; 337: 670-676.
(Type II evidence - randomised controlled trial )
iv. Heikinheimo RJ, Inkovera JA, Harju EJ et al. Annual injection of vitamin D and fractures of aged bones. Calcified Tissue International 1992; 51: 105-110.
(Type II evidence- randomised controlled trial )
v. Homik J, Suarez-Almazor ME, Shea B, Cranney A, Wells G, Tugwell P. Osteoporosis (OP): Calcium (Ca) and Vitamin D for the treatment of corticosteroid induced osteoporosis. Cochrane Database of Systematic Reviews. Cochrane Library 1998, Issue 2.
http://www.update-software.com/ccweb
cochrane/revabstr/ab000952.htm

(Type I evidence - systematic review)
2.2e. Observational studies show that Hormone Replacement Therapy (HRT) is associated with fewer fractures, less heart disease and more breast cancer (see also Cardiovascular Diseases and Cancers Bulletins)i ii,iii. The effect of selection biases is unknown. One small trial showed decreased vertebral fractures in those with existing vertebral fractures. This was the only randomised controlled trial found of HRT is women aged 50-64 years at recruitment. Results of a large long-term trial (funded by the Medical Research Council) are awaited. The study started in 1997 with a planned median follow up of 10 years, outcomes: cardiovascular disease, major fractures, cancers (breast) and dementia. An international limb of the trial will boost numbers to 34,000.
(Health Gain Notation -3 "trade off between beneficial and
adverse effects "
)
i. Due for publication, 1998.
ii. Grodstein F, Stampfer MJ, Colditz GA et al. Postmenopausal hormone therapy and mortality. New England Journal of Medicine 1997; 336: 1769-1775.
(Type IV evidence - observational studies)
iii. Lufkin EG , Wahmer HW, O’Fallon WM et al. Treatment of postmenopausal osteoporosis with transdermal oestrogen. Annals of Internal Medicine 1992; 117: 1-9.
(Type II evidence - randomised controlled trial)

 

 

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2.2f. Bisphosphates reduce the incidence of new fractures in elderly women with pre-existing vertebral fracturesi,ii. Bisphosphonates reduce bone loss and prevent fracture in postmenopausal women on corticosteroids iii.
(Health Gain Notation - 1 " beneficial")
i. Black DM , Cummings SR, Karpf DB et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 1996; 238: 1535-1540.
(Type II evidence - randomised controlled trial)
ii. Harris ST, Watts NB, Jackson RD et . Four year study of intermittent cyclic etidronate treatment of postmenopausal osteoporosis: three years of blinded therapy followed by one year of open therapy. American Journal of Medicine 1993; 95: 557-567.
(Type II evidence - randomised controlled trial)
iii. Adachi JD, Cranney A, Goldsmith CH et al. Intermittant etidronate therapy to prevent corticosteroid induced osteoporosis. New England Journal of Medicine 1997; 337: 382-387.
(Type II evidence - randomised controlled trial)
2.2g. Calcitonin may be effective in preventing osteoporotic fractures. A single small trial of intra nasal salmon calcitonin demonstrated benefit in 68-72 year old women with low bone density. The confidence intervals are wide
(risk reduction = 23-93%) i.
(Health Gain Notation - 2 "likely to be beneficial")
i. Overgaard K, Hansen MA, Jensen SB et al. Effect of Salcatonin given intra nasally on bone mass and fracture rates in established osteoporosis: a dose response study. British Medical Journal 1992; 305: 556-561.
(Type II evidence - randomised controlled trial)
2.2h. Hip protectors can significantly reduce hip fractures in elderly people in nursing homes (reduction in risk = 60%). However, compliance is poor. Further studies are ongoing i.
(Health Gain Notation - 2 "Likely to be beneficial")
i. Lauritzen JH, Paterson MM, Lund B, Effect of external hip protectors on hip fractures. Lancet 1993; 341: 11-13.
(Type II evidence - randomised controlled trial)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk