Geriatrician-Managed Program Reduces Falls and Fractures

Jim Kling

May 09, 2012

May 9, 2012 (Seattle, Washington) — A falls and fractures clinic run by geriatricians, in collaboration with a multidisciplinary team, was able to reduce falls by 65% and fractures by a predicted 72%, according to research presented here at the American Geriatrics Society 2012 Annual Scientific Meeting.

Falls and fractures are a very common problem in older people, but their care is disjointed because geriatricians generally deal with falls and other specialists generally deal with fractures.

"We're trying to promote the combined model of falls and fracture prevention. Most geriatricians are dedicated to falls prevention, but they don't consider that falls and fractures share all the same risk factors and the same mechanisms," Gustavo Duque, MD, PhD, professor of medicine and director of the division of geriatric medicine at the University of Sydney in New South Wales, Australia, who presented the research, told Medscape Medical News.

The researchers investigated whether an integrated program for secondary prevention run by geriatricians would be effective in reducing falls and predicted fractures in a high-risk population of older adults.

The study involved 430 subjects (mean age, 82 years; 65% female) who were assessed at the falls and fractures clinic at Nepean Hospital in Penrith, New South Wales. Factors examined included fear of falling (measured on the Safety and Fear of Falling in the Elderly instrument), risk factors for falls and fractures, nutritional deficiencies, depression, grip strength (measured with a dynamometer), densitometry, posturography (measured using an instrument manufactured by Medicaa, Uruguay), and gait parameters (measured using the GAITRite system).

The research team — made up of 2 geriatricians, 1 rehab specialist, 1 nurse, 2 physiotherapists, 1 occupational therapist, 1 dietician, 1 exercise physiologist, and 1 clinic coordinator — also tested blood for secondary causes of osteoporosis, such as vitamin D deficiency and excess parathyroid hormone.

The team then created a plan tailored to the individual's risk factors. Participants were interviewed by phone after 3 months and reassessed at the clinic after 12 months.

Before the initial assessment, 77% of participants had fallen and 38% had experienced a fracture. Subjects had fallen an mean of 6.5 times and had a mean of 3.5 fracture risk factors. At the final assessment, falls had been reduced by 65% (P < .01) and the incidence of fractures, predicted using a Web-based predictive tool, had been reduced by 72% (P < .01).

Vitamin D supplementation increased from 16% to 89% and was corrected in 92% of subjects who had been deficient. The incidence of secondary hyperparathyroidism fell from 14% to 3%. Among those at high risk for fracture, osteoporosis treatment rates rose from 9% to 68% (P < .01).

The researchers noted improvement from baseline to 6-month assessment in gait velocity (74.6 ± 26.2 vs 102.6 ± 12 cm/s; P = .03), limits of stability (129.3 ± 57 vs 175.2 ± 27.5 cm²; P = .03), and fear of falling (72% ± 16% vs 45% ± 12%; P = .04).

The program incorporates a lot of technology to measure gait and balance parameters and to train for better balance. The reductions in fall and fracture risk "are higher than in other [prevention] programs," said Dr. Duque.

The generalizability of the program will depend on the resources available. Medicare won't pay for some of the technology components used. "We have to find a way to bill the government for these kinds of things, or present cost/benefit analyses [to justify the expenditures]. The technology is commercially available," Dr. Duque explained.

Dealing with falls and fractures together could have a synergistic impact on morbidity, according to Susan Friedman, MD, MPH, associate professor of medicine at the University of Rochester in New York, who moderated the session.

Geriatricians are natural collaborators, but have stayed out of fracture prevention, she noted. "In our institution, the bone metabolism clinic is run by the orthopedic specialists. Geriatricians are beginning to have some inroads in that, but it's a matter of not wanting to step on other people's toes or invade their turf," Dr. Friedman told Medscape Medical News.

The study was funded in part by unrestricted medical education grants from Merck, Servier, and Novartis. Dr. Friedman has disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2012 Annual Scientific Meeting: Abstract P15. Presented May 3, 2012.