Stroke Patients at Increased Risk for Fractures

December 06, 2016

Stroke patients should be targeted for bone mineral density screening and fall prevention programs, researchers say, according to a study showing they are at increased risk for low-trauma fractures.

The study, published online in Neurology on November 23, was conducted by a team led by Moira K. Kapral, MD, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.

They compared fracture rates in 23,000 stroke patients with those from age- and sex-matched controls and found that stroke patients had a 32% increased risk for low-trauma fractures compared with patients with transient ischemic attack (TIA) and a 47% increased risk compared with the general population.

"This is an observational study, so we can't say for sure," Dr Kapral commented to Medscape Medical News. "But our stroke cases were very well matched to the control populations, which increase the likelihood of a causal association."

She noted that possible reasons for an increased fracture rate in stroke patients include lower bone mineral density caused by reduced mobility and trouble with balance increasing risk for falls.

"The combination of thinner bones and increased falls, which are both more likely in stroke patients, probably explains why we saw an increased fracture rate."

She says awareness needs to be raised about this possibility and preventive action taken to reduce fracture risk in this population.

"There have been a couple of prior studies suggesting an increasing fracture risk in stroke patents, but this is not well recognized. Physicians do not really consider fractures as a complication of stroke. They need to think about this as part of the follow-up care of stroke patients."

For the study, the researchers analyzed data from the Ontario Stroke Registry; they identified 23,751 patients hospitalized with stroke and 11,240 hospitalized with TIA and discharged alive between 2003 and 2012. The Canadian Institute for Health Information Discharge Abstract Database and National Ambulatory Care Reporting System Database were used to identify hospitalizations and emergency department visits for fractures, falls, and other medical conditions.

The primary analysis compared the risk for low-trauma fractures in patients with stroke with that in patients with TIA by using propensity score methods to adjust for differences in baseline factors. A secondary analysis compared fracture risk after stroke with that in 23,751 age- and sex-matched controls from the general population identified from the Ontario Registered Persons Database.

Results showed a 2-year fracture rate of 5.7% for stroke patients compared with 4.8% in those with TIA (adjusted cause-specific hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.19 - 1.46) and 4.1% in age- and sex-matched controls (HR for stroke patients vs controls, 1.47; 95% CI, 1.35 - 1.60).

Dr Kapral suggested that measures to prevent fractures in stroke patients should be considered. These could include screening all stroke patients for bone mineral density and treating those with low values using osteoporosis drugs.

"There are guidelines for osteoporosis prevention in many countries that recommend screening the whole population after a certain age, but in practice only about 20% of the population actually gets such screening," she said. "We believe that if a patient has had a stroke, then this should be an additional reason for considering bone mineral density screening."

"Fall prevention programs would also be useful. These are part of some stroke rehabilitation programs, but many patients don't get such programs," she said.

The researchers also found certain factors within the stroke population that were associated with a higher risk for fractures. These included older age; female sex; past fractures; and history of falls and preexisting osteoporosis, rheumatoid arthritis, hyperparathyroidism, and atrial fibrillation. "These factors could be used to select out higher-risk groups for preventative programs," she noted.

In terms of stroke severity, patients who had a moderate stroke were at the highest risk for fracture. "Those with mild strokes are at less risk for falling," Dr Kapral explained. "And those with severe strokes are often confined to bed. But those with moderate strokes often have some mobility issues so tend to lose some bone mineral density but have enough mobility to be able to walk around but are at high risk of falling."

The Ontario Stroke Registry was funded by the Canadian Stroke Network and the Ontario Ministry of Health and Long-Term Care (MOHLTC). The Institute for Clinical Evaluative Sciences is supported by an operating grant from the MOHLTC. Individual authors are supported by awards from the Heart and Stroke Foundation and the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Neurology. Published online November 23, 2016. Abstract

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