USPSTF Draft Recommendations for Falls and Fracture Prevention

Pam Harrison

September 26, 2017

Exercise is moderately beneficial for the prevention of falls in older adults who are at increased risk of falling, according to new draft recommendations from the US Preventive Services Task Force (USPSTF).

"Muscle weakness, gait disturbances, and imbalance are important factors that contribute to increased risk for falls in older persons, [and] exercise and physical therapy may improve strength and balance and therefore may result in fewer falls," the USPSTF authors state.

The "USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls," they add. They note, however, that the benefit of routinely recommending different kinds of interventions for fall prevention is small. The task force members also did not recommend the use of vitamin D supplementation to prevent falls.

And in a separate set of draft USPSTF guidelines, other authors say they do not support the use of vitamin D or calcium supplementation, either alone or in combination, for the primary prevention of fractures in postmenopausal women, premenopausal women, or men.

This updated USPSTF draft recommendation is consistent with one made earlier in 2013 on vitamin D supplementation, with or without calcium, to prevent fractures.

Somewhat in contrast, the National Academy of Medicine and the World Health Organization both recommend individuals meet adequate daily requirements for vitamin D and calcium intake as part of an overall strategy to improve health, but neither organization recommends supplementation specifically for the prevention of fracture.

Both draft recommendation statements and draft evidence reviews are available for review and public comment from September 26 to October 23. 

Vitamin D, Calcium, and Fracture Prevention

The USPSTF Task Force feels that evidence supporting the use of daily supplementation with greater than 400 IU of vitamin D and greater than 1000 mg of calcium for the primary prevention of fractures in community-dwelling postmenopausal women is insufficient.

Nor is taking 400 IU or less of vitamin D, and 1000 mg or less of calcium beneficial for the primary prevention of fractures in postmenopausal women, they state.

And supplementation with vitamin D and calcium isn't useful for the primary prevention of fractures in men or premenopausal women either, they add.

For this particular set of draft recommendations, USPSTF authors assessed eight randomized controlled trials (RCTs) in which the benefit of supplementation on fracture risk were analyzed along with nine RCTs assessing the harms of supplementation.

The doses of vitamin D studied ranged from 300 IU a day to 100,000 IU every 1 to 4 months and between 600 to 1600 mg a day for calcium.

"Vitamin D and calcium supplementation are often recommended for women, especially postmenopausal women, to prevent fractures, although actual use is uncertain," the USPSTF authors note.

"[But] in unselected, community-dwelling populations, the evidence does not support a finding of fewer fractures with vitamin D supplementation alone or with calcium; the evidence for supplementation with calcium alone is limited," they conclude.

Task-force members also note that the combination of vitamin D plus calcium is associated with an increased incidence of kidney stones.

Fall Prevention in Older Adults

The USPSTF last issued recommendations on fall prevention for older adults in 2012.

Task-force members identified 62 trials in which seven types of interventions were evaluated for their ability to reduce the risk of falls and injurious consequences of those falls.

Most commonly, studies evaluated interventions that featured components of gait, balance, and functional training, most often offered three times a week for a year.

"Meta-analysis of multifactorial intervention trials showed a 21% reduction in falls with substantial heterogeneity."

The analysis also indicates that protection against falls is associated with both multifactorial and exercise interventions, but evidence is most consistent for exercise trials.

Task-force members were unable to pinpoint any one instrument as being the best prediction tool to assess fall risk in older adults, but an individual history of falls was one factor they singled out.

"When determining to whom these recommendations apply, primary-care clinicians can reasonably consider a small number of risk factors to identify older adults who are at increased risk for falls," they suggest.

For example, age is a major risk factor for falls, as are impairments in mobility, gait, and balance.

Thus, a practical way to identify patients at risk is to simply ask patients if they have fallen recently and assess for any deficit in physical function or mobility issues. The "Timed Up and Go" test could also be a useful assessment tool, task-force members suggest.

Fracture Prevention Around Falls

As the USPSTF members point out, falls are the leading cause of injury in adults 65 years of age and older, where it's estimated that about one-third of older adults fall at least once a year.

"Fractures are an important injury associated with falls," USPSTF members state.

To prevent fractures, task-force members recommend women 65 years of age and older be screened for osteoporosis, as well as younger women if their fracture risk is at least equal to that of a 65-year-old white female with no risk factors for fracture other than age.

In 2014, approximately 2.8 million older adults in the United States sought treatment for falls in the nation's emergency department, and about 27,000 older adults died from a fall in the same year.

Some 800,000 older adults required hospitalization in 2014 because of a fall.

The US Department of Health and Human Services recommends older adults get at least 150 minutes a week or moderate-intensity exercise or 75 minutes a week of vigorous-intensity, aerobic activity.

They also recommend older adults engage in activities that strengthen muscles twice a week, and for those specifically at risk for falls, they recommend balance-training exercises 3 or more days a week.

The USPSTF authors had no relevant financial relationships.

US Preventive Services Task Force. Falls Prevention in Community-Dwelling Older Adults: Interventions, Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Adults: Preventive Medication, Draft Evidence Review for Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Adults: Preventive Medication

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