Adding Exercise, Assessments to Mailed Info Fails to Curb Fractures in Seniors

By Gene Emery

November 05, 2020

(Reuters Health) - More isn't better when it comes to preventing fractures in the elderly.

A pragmatic study across England has concluded that adding exercise or a multifactorial fall prevention program to a mail campaign that offers fall-prevention tips to seniors does not prevent falls or fractures.

In fact, people age 70 and older who received the additional intervention actually reported more fractures per 100 person-years than people who received the mailer, although not by a margin that was statistically significant.

The result of the study and the 10 years it took to complete was both surprising and disappointing, chief author Prof. Sarah Lamb of the University of Exeter told Reuters Health in a telephone interview.

"The most important message is that researchers and clinicians need to rethink the cause of fractures in later life and find more effective treatments," she said, stressing that "people should not stop exercising" because other tests have shown that exercise reduces falls, even if it didn't cut the rate of fracture in this study.

The results appear in The New England Journal of Medicine.

Dr. Ian Reid, head of the department of medicine at the University Auckland, who was not involved in the study, agreed that "These results challenge those designing and delivering falls prevention programs, but do not change the advice regarding falls and exercise provided to the general public."

He told Reuters Health by email that the new results are "similar to the negative findings of another large study published in The New England Journal in July this year.... These two studies will require a major reevaluation of how falls prevention programs are delivered across communities, and to whom they are targeted within the at-risk groups." (https://bit.ly/2JCxUeN)

"It's a landmark study in a field where it's rare to be able to study over 9,000 people," said Dr. Elizabeth Goldberg, a falls and fall prevention researcher at Brown University's Warren Alpert Medical School in Providence, Rhode Island.

The lack of benefit "is a disappointment," she told Reuters Health by phone, but the overall patient population was not particularly high risk, "so that may explain why you didn't see a benefit."

All of the 9,803 volunteers were living in their own homes. The exercise group was shown how to do progressive home exercises for strength and balance, given ankle weights and advised to do recreational walking.

The multifactorial intervention included the exercises but added a broad range of assistance, including gait and balance tests, a medication review and visual acuity testing, along with foot and footwear assessments.

In the advice-by-mail group, the rate of fracture was 2.76% per person per year over 18 months. In the group where exercise was added, the rate was 3.06%, or 20% higher.

When the multifactorial fall prevention program was added, the rate was 3.50%, or 30% higher than in the mailer-alone group.

Even when the researchers focused on the 4,291 people who were at a higher risk of falling, the more-intensive programs did not produce a significant difference.

Fracture rates were 4.28% in the mail-only group, 5.12% when multifactorial fall prevention was added and 3.70% when exercise was added (a 6% reduction with exercise, but not one that was sizable enough to make a clear difference).

Total medical care cost was lower in the mailer-only group. It averaged $4,352 (3,373 pounds) in the advice-by-mail group, $4,799 (3,720 pounds) in the exercise group and $4,826 (3,941 pound) in the multifactorial fall prevention group.

"An exercise intervention that is more prolonged or more intense, or both, may have a more sustained effect on falls but would cost more," the researchers speculated. "Future studies should include interventions with better long-term adherence among persons at greatest risk for a fracture."

Adherence is a big issue, said Prof. Lamb, and people "need to focus on sticking to exercise, particularly over the long term. People start off with good intentions, but people really struggle if they have a break for hospitalization or ill health. They have to pick it up again. They really need to be supported and encouraged to do that by family, friends and medical providers."

In the future, researchers may want to look beyond strength and balance, she said. Age-related changes in visual perception might increase the risk, for example.

"Something that might be nothing when you are younger, like the edge of a curb, might be enough to tip you over," said Prof. Lamb.

Also, "quite a lot of fractures happen in very unusual situations. There were quite a lot of injuries with escalators; people can have some really quite nasty accidents. You look at them and think, 'No amount of exercise will affect what happens in that situation.' We need to look at those again," she said.

Finally, there may be too-little attention to alcohol and other substance abuse issues as a factor in elderly falls.

SOURCE: https://bit.ly/3mHjB6Z The New England Journal of Medicine, online November 4, 2020.

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