Dr Chris Barclay assesses new SIGN guidance on preventing and treating hip fractures, and argues for a national strategy
Our elderly are more fragile than they were a decade ago. Figures from Scotland have revealed a 43% increase in the incidence of hip fracture from 1982 to 1998. Inpatient and community care costs around £10000 per case. The cost to the individual sustaining the fracture is also considerable - around one-third die within a year, and many move to residential care after discharge from hospital.
The SIGN publication, Prevention and management of hip fracture in older people1 dovetails nicely with the requirements of the National Service Framework for Older People, which sets standards for primary care.2 The document addresses hip fracture from prevention, through management in A&E and operative techniques to rehabilitation. Of especial relevance to GPs is the advice on preventing both falls and fractures. Major predictors for falls include immobility and muscular weakness, poor gait and eyesight and adverse home layout.
The guideline recommends a multidisciplinary approach for patients who are identified as high risk. Patients should be offered occupational therapy and physiotherapy; they should be supplied with walking and balance appliances and their homes should be assessed for hazards.
I found the checklist suggestions for identifying those at risk of osteoporotic fracture most interesting. They referred only to studies conducted in the USA and the Netherlands rather than the UK population.
Risk factors for fractures:
- Previous fragility fracture (e.g. Colles fracture): the strongest predictor of future fracture
- Maternal history of hip fracture
- Cigarette smoking: found to be predictive in the USA but not the Netherlands. (UK studies have also failed to find this a useful predictor.)
- Leanness (BMI <18.5)
Risk factors for falls:
- Slow gait: a general sign of deteriorating stability. (Another might be ïstops walking to talkÍ.)
- Medical predisposition to falls: history of stroke, ParkinsonÍs disease, foot arthritis and poor vision.
Both SIGN 56 and the NSF for Older People listed risk factors, but neither went on to define unambiguously a quantitatively validated and weighted checklist for use in primary care.
So what are the preventive interventions at our disposal? First, the guideline recommends that all those at risk of a fall or fracture should be given calcium and vitamin D supplements. This is the most cost-effective intervention in the elderly, it says.
The guideline states that bone densitometry should be performed in those identified at risk of osteoporosis. Bisphosphonates were highly recommended in treating osteoporosis, but the guideline development group did not assess the alternatives, for example calcitonin and SERMs.
The group dismissed HRT as an effective intervention, not because it does not work but because in practice so few women are prepared to take it for long enough to gain worthwhile protection.
The development group also observed that hip protectors are remarkably effective when used.
Both SIGN 56 and the NSF for Older People are propelling primary care into a much more proactive approach to the identification and treatment of those at risk of osteoporosis and falls. GPs are well aware of the scale of the ïsilent epidemicÍ; however, a simple, nationally agreed policy on what risk factors we should look for and precisely what action should follow is still urgently needed.
(1) Scottish Intercollegiate Guidelines Network. SIGN 56: Prevention and management of hip fracture in older people. Edinburgh: SIGN, January 2002. The guideline can be downloaded from the SIGN website: http://www.sign.ac.uk
(2) Department of Health. The National Service Framework for Older People. London: TSO, 2001.