L. Elffors

Risk Factors for Hip Fracture in Men from Southern Europe: The MEDOS Study

Abstract: The aims of this study were to identify risk factors for hip fracture in men aged 50 years or more. We identified 730 men with hip fracture from 14 centers from Portugal, Spain, France, Italy, Greece and Turkey during the course of a prospective study of hip fracture incidence and 1132 age-stratified controls selected from the neighborhood or population registers. The questionnaire examined aspects of work, physical activity past and present, diseases and drugs, height, weight, indices of co-morbidity and consumption of tobacco, alcohol, calcium, coffee and tea. Significant risk factors identified by univariate analysis included low body mass index (BMI), low sunlight exposure, a low degree of recreational physical activity, low consumption of milk and cheese, and a poor mental score. Co-morbidity including sleep disturbances, loss of weight, impaired mental status and poor appetite were also significant risk factors. Previous stroke with hemiplegia, prior fragility fractures, senile dementia, alcoholism and gastrectomy were associated with significant risk, whereas osteoarthrosis, nephrolithiasis and myocardial infarction were associated with lower risks. Taking medications was not associated with a difference in risk apart from a protective effect with the use of analgesics independent of co-existing osteoarthrosis and an increased risk with the use of anti-epileptic agents. Of the potentially ‘reversible’ risk factors, BMI, leisure exercise, exposure to sunlight and consumption of tea and alcohol and tobacco remained independent risk factors after multivariate analysis, accounting for 54% of hip fractures. Excluding BMI, 46% of fractures could be explained on the basis of the risk factors sought. Of the remaining factors low exposure to sunlight and decreased physical activity accounted for the highest attributable risks (14% and 9% respectively). The use of risk factors to predict hip fractures had relatively low sensitivity and specificity (59.6% and 61.0% respectively). We conclude that lifestyle factors are associated with significant differences in the risk of hip fracture. Potentially remediable factors including a low degree of physical exercise and a low BMI account for a large component of the total risk.

CIRCUMSTANCES AROUND THE FALL IN A MULTINATIONAL HIP FRACTURE RISK STUDY :A DIVERSE PATTERN FOR PREVENTION

Hip fracture is a major public health problem, but with a potential for prevention. Data from a European multicentre study on hip fracture epidemiology with a case control design, the MEDOS study, were used to describe and analyse circumstances around falls associated with hip fracture. The study includes 2185 fracture cases age > 50 years from 14 centres in southern Europe: Portugal, Spain, France, Italy, Greece and Turkey. Information was collected by a standardized and validated questionnaire translated into six languages and administered by trained interviewers. Circumstances around the fall were categorized according to: (1) place, age group and time of day; (2) functional disability; (3) drug consumption including alcohol; and (4) environmental factors. Possibilities for prevention were also analysed. High risk falls were identified using seven reasonably well-established risk factors, and similarly eight risk factors were used to identify high risk fallers. Selected trains of events were also studied. A pattern of great diversity was found both among the fallers and the environment in which they fell and fractured the hip. Those with more than one factor involved constituted only 14.7% of female and 19.7% of male fractures. A majority of cases were not physically disabled before the fall. A majority (66.5%) fell and fractured their hip indoors and only 4.3% outside in darkness. Cardiovascular and cerebrovascular comborbidity were observed with 4.9 and 7.8%, of falls respectively. Falls in a stairway comprised 11% of falls. The correlation between the number of the risk factors of the faller and in the environment was 0.07 and there was no difference between males and females. The pattern of causality behind falls that cause hip fracture and therefore of prevention comprises many sometimes small groups and intricate time sequence. The results suggest that global preventive strategies could presently not be implemented. Instead, the pattern of prevention should include different target groups and be country and site specific. For the high risk group of institutionalized patients prevention can be implemented without delay.

Methodology of MEDOS multicentre study of hip fracture incidence: validity and relevance considerations.

The Mediterranean osteoporosis (MEDOS) study was carried out in 14 centres from six countries in Southern Europe to determine the incidence rates and risk factors associated with hip fracture over the age of 50 years. This paper discusses both the validity and relevance of the data, that is, whether the number of collected cases of hip fracture and the size and age distribution of the population are representative of the population as a whole, and whether the incidence measures used in the study are suitable for comparing the risk of hip fracture between populations and for predicting future risk within populations. Five measures of risk were assessed at each centre: crude incidence over the age of 50 years; age-standardised incidence; risk increase/fracture doubling time by age; computed incidence at 50 years; and excess morbidity. Three standardised populations were used for comparison: the MEDOS population (incidences standardised to the overall age and sex distribution of all the participating centres); the weighted MEDOS population (only including the age range 60 to 84 years); and the Swedish population at the start of the study. The MEDOS study showed that the incidence of hip fracture increased exponentially with age in both sexes at all centres. The regression slope of incidence against age was affected by the age distribution of the population, but not by the absolute size of the population. Methods used to define the population of the catchment areas did not introduce errors of a greater magnitude than would the occasional addition or removal of single fracture cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Falls and Hip Fracture. A Reasonable Basis for Possibilities for Prevention?: Some Preliminary Data from the MEDOS Study

UNLABELLED The Mediterranean Osteoporosis Study (MEDOS), a multicentre study on incidence, risk factors, and means of prevention of hip fracture in the Mediterranean region, started in 1986 and involved 14 centres, in Portugal, Spain, France, Italy, Greece, and Turkey. The design includes a case-control study comparing 8,185 individuals in age groups above 50 (2,816 cases and 5,369 controls; two controls per case). Information on falls was only collected for a small fraction of the controls. In a questionnaire including 160 main questions eleven referred to circumstances around the fall. Falls were classified according to a) high risk environment, e.g. occurred in darkness and b) high risk fallers, e.g. confusion, reduced functional ability. There was great variation between centra for a majority of the results. However, 2/3 of fractures happened during daylight. 9% of fractures, same for both males and females, took place in darkness. Females have more indoor fractures than males. Around 15% of fractures took place in connection with going to the toilet. Mental factors play a minor role as reported immediate cause to the fall. Before the fall that caused the hip fracture between 28-84% could get up from a chair without any difficulties. Of the males 0-26% lived alone as against 0-37% or females. CONCLUSION The data on circumstances around the fall shows a complex pattern with substantial variation between different cultures, but where a, however, minority took place under risk circumstances that have a clear preventive potential.

On assessing the validity of the main diagnosis in patient data bases: The impact of aims for making diagnosis

Computerized medical personal registers are created for administrative purposes but are frequently used in research. It can be shown that this divergence of aims deeply affects the validity of the diagnosis in register research. The diagnostic process is embedded within the process of creating the data base. This process is guided by the aims for making diagnosis.Five different aims for making diagnosis in clinical practice have been analysed and eight suggestions for validity control are proposed on the basis of the study.

Preliminary Thoughts on Future Projection of World Hip Fracture Incidence

The world population aged more than 50 years will increase in number from 396 million in 1950 to 2129 million in 2025. We are facing an era of elderly, physically increasingly incapacitated populations. Degenerative and other age-dependent disorders, diseases and handicaps will increase in all countries during the next thirty years. Since, in addition, the elderly parts of the populations increase proportionately faster than other age-groups, the increasing economic burden of health expenditure will be carried by relatively smaller parts of populations.