Mika Palvanen

Prevention of falls and consequent injuries in elderly people

Injuries resulting from falls in elderly people are a major public-health concern, representing one of the main causes of longstanding pain, functional impairment, disability, and death in this population. The problem is going to worsen, since the rates of such injuries seem to be rising in many areas, as is the number of elderly people in both the developed and developing world. Many methods and programmes to prevent such injuries already exist, including regular exercise, vitamin D and calcium supplementation, withdrawal of psychotropic medication, cataract surgery, professional environment hazard assessment and modification, hip protectors, and multifactorial preventive programmes for simultaneous assessment and reduction of many of the predisposing and situational risk factors. To receive broader-scale effectiveness, these programmes will need systematic implementation. Care must be taken, however, to rigorously select the right actions for those people most likely to benefit, such as vitamin D and calcium supplementation and hip protectors for elderly people living in institutions.

Prevention of Hip Fracture in Elderly People with Use of a Hip Protector

BACKGROUNDnHip fractures are common in frail elderly adults worldwide. We investigated the effect of an anatomically designed external hip protector on the risk of these age-related fractures.nnnMETHODSnWe randomly assigned 1801 ambulatory but frail elderly adults (1409 women and 392 men; mean age, 82 years), in a 1:2 ratio, either to a group that wore a hip protector or to a control group. Fractures of the hip and all other fractures were recorded until the end of the first full month after 62 hip fractures had occurred in the control group. The risk of fracture in the two groups was compared, and in the hip-protector group the risk of fracture was also analyzed according to whether the protector had been in use at the time of a fall.nnnRESULTSnDuring follow-up, 13 subjects in the hip-protector group had a hip fracture, as compared with 67 subjects in the control group. The respective rates of hip fracture were 21.3 and 46.0 per 1000 person-years (relative hazard in the hip-protector group, 0.4; 95 percent confidence interval, 0.2 to 0.8; P=0.008). The risk of pelvic fracture was slightly but not significantly lower in the hip-protector group than in the control group (2 subjects and 12 subjects, respectively, had pelvic fracture) (relative hazard, 0.4; 95 percent confidence interval, 0.1 to 1.8; P > or = 0.05). The risk of other fractures was similar in the two groups. In the hip-protector group, four subjects had a hip fracture (among 1034 falls) while wearing the protector, and nine subjects had a hip fracture (among 370 falls) while not wearing the protector (relative hazard, 0.2; 95 percent confidence interval, 0.05 to 0.5; P=0.002).nnnCONCLUSIONSnThe risk of hip fracture can be reduced in frail elderly adults by the use of an anatomically designed external hip protector.

Update in the epidemiology of proximal humeral fractures.

We sought to determine current trends in the number of fall-related and osteoporosis-related proximal humeral fractures in elderly Finns during last three decades. We collected data from the National Hospital Discharge Register on all patients 60 years or older who were admitted to Finnish hospitals from 1970 to 2002 for primary treatment of proximal humeral fractures. Fractures induced by traffic accidents or other high-energy traumas were excluded. The number and incidence (per 100,000 patients) of fractures increased from 208 (number) and 32 (incidence) in 1970 to 1120 (number) and 105 (incidence) in 2002. The age adjusted incidence of proximal humeral fractures also showed an increase, from 51 (1970) to 129 (2002) in women, and from 14 (1970) to 48 (2002) in men. In women 80 years or older, the age specific incidence of fracture increased from 90 (1970) to 294 (2002), while in the other age groups trend changes were less extensive. The mean patient age also increased, from 73 years (1970) to 78 years (2002) in women and from 70 years (1970) to 73 years (2002) in men. If these trends continue, the number of fractures in elderly Finns will triple during the next three decades.Level of Evidence: Prognostic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Majority of Hip Fractures Occur as a Result of a Fall and Impact on the Greater Trochanter of the Femur: A Prospective Controlled Hip Fracture Study with 206 Consecutive Patients

Abstract. The objectives of this study were to learn how hip fracture patients fall, and to compare the mechanics of their falls with those falls that did not result in hip fracture. In this way we sought to obtain reliable insight into the etiology and pathogenesis of hip fracture and fracture prevention. A total of 206 consecutive patients with fresh hip fracture and 100 controls were interviewed and examined between October 1994 and May 1996. The only inclusion criterion was that the fracture had occurred within 24 hours of hospital admittance. The control subjects were admitted from the same community after an accidental fall that did not result in hip fracture. The characteristics of the accident were determined by personal interview and examination of the patients within 24 hours of the event. In 98% of the hip fracture patients, the fracture was a result of a fall. The majority of the patients (76%) reported that they had fallen directly to the side. Forty-eight fracture cases had one or more eyewitnesses and their reports supported this observation. In 56% of the hip fracture patients, a fresh subcutaneous hematoma was seen on the greater trochanter of the proximal femur; such a hematoma was rare in the controls (6%) (P < 0.001), and this gave evidence for the direct impact of the greater trochanter during the fall of the hip fracture subjects. Most of the elderly fallers who fractured a hip did not manage to break the fall, e.g., with an outstretched arm. In conclusion, our results suggest that a typical hip fracture is the result of a fall and a subsequent impact on the greater trochanter of the proximal femur. The clinical implication of this finding is that effective prevention of hip fractures could be achieved by the diminution of the number and severity of falls of the elderly. We suggest that the severity of the falls (impacts on the greater trochanter) could be decreased by an external hip protector.

Hip fractures in Finland between 1970 and 1997 and predictions for the future.

BACKGROUNDnHip fractures in elderly people are common worldwide, and the predicted ageing of populations is increasing the burden of these fractures on health-care systems. However, prediction of the true increases in number of patients needing treatment requires exact knowledge of whether the number of hip fractures is rising more rapidly than can be accounted for by demographic changes alone. We aimed to make such a prediction for people aged 50 years or more in Finland.nnnMETHODSnAll patients aged 50 years or more, who were admitted to hospitals in Finland during 1970-97 for primary treatment of first hip fracture were selected from the National Hospital Discharge Register. The age-specific and age-adjusted fracture incidences were expressed as the number of patients per 100,000 individuals per year, and prediction of the number, and incidence of hip fractures in Finland (population 5 million) until the year 2030 was calculated with a regression model.nnnFINDINGSnThe number of hip fractures in Finnish people aged 50 or more rose during the study period, from 1857 in 1970 to 7122 in 1997. The corresponding fracture incidence (per 100,000 people) increased from 163 to 438. The age-adjusted incidence of hip fractures also showed a steady increase from 1970 to 1997: in women, from 292 to 467, and in men, from 112 to 233. If this trend continues, the number of hip fractures in Finland will be almost three-fold higher in the year 2030 than in 1997.nnnINTERPRETATIONnThe number of hip fractures in elderly Finnish men and women is increasing at a rate that cannot be explained merely by demographic changes. The precise reasons for this are not known, but deterioration in age-adjusted bone-mineral density and strength, with accompanying increase in the age-adjusted incidence of injurious falls of the elderly, could partly account for the development.

Nationwide Decline in Incidence of Hip Fracture

This epidemiologic study determined the trend in the number and incidence (per 100,000 persons) of hip fracture among older adults in Finland, an EU country with a well‐defined white population of 5.2 million, between 1970 and 2004. The results show that the alarming rise in the fracture incidence from early 1970s until late 1990s has been now followed by declining fracture rates. Reasons for this are largely unknown, but a cohort effect toward a healthier aging population and increased average body weight and improved functional ability among elderly Finns could partly explain the phenomenon.

Increasing number and incidence of low-trauma ankle fractures in elderly people: finnish statistics during 1970–2000 and projections for the future

To increase knowledge about recent trends in the number and incidence of various low-trauma injuries among elderly people, we selected, from the National Hospital Discharge Register, all patients > or =60 years of age who were admitted to hospitals in Finland (5 million population) for primary treatment of a first low-trauma ankle fracture during 1970-2000. In each year of the study, the age-adjusted and age-specific incidence of fracture was expressed as the number of patients per 100,000 persons. The predicted numbers and incidence rates of fractures until the year 2030 were calculated using a regression model. For the study period, the number and incidence of low-trauma ankle fractures in Finnish persons > or =60 years of age rose substantially: the total number of fractures increased from 369 in 1970 to 1545 in 2000, a 319% increase, and the crude incidence increased from 57 to 150, a 163% increase. The age-adjusted incidence of these fractures also rose in both women (from 66 in 1970 to 174 in 2000, a 164% increase) and men (from 38 in 1970 to 114 in 2000, a 200% increase). The regression model indicates that, if this trend continues, there will be about three times more low-trauma ankle fractures in Finland in the year 2030 than there was in 2000. In conclusion, the number of low-trauma ankle fractures in elderly Finns is rising rapidly at a rate that cannot be explained simply by demographic changes and, therefore, potentially effective preventive measures, such as prevention of slippings, trippings, and falls in elderly people, and use of ankle supports, should be urgently studied.

The Injury Mechanisms of Osteoporotic Upper Extremity Fractures Among Older Adults: A Controlled Study of 287 Consecutive Patients and Their 108 Controls

Abstract: The risk factors for falls in older adults are well known but knowledge on the direct injury mechanisms that result in various osteoporotic fractures has been very sparse. The purpose of this study was therefore to clarify the injury mechanisms of osteoporotic upper extremity fractures of older adults and to compare these mechanisms with those of the control fallers, and in this way to obtain reliable insight into the etiology and pathogenesis of upper extremity fractures and thus to enable fracture prevention. One hundred and twelve patients with a fresh fracture of the proximal humerus, 65 patients with an elbow fracture, 110 patients with a wrist fracture and 108 controls (no fracture, or a fracture other than the case fracture) were interviewed and examined between September 1995 and December 1997. The inclusion criteria of the subjects were that the patient was 50 years of age or older at the time of the accident, and that the fracture/injury had occurred as a result of low-energy trauma (typically a fall from standing height or less) within a week before the interview and examination. In 97% of patients with a proximal humerus or elbow fracture, and in all patients (100%) with a wrist fracture, the fracture was a result of a fall. In the control group this figure was 93%. In a polychotomous logistic regression analysis the intergroup differences in the fall directions (adjusted by gender, age and functional capacity) were statistically highly significant (χ2= 43.6, d.f. = 15, p<0.001). Most of the patients with a proximal humerus fracture or elbow fracture reported that they had fallen “obliquely forward” (43% and 38%) or “to the side” (29% and 26%), whereas in the wrist fracture group the main fall direction was also “obliquely forward” (34%) but the other fall directions (i.e., “forward”, “to the side”, “obliquely backward” and “backward”) were quite equally represented (13–19%). The odds ratio (OR) for an obliquely forward fall resulting in a proximal humerus fracture was 3.5 [95% confidence interval (CI) 1.4–9.2), as compared with the fall directions of the controls and the “obliquely backward” fall direction. In a logistic regression analysis the patients with a wrist fracture managed to break their fall (e.g., with an outstretched arm) more frequently than the patients in the other groups (OR 3.9; 95% CI 2.0–7.3). The patients with a proximal humerus fracture, in turn, managed to break their fall less frequently than the controls (OR 0.33; 95% CI 0.14–0.80). The same was true of the patients with an elbow fracture, although the difference was not significant (OR 0.49%; 95% CI 0.19–1.3). As objective evidence for a direct fall-induced impact on the fracture site, 68% of patients with a proximal humerus fracture revealed a fresh subcutaneous hematoma on the shoulder/upper arm, while such a hematoma was rare in the controls (2%) (p<0.001). Correspondingly, 62% of patients with an elbow fracture showed a similar hematoma on the elbow area, while this was seen in none of the controls (p<0.001). In patients with a wrist fracture a hand/wrist hematoma was seen in 58% of the victims, as compared with 18% of the controls (p<0.001). The study shows that the most typical osteoporotic upper extremity fractures of older adults have their specific injury mechanisms. A great majority of these fractures occur as a result of a fall and a subsequent direct impact of the fractured site. Effective fracture prevention could be achieved by minimizing the obvious risk factors of falling and reducing the fall-induced impact force with injury site protection.

Osteoporotic fractures of the proximal humerus in elderly Finnish persons: Sharp increase in 1970-1998 and alarming projections for the new millennium

We determined the current trends in the number and incidence of osteoporotic fractures of the proximal humerus in Finland by collecting from the National Hospital Discharge Register all patients 60 years of age or more who were admitted to Finnish hospitals in 1970-1998 for primary treatment of such fractures. The fracture was defined osteoporotic if it was caused by a low-energy trauma only, i.e., a fall from standing height or less. The number and incidence (per 10 5 persons) of fractures increased sharply from 208 (number) and 32 (incidence) in 1970 to 1,105 and 110 in 1998. Even after the age-adjustment, the incidence of fractures showed a clear increase: in women from 50 in 1970 to 133 in 1998, and in men from 14 in 1970 to 49 in 1998. If this trend continues, there will be three times more osteoporotic fractures of the proximal humerus in Finland in the year 2030 than there were in 1998.

Fall-Induced Deaths Among Elderly People

Falls and fall-induced injuries in older people are a major public health problem in modern societies with aging populations. Injury is the fifth leading cause of death in older adults, and most of these fatal injuries are related to falls. We have assessed the nationwide trends in fall-induced deaths of older people in Finland for more than 3 decades (1971-2002), and the results showed that the number of fall-induced deaths among elderly Finns is clearly increasing, especially among men.