Cathy R. Kessenich, DSN, ARNP, Professor of Nursing, University of Tampa, Tampa, FL, USA.
Darlene A. Higgs, RN, BSN, Nurse Practitioner Student, University of Tampa, Tampa, FL, USA.

Osteoporosis is a major cause of health problems in residents of long-term care facilities. It often results in bone fracture, causing poor quality of life and a national financial burden. As the population ages, the incidence of osteoporosis and its consequences increase. It is essential to employ fracture-prevention strategies that have proven most beneficial in long-term care settings and those tailored to promote adherence among older adults. This article reviews osteoporotic treatment appropriate for individuals in long-term care, including treatment through pharmacology, nutritional support, fall prevention, and hip fracture prevention.
Key words: osteoporosis, long-term care, hip protectors, fall prevention, vitamin D.

Kristin Casady, MA, Editorial Director, Geriatrics & Aging, Toronto, ON.

Falls are the leading cause of unintentional death among Canadians. According to a report of the Canadian Task Force on Preventive Health Care, falls resulting in serious injury or death are much more frequent among those age 55 and over; 70% of fatal falls occurred among persons 75 years and over. Ninety-five percent of injuries among older adults living in long-term care facilities were due to falls. One percent of falls by individuals aged 65 and over result in hip fracture.¹ Given these statistics, studies examining the efficacy of interventions to prevent falls and/or address the negative sequelae of falls are of significant interest to health care practitioners working with an older adult patient population.

A recent study has analyzed strategies employed in long-term care facilities and hospitals to prevent falls and fractures, as well as the evidence on the effects of cognitive impairment on fall risk.² The authors conducted a systematic review and meta-analysis, using meta-regression to investigate the effects of dementia. Researchers found that some interventions employed in hospitals lead to falls reduction, and that the use of hip protectors in care facilities prevents hip fractures. However, the evidence detected for the use of other single interventions was not significant.

Fall prevention strategies, the authors point out, are often derived from procedures and models suited for the community-dwelling, which do not precisely map on to the needs for fall and injury prevention among transient and institutionalized segments of the population. One particular reason that this is so is that many of those in hospital or long-term care have varying degrees of cognitive impairment. The authors suggest that awareness of the effect of cognitive impairment in incidences of falls should guide the development of best practice in order to avoid the implementation of ineffective prevention strategies.

The range of the 43 studies examined included multifaceted incorporated programs in hospitals and care settings that evaluated a wide range of items from risk factor assessment to medication review to education and exercise programs. The single-intervention programs studied tended to be components represented in the multi-intervention programs.

Among the key findings were that the multifaceted approach programs to prevent falls in hospital yielded the highest benefits, with meta-analysis showing a rate of falls reduction of 18%, but no significant effects on fracture (rate ratio of 0.82 [95% confidence interval 0.68 to 0.997]). Review of 11 studies of the effect of hip protectors showed an overall positive effect of the use of the devices: the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and, the authors asserted, not enough studies on fallers. There was no evidence as to the efficacy of exercise as a single intervention; however, it was a component of successful multifaceted programs. There was no evidence to suggest that removal of physical restraints was efficacious. However, the authors did find two studies in which oral supplementation with calcium and vitamin D reduced rates of falls and fractures in long-term care facilities. Importantly, they found no evidence that effect size of interventions were modified by the prevalence of dementia.

The authors concluded that significant gaps remain in the data yielded by studies of fall reduction interventions. They singled out the need for studies specifically examining programs for the cognitively impaired, the cost-effectiveness of single interventions, and alterations of physical environment, among others, as sources of needed evidence. They surmise that at present health care providers are incurring significant costs by using injury prevention strategies of unproven value.

References

1. Elford RW, for the Canadian Task Force on Preventive Health Care. Prevention of household and recreational injuries in the elderly. Online at http://www.ctfphc.org/ Full_Text/Ch76full.htm
2. Oliver D, Connolly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2006 Dec 8; [Epub ahead of print].