Special Article
Risk Factors for Falls as a Cause of Hip Fracture in Women
N Engl J Med 1991; 324:1326-1331May 9, 1991
- Abstract
- Abstract
Background.
Although even in the elderly most falls are not associated with fractures, over 90 percent of hip fractures are the result of a fall. Few studies have assessed whether the risk factors for falls are also important risk factors for hip fracture.
Methods.
To examine the importance of risk factors for falls in the epidemiology of hip fracture, we performed a case–control study of 174 women (median age, 80 years) admitted with a first hip fracture to 1 of 30 hospitals in New York and Philadelphia. Controls, matched to the case patients according to age and hospital, were selected from general surgical and orthopedic surgical hospital services. Information was obtained by direct interview.
Results.
As measured by the odds ratio, increased risks for hip fracture were associated with lower-limb dysfunction (odds ratio = 1.7; 95 percent confidence interval, 1.1 to 2.8), visual impairment (odds ratio = 5.1; 95 percent confidence interval, 1.9 to 13.9), previous stroke (odds ratio = 2.0; 95 percent confidence interval, 1.0 to 4.0), Parkinson's disease (odds ratio = 9.4; 95 percent confidence interval, 1.2 to 76.1), and use of long-acting barbiturates (odds ratio = 5.2; 95 percent confidence interval, 0.6 to 45.0). Of the controls, 44 (25 percent) had had a recent fall. The case patients were more likely than these controls to have fallen from a standing height or higher (odds ratio = 2.4; 95 percent confidence interval, 1.0 to 5.7). Of those with hip fracture the younger patients (<75 years old) were more likely than the older ones (≥75 years old) to have fallen on a hard surface (odds ratio = 1.9; 95 percent confidence interval, 1.04 to 3.7).
Conclusions.
A number of factors that have been identified as risk factors for falls are also associated with hip fracture, including lower-limb dysfunction, neurologic conditions, barbiturate use, and visual impairment. Given the prevalence of these problems among the elderly, who are at highest risk, programs to prevent hip fracture should include measures to prevent falls in addition to measures to slow bone loss. (N Engl J Med 1991; 324:1326–31.)
Media in This Article
Table 1
Demographic Characteristics of the Case Patients with Hip Fractures and the Controls.*Table 2
Multivariate Adjusted Odds Ratios for the Major Risk Factors for Hip Fracture.*Article Activity
- Article
HIP fracture is the most serious consequence of osteoporosis. More than 90 percent of such fractures occur in persons over 70 years of age.1 , 2 The dramatic age-related increase in rates of hip fracture is widely believed to result primarily from postmenopausal and age-related osteoporosis.3 However, preventive measures currently recommended to slow perimenopausal bone loss, including estrogen-replacement therapy,1 , 3 may be less beneficial for elderly women, whose remaining bone mass may be inadequate to prevent fractures.4
Although only 1 to 14 percent of falls in women result in hip fracture, over 90 percent of hip fractures are the result of a fall.5 6 7 8 9 Few studies have assessed the influence of risk factors for falls in causing hip fracture.10 11 12 13 14 15 These studies have mostly focused on the role of psychoactive medications.10 , 11 , 13 It has been suggested not only that risk factors for falls may increase the likelihood of a hip fracture in general, but also that specific factors, such as neuromuscular abnormalities and the type of fall, may determine whether any given fall will result in a hip fracture.16 We conducted a case–control study of hip fractures to determine whether risk factors for falls and circumstances of falls are predictive of hip fractures in elderly women.
Methods
Study Design and Subjects
In this case–control study, women with hip fractures (case patients) were compared with women without hip fractures (controls) to determine whether the risk factors for falls differed between the groups. The case patients were white women 45 years of age or older with a radiologically confirmed diagnosis of a first hip fracture who were randomly selected at 1 of the 10 participating hospitals in New York City or 1 of the 20 participating hospitals in Philadelphia from September 1987 through July 1989. All the subjects were required to have resided before hospitalization in one of the five boroughs of New York City or one of the five counties surrounding and including Philadelphia County. One hundred forty-three women were excluded, for the following reasons: cognitive impairment (82), death before the interview (28), pathologic fracture due to cancer (14), severe impairment of speech or hearing (10), and severe medical instability (9). Of the remaining 286 subjects, 174 (61 percent) participated in the study, 82 subjects declined to participate, 14 physicians declined on behalf of their patients, and 16 patients could not be traced after hospital discharge. There were no important differences in age or city of residence between the subjects who agreed to participate and those who declined.
The protocol was amended after eight months of study to allow the recruitment of proxy respondents for the subjects who were medically unstable or cognitively impaired. Proxy respondents were recruited for 31 of the 71 case patients eligible to be assigned such respondents. The most common reasons for the nonparticipation of a proxy were that no proxy was available (14 patients) or that the proxy declined to participate (11 patients).
The controls were white women hospitalized in either a general surgical or an orthopedic service who had not had a previous hip fracture or hip replacement and who lived within the geographic areas included in the study. Admission for fractures other than hip fractures was an additional criterion for exclusion, although no potential controls identified were admitted because of another type of fracture. We used frequency matching to select controls for the case patients according to age (within 10-year age strata) and hospital. Forty-four subjects were excluded because of cognitive impairment (14) or death before the interview, medical instability, or severe impairment of speech or hearing (30). Of 311 patients eligible as controls, 174 (56 percent) were interviewed; 59 patients declined to participate, 53 physicians declined on behalf of their patients, and 25 patients could not be followed after discharge from the hospital. Proxy respondents were recruited for 18 of 45 patients eligible to be controls.
The diagnoses at the time of admission of the controls, including the 18 for whom there was a proxy respondent, were breast cancer (30 patients), colon cancer (6), other cancers (26), intestinal disorders (29), other digestive disorders (37), osteoarthritis (24), ischemic heart disease or peripheral vascular disease (11), skin disorders (10), and other problems (19).
Data Collection
Trained interviewers used a standardized questionnaire to ask the subjects about lower-extremity function, eyesight, medical and surgical history, use of medications before hospitalization, dietary and reproductive history, height, weight, symptoms related to balance and gait, sociodemographic information, and the circumstances either of the fall resulting in a hip fracture (for the case patients) or of the most recent fall (for the controls). The median period from the hospital admission to the interview was 9 days for the case patients and 10 days for the controls. All the interviews were conducted in person except one proxy interview that was conducted by telephone.
Inpatient medical records were abstracted for 38 randomly selected case patients and controls. Agreement between the results of the interview and the medical records was assessed with respect to the major classes of medications and the diseases under study. The kappa statistics were 0.75 or higher for each factor assessed. Inpatient medical records were also abstracted for a sample of the potential case patients (12) and controls (19) who had declined to participate. These records were compared with the medical records of the participating case patients and controls, respectively, from the same hospitals. No differences were found with respect to age, underlying medical illnesses, or major classes of medications.
Lower-Limb Function before the Fracture
The respondents were asked whether they needed assistance in performing four activities related to lower-limb function: walking across a small room, getting out of a chair, walking outside on level ground, and walking up or down stairs. Their scores were calculated as the total number of tasks for which assistance was needed. Subjects totally confined to a bed or chair were given a score of 5. The subjects' degree of physical impairment was determined separately by assessing the need for ambulatory aids, such as a cane or walker. The subjects were also asked whether they had recently had problems with ambulation, balance, or lower-limb sensation.
Visual Impairment
The subjects were asked whether a doctor had ever told them they had glaucoma or cataracts. If they said they had had cataracts and still had them at the time of the study, the subjects were classified as having cataracts. Subjects who reported that they could not see well enough (with their glasses or contact lenses) to recognize a friend across the room were classified as being visually impaired.
Neurologic Disease and Cognitive Function
The subjects were asked whether they had a history of Parkinson's disease or stroke. Cognitive function was measured by the number of errors scored on a modified Kahn—Goldfarb Mini—Mental Status Examination.17 Subjects with four or more errors were classified as having severe cognitive impairment. Those with three errors were classified as having moderate cognitive impairment, and those with two errors or fewer as having minimal or no impairment.
Alcohol and Medications
To assess the subjects' alcohol use, they were asked about their recent use and the frequency of their usual use as adults; they were classified as light, moderate, or heavy users in accordance with the categories used in the Framingham Study.18 The subjects were questioned about their recent use of anxiolytic agents, hypnotic drugs, antidepressants, and antipsychotic medications. Finally, they were asked whether they had ever received estrogen-replacement therapy or used thiazide diuretic agents. Preparations were classified as long-acting if their half-lives were 24 hours or more according to the American Medical Association's Drug Evaluations, fifth edition.19
Adjusted Weight
The subjects' self-reported current height (in meters) and weight (in kilograms) were used to calculate the body-mass index or Quetelet index,20 , 21 which is the weight in kilograms divided by the height in meters squared.
Circumstances of the Fall
The case patients and controls who reported a recent fall were asked whether they had fallen from a lying, sitting, or standing position or from a greater height, such as falling down one or more steps. The surface onto which they fell was described as hard if it was made of concrete, asphalt, or ceramic tile.
Statistical Analysis
In a case–control study the odds ratio (and the 95 percent confidence interval) is an estimate of the relative risk.22 23 24 Because of the large number of hospitals participating in the study (30), conditional logistic regression was used to remove the effect of matching case patients and controls according to hospital.23 A set of indicator variables for age categories was included in the regression model to account for the frequency matching according to age. An additional set of potential confounders was also included in the regression model: use of thiazide diurectic agents, estrogen use, number of chronic illnesses, moderate as compared with minimal cognitive impairment, and smoking. These variables were selected because they are thought to affect the risk of hip fracture.1 To test whether the odds ratios differed according to age, we included second- order interaction terms with age for each risk factor.
We evaluated whether there was a significant difference in odds ratio between the subjects interviewed directly and the subjects for whom a proxy was required, by testing the significance of interaction terms of risk factor according to proxy status. An interaction was detected for only one factor, lower-extremity dysfunction, for which results are presented separately for the proxy respondents. Because the proxy interview included only approximately half the items on the nonproxy questionnaire and there were otherwise no differences between case patients and proxies except for lower-extremity dysfunction, only the results from the direct interviews are given here.
We assessed whether the inclusion in the control group of patients with specific conditions could bias the study results by successively excluding each subgroup of controls that represented 10 percent or more of the diagnoses at the time of admission and repeating the analyses. The direction and magnitude of the odds ratios did not change more than 15 percent when any subgroup of controls was thus excluded.
Finally, we compared the circumstances of the falls resulting in hip fractures in the case patients with the circumstances of the falls in the subgroup of controls (25 percent) who reported a fall in the previous six months. We also compared the younger case patients with the older ones in relation to the circumstances of the falls resulting in a hip fracture.
Results
Analysis of the causes of hip fractures showed that 97 percent resulted from a fall; four women reported that their hip "just broke," and one woman was struck by a bicycle. Table 1Table 1
Demographic Characteristics of the Case Patients with Hip Fractures and the Controls.* shows the demographic characteristics of the case patients and the controls. The case patients ranged in age from 55 to 103 years (median, 80); 71 percent were 75 years of age or older. Marital status differed between case patients and controls (P = 0.06), mainly because the proportion who had never married was higher among the case patients (18 percent) than among the controls (10 percent).The factors associated with an increase in risk included lower-limb dysfunction, visual impairment, and the use of an ambulatory aid. The data are given in detail in a table available from the National Auxiliary Publications Service.* The odds ratios were elevated for stroke and Parkinson's disease, the two neurologic disorders evaluated. The risk of hip fracture was elevated among users of long-acting barbiturates, although the prevalence of such use was relatively low (4 percent of the case patients) and the confidence limits were wide. Finally, increased body mass was associated with a significantly reduced risk.
No associations were detected for self-reported symptoms of dizziness, limping, numbness, or problems with balance. There was no increased risk associated with alcohol use or use of long-acting benzodiazepine medications. No significant interactions with age were detected for any of these factors.
Table 2Table 2
Multivariate Adjusted Odds Ratios for the Major Risk Factors for Hip Fracture.* shows the odds ratios for each of the major risk factors, with control for the variables in the table as well as estrogen use, use of thiazide diuretic agents, smoking, moderate cognitive impairment, and the number of chronic illnesses. The major risk factors remained independent predictors of hip fracture. In the case of Parkinson's disease, odds ratios could not be computed with adjustment for potential confounders, because the disease was uncommon (occurring in 6 percent of the case patients and one control); information on estrogen use was missing from the one interview with an exposed control.Circumstances of Falls
We compared the circumstances of the falls resulting in hip fractures in the case patients with the circumstances of the most recent fall in the 44 controls (25 percent) who reported falling in the previous six months. The case patients were more likely than the controls to have fallen from a standing height or higher (odds ratio = 2.4; 95 percent confidence interval, 1.0 to 5.7). There was no difference between the case patients (43 percent) and the controls (47 percent) in the proportion who struck a hard surface during the fall.
When the circumstances of the fall were compared in younger and older case patients, however, the proportion of falls involving a hard surface was higher among the case patients younger than 75 years than among those 75 or older (odds ratio = 1.9; 95 percent confidence interval, 1.04 to 3.7). When the falls were stratified according to location (i.e., outdoors or indoors) the relation between age and the hardness of the surface persisted for falls that occurred indoors but was not apparent for the outdoor falls (most of which occurred on concrete or asphalt surfaces). The younger case patients also appeared more likely than their older counterparts to have fallen from a standing height or a greater height, although the confidence limits were wide (odds ratio = 1.7; 95 percent confidence interval, 0.6 to 4.8).
Discussion
In this case–control study we identified several risk factors for falls and circumstances of falls that were associated with an increased risk of hip fracture. Impaired neuromuscular function, impaired vision, and barbiturate use are likely to increase the risk of falls in genera5 , 6 , 25 and to impair the protective responses when a fall occurs.16 The case patients with hip fractures fell from greater heights than the control patients. Finally, factors that could act as local shock absorbers were found to affect the risk of hip fracture: the case patients were thinner than the controls (obesity may provide a protective layer of fat padding around the hip), and the younger case patients were more likely than the older ones to have landed on a hard surface in the fall that resulted in hip fracture, implying that more trauma may be required for a hip fracture to occur in younger than in older women.
The results of this study support the theory of Cummings and Nevitt16 that certain conditions are necessary for a fall to result in a hip fracture. They propose that the fall must be from a height sufficient for it to have the potential energy required for a fracture to occur, that the protectiveness of local shock absorbers must be reduced so that the residual energy of the fall transmitted to the proximal femur exceeds a critical threshold, that protective responses must be inadequate to reduce the energy of the fall below the critical threshold, and that bone strength must be insufficient to resist the residual energy of the fall transmitted to the hip.
Some limitations of our study should be mentioned. As compared with the response rate in studies of younger persons, ours may seem low. Even lower response rates are common, however, in studies of very old people.26 27 28 The response rates in our study did not differ between the case patients and the controls, and the respondents were similar to the nonrespondents with respect to age and city of residence. We reviewed a sample of medical records of case patients and controls who declined to participate in the study and compared them with the medical records of those who did participate. No differences were found in the prevalence of underlying medical conditions or the use of major classes of medications. As with all data based on interviews, the results of this study could be biased if recall by the case patients and the controls differed. We do not believe, however, that the case patients differed from the controls in their recall of the risk factors for falls, because these factors were not usually perceived as risk factors for hip fracture.
Hospitalized control subjects may have a greater prevalence of risk factors for falls, such as neurologic illnesses, lower-limb disability, use of psychoactive medications, and alcohol use, than the general population. Thus, the comparison of case patients with hospitalized controls is likely to underestimate the effect of these factors on the risk of hip fracture. To assess whether the inclusion in the control group of patients with specific conditions could bias our results, we repeated the analyses after excluding subgroups of controls. The direction and magnitude of the odds ratios did not change more than 15 percent when any subgroup of controls was excluded. In particular, when we excluded hospitalized controls who were admitted to surgical services because of osteoarthritis or other neuromuscular conditions, the odds ratios for lower-limb disability and previous use of an ambulatory device increased only slightly.
Finally, since some persons were excluded because of severe cognitive impairment and some factors could not be assessed through proxy interviews, the results of this study cannot be generalized to women with severe cognitive impairment. Many of the risk factors identified in this study — i.e., lower-limb dysfunction and previous stroke — may be even more important among patients with severe cognitive impairment, but we cannot determine that from these data.
Our study results support the notion that an increased risk of falls increases the risk of hip fracture. Self-reported lower-extremity disability and neurologic disease are associated with abnormalities of gait and balance previously shown to increase the risk of falling and hip fracture among elderly persons.5 , 6 , 14 , 15 , 25 Impaired gait may also result in decreased physical activity and reduced bone mass, although these factors were not assessed in this study. Visual impairment is more frequent among people who fall recurrently than among those who do not fall,5 and it has recently been shown in the Framingham Study to be a risk factor for hip fractures in women.12 Previous studies9 , 29 30 31 32 33 34 35 36 37 38 39 have found a protective association between hip fracture and increased body weight. Possible explanations for this association in-
clude greater bone mass among heavier persons, the conversion of adrenal androgens to estrogens in adipose tissue, and the protection offered by fatty tissue during a fall.1 Finally, the height of the fall may be important. Lotz and Hayes40 have documented that a fall from a standing height has the potential energy to fracture even a normal hip.40
Like Taggart,11 we did not find the association between the use of long-acting benzodiazepine medication and hip fracture that was reported by Ray et al.,10 , 13 although we found a higher prevalence of barbiturate use among the case patients than among the controls. All the subjects who used these agents reported using barbiturates for sleeping or as anxiolytic agents, not for seizures. We did not find the association between alcohol use and hip fracture that has been found in some but not all studies.1 , 18 , 34 Felson et al.18 found increased risks of fractures with alcohol use in those under 65 years of age. Although no interaction with age was detected for alcohol use in our study, the number of subjects under 65 years of age (32) was very small, and the power of this study to assess an effect in that subgroup would be limited.
Our results suggest that effective programs to prevent falls will also prevent hip fractures. This may be especially relevant among elderly women whose proximal femoral bone density is already considerably below the fracture threshold and for whom measures to prevent bone loss may be of little benefit. Measures to minimize risk factors for falls include aggressive treatment of ocular disease and visual impairment, as well as physical therapy for persons with impaired mobility. Consideration should be given to discontinuing medications that affect cognitive function. Finally, because most falls occur in the home,41 the home could be modified through measures to reduce the height of falls and the likelihood of landing on a hard surface. Such measures might include lowering beds, installing wall-to-wall carpeting, or providing grab bars, additional stair rails, or other aids to help prevent a falling person from landing on the floor. Studies should be carried out to evaluate these interventions in various settings.
From the Clinical Epidemiology Unit, Section of General Internal Medicine, School of Medicine, University of Pennsylvania, Philadelphia (J.A.G., B.L.S., G.Y.C., G.M., L.A.O.); the Division of Epidemiology, Columbia University, New York (J.L.K., S.H.); and the Hospital of the University of Pennsylvania, Department of Orthopedics, Philadelphia (F.K.). Address reprint requests to Dr. Grisso at the Clinical Epidemiology Unit, University of Pennsylvania, 317R Nursing Education Bldg., 420 Service Dr., Philadelphia, PA 19104–6095.
Supported by a grant (R01–AR35409) from the National Institutes of Health.
The Northeast Hip Fracture Study Group includes, in Philadelphia, Dr. David Junkin, Abington Hospital; Dr. Robert Good, Bryn Mawr Hospital; Dr. Malcolm Ecker, Chestnut Hill Hospital; Dr. William DeLong, Cooper Hospital/University Medical Center; Dr. Charles Hummer, Crozer—Chester Medical Center; Dr. Milton Wohl, Albert Einstein Medical Center; Dr. Herbert Stein, Frankford Hospital and Frankford—Torresdale Division; Dr. James Anthony, Mercy Catholic Medical Center (Misericordia Division and Fitzgerald Mercy Division); Dr. William Markman, Jeanes Hospital (Fox Chase Cancer Center); Dr. Pekka Mooar, Medical College of Pennsylvania; Dr. Jerome Cotler, Jefferson University Hospital; Dr. Brendan Wynne, Philadelphia College of Osteopathic Medicine; Dr. Z.B. Friedenberg, Presbyterian—University of Pennsylvania Medical Center; Dr. Dennis Zaslow, St. Joseph's Hospital; Dr. Michael Clancy, Temple University Health Sciences Center; and Dr. Charles Hummer, Sacred Heart Hospital; and in New York, Dr. Harvey Insler, Bronx–Lebanon Hospital Center; Dr. Placido Menezes, Interfaith Medical Center; Dr. Steven Ravich, Coney Island Hospital; Dr. Ronald Rosenthal, Long Island Jewish Medical Center; Dr. Arthur Sadler, Bronx Municipal Hospital Center—Jacobi Hospital; Dr. Julian Sallis, North Central Bronx Hospital; Dr. Marvin Shelton, Harlem Hospital Center; Dr. Joel Teicher, Brookdale Hospital Medical Center; Dr. Harold Dick, Columbia–Presbyterian Medical Center; Dr. William Fielding, St. Luke's Hospital; and Dr. Edward Habermann, Montefiore Medical Center/Albert Einstein College of Medicine.
We are indebted to Paul Stolley and Marie Kaufmann for their help and support in this study, and to Stephanie Humphrey, whose energy and dedication made this work possible; her untimely death was a great loss, and we dedicate this paper to her memory.
Source Information
Northeast Hip Fracture Study Group*
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NAPS document no. 04859 for six pages of supplementary material. Order from NAPS c/o Microfiche Publications, P.O. Box 3513, Grand Central Station, New York, NY 10163–3513. Remit in advance (in U.S. funds only) $7.75 for photocopies or $4 for microfiche. Outside the U.S. and Canada add postage of $4.50 ($1.50 for microfiche postage). There is an invoicing charge of $15 on orders not prepaid. This charge includes purchase order.
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