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Keywords:

  • elderly people;
  • fractures;
  • osteoporosis;
  • falls;
  • prevention

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE
  5. TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES
  6. IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION
  7. Acknowledgements
  8. REFERENCES

Low-trauma fractures of elderly people are a major public health burden worldwide, and as the number and mean age of older adults in the population continue to increase, the number of fractures is also likely to increase. Epidemiologically, however, an additional concern is that, for unknown reasons, the age-standardized incidence (average individual risk) of fracture has also risen in many populations during the recent decades. Possible reasons for this rise include a birth cohort effect, deterioration in the average bone strength by time, and increased average risk of (serious) falls. Literature provides evidence that the rise is not due to a birth cohort effect, whereas no study shows whether bone fragility has increased during this relatively short period of time. This osteoporosis hypothesis could, however, be tested if researchers would now repeat the population measurements of bone mass and density that were made in the late 1980s and the 1990s. If such studies proved that women's and men's age-standardized mean values of bone mass and density have declined over time, the osteoporosis hypothesis would receive scientific support. The third explanation is based on the hypothesis that the number and/or severity of falls has risen in elderly populations during the recent decades. Although no study has directly tested this hypothesis, a great deal of indirect epidemiologic evidence supports this contention. For example, the age-standardized incidence of fall-induced severe head injuries, bruises and contusions, and joint distortions and dislocations has increased among elderly people similarly to the low-trauma fractures. The fall hypothesis could also be tested in the coming years because the 1990s saw many research teams reporting age- and sex-specific incidences of falling for elderly populations, and the same could be done now to provide data comparing the current incidence rates of falls with the earlier ones.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE
  5. TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES
  6. IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION
  7. Acknowledgements
  8. REFERENCES

LOW-TRAUMA OR age-related fracture of an older adult is defined as a bone fracture that occurs in an elderly person as a consequence of mild-moderate trauma only (typically a fall to the floor from standing height or less).(1–9) Compromised bone strength (osteopenia or osteoporosis) and falling, alone, or more frequently in combination, are the main independent and immediate risk factors of these fractures through which all the other, more distant risk factors operate.(1,10–24)

Today, low-trauma fractures of older adults are a major public health burden, not only economically, but also on the health and well-being of elderly people, because these fractures represent one of the most important causes of long-standing pain, functional impairment, disability, and death among this population.(1,3,4,8–13) In addition, a fracture, or even a mere fear of fracture consequences, can cause significant mental suffering and psychological burden to these people; in a time trade-off study, Salkeld et al.(25) reported that a great majority of elderly women would rather die than be admitted to a nursing home following a hip fracture.

Worldwide, over 8,000,000 low-trauma fractures occur annually among persons ages 60 years or older (of which about 20% are hip fractures), and as the number and mean age of older adults in the populations continue to increase, the number of fractures is likely to increase as well.(3,4,8,26–30) Epidemiologically, a substantial additional concern is that, besides the demographic change in populations, the age-standardized incidence (i.e., the average individual risk) of fracture is rising in many populations and countries(9,31–36) including Finland(4–7) (Figs. 1A–1D). Although some studies have reported stabilizing rates of fractures,(37–40) the trend observed most systematically and convincingly in the very high-risk countries,(39,40) it is essential to acknowledge this general phenomenon of rising age-standardized incidence of fracture. Dennison and Cooper(28) calculated that while demographic changes alone will account for an almost 3-fold increase in the number of hip fractures by the year 2050, a mere 1% annual increase in the age-standardized incidence of fracture would almost double hip fracture rates by the 2050. This has been also highlighted by Hoffenberg et al.,(41) who calculated that population aging alone will increase the annual number of hip fractures in England and Wales by about 30% between 1985 and 2015, but if the age-standardized and sex-standardized incidence rates continue to rise as they did before 1985, the increase in the number of hip fractures will be as high as 150%. Simply, health care systems would be unable to carry out the necessary surgery, nor cope with the financial burden of such an increase.(42)

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Figure FIG. 1. Age-standardized incidence (per 100,000 persons) of low-trauma fractures in Finland in women and men (age ≥60 years) between 1970 and 1999: (A) Hip fracture, (B) pelvic fracture, (C) ankle fracture, and (D) proximal humeral fracture. For comparison, the age-standardized incidence of injuries other than bone fractures are presented as follows: (E) fall-induced severe bruises and contusions and (F) fall-induced severe joint distortions and dislocations.

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Thus, there is a clear need to examine the existing evidence of, and discuss the possible reasons for, the clear rise in the average fracture risk of elderly people, especially because improved knowledge on the changes in the etiology, pathogenesis, and injury mechanisms of these age-related fractures could provide important clues for fracture prevention. As such, the causes and risk factors of fractures of the older adults have been well described in the literature(1,10–24) and are not discussed here further.

POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE
  5. TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES
  6. IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION
  7. Acknowledgements
  8. REFERENCES

Possible reasons for the rising age-standardized incidence of fracture in older people include a birth cohort effect (that is, one birth cohort would be more susceptible to fracture than the others), deterioration in the average bone strength (increasing incidence of osteopenia and osteoporosis), or increasing average risk of falling (especially severe falling), alone or in a combination.(4–6,9,10,14–18,43) As noted above, all the other, more distant risk factors of fracture operate via bone fragility, falling, or both, and thus, the possible effect of their secular change on the rising risk of fracture is covered via understanding the secular changes in these two.(1,10–24)

Concerning the first option or a birth cohort effect, literature provides no evidence that such an effect exists. Recently we examined in detail the Finnish hip fracture data in terms of birth cohort but found no signs of such an effect behind the increasing age-standardized incidence of hip fracture in Finland between 1970 and 1997.(4) In fact, our analysis revealed a pattern that in each 10-year cohort, the fracture incidence behaved similarly with age, but that in a cohort-to-cohort comparison, a younger birth cohort always showed a higher incidence of fracture than its older counterparts. In other words, the study found no evidence for a hypothesis that the rising age-standardized incidence of hip fracture would stabilize as a result of the already-started weakening cohort effect on fracture risk.(4)

Concerning the second explanation, or the osteoporosis hypothesis, literature provides some evidence that in the long-term, that is, with a perspective of hundreds of years, the age-specific bone density and strength may have reduced over time.(44–47) Decreased bone quality and strength have been explained by such factors as increased environmental pollution, increased body height (leading to longer moment arms of bones and reduced fracture resistance), less physically active lifestyles, poorer nutritional status (calcium, vitamin D), greater occurrence of chronic, bone-affecting diseases, and greater consumption of tobacco, alcohol, and bone-affecting drugs.(4–6,9,10,17,18,43–45,47,48) The findings of Lees et al.,(44) for example, suggest that a modern-day 70-year-old woman would have a lower bone density than a 70-year-old woman living two centuries ago, most likely because of a lower degree of physical activity. All these explanations seem, however, rather insufficient in explaining the above-noted clear increase in fracture risk during the most recent three decades (since the 1970s), and no reliable evidence exists to show that bone fragility (osteopenia, osteoporosis, or both) has increased in the populations during this relatively short period of time.

Finally, considering the third option, or the fall hypothesis (i.e., the number and/or severity of falls have risen in elderly populations during the recent decades), there is no direct evidence available. In other words, there is no study to show how elderly people's age-standardized or age-specific incidence of falling has changed since the early 1970s, although we may suspect that in addition to the above noted risk factors of bone fragility, many risk factors of falling (such as impaired muscle strength, balance, reaction time, and gait) have become more common in our elderly populations, perhaps as a result of a greater occurrence of less-active lifestyles, coexisting medical problems, and more common use of gait- and balance-affecting drugs. Despite lack of direct evidence, we have, however, lots of indirect epidemiologic evidence to support the fall hypothesis: the age-standardized incidence of fall-induced severe injuries other than bone fractures (fall-induced bruises, contusions, and joint distortions and dislocations requiring hospital admission) have risen among our elderly people in a similar way as the previously mentioned low-trauma fractures (Figs. 1E and 1F). Also, the risk of a fall-induced severe head injury, an injury that has little to do with bone density and osteoporosis, has risen at the same rate as the above-noted bone fractures.(49) Moreover, the fall hypothesis is rather plausible because falling, not osteoporosis, is the strongest single risk factor for a fracture of an older adult.(14,16,19–21,50,51) As such, falls are extremely common among elderly people (about one-third of 65-year-old or older persons living in the community and more than one-half of those living in institutions fall every year, and about one-half of those who fall do so repeatedly), and although not all falls of older persons are injurious and life-threatening, about 5% of them result in a fracture, and other serious injuries occur in 5-11% of falls.(52–55)

TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE
  5. TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES
  6. IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION
  7. Acknowledgements
  8. REFERENCES

Because the exact reasons for the rising risk of fractures among our elderly persons are not clear, both the osteoporosis hypothesis and fall hypothesis need epidemiologic testing. The osteoporosis hypothesis could be tested if researchers around the world would now repeat the cross-sectional population measurements of bone mass and density that they made with dual energy X-ray absorptiometry (DXA) in the late 1980s and the 1990s. If it was discovered that our women's and men's age-standardized or age-specific mean values of bone mass and density have declined over time, the osteoporosis hypothesis would receive scientific support.

The same approach to hypothesis testing could apply to falls. In the 1990s, many research teams around the world reported the age-specific and sex-specific incidences of falling in elderly populations, and the same could be done now to permit comparison of current and past incidence rates of falls. In addition, if the incidence of falling had increased in time, it might be possible to clarify further whether the rise is truly caused by increased risks of falling, increased exposure time (active waking hours) to falling, or both. Also, the type of falling is important in determining the risk of fracture,(14,16,19,20,51) and it would be of interest to know whether fall severity has changed by time.

IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE
  5. TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES
  6. IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION
  7. Acknowledgements
  8. REFERENCES

Low-trauma fractures of elderly people are such a huge public health problem that both of the above noted hypotheses should be tested and verified because the results would have direct implications for fracture prevention. Prevention of osteoporosis by exercise, calcium and vitamin D supplementation, and specific drugs has a strong scientific basis and has been recommended by many authorities and consensus conferences,(22,56,57) and although this approach to bone health is unarguable, the effect on fracture prevention at the population level can be more limited than generally thought if the proposed epidemiologic studies showed little change in osteoporosis rates over time (i.e., unchanged risk of osteoporosis in a given age-specific group of women or men). On the other hand, if the gender- and age-specific rates of osteoporosis have indeed become (and are yet becoming) more common in the elderly populations, it would justify extended efforts to target strategies aimed at improving bone strength.

The same basic arguments apply to fall prevention strategies. Although all fall prevention trials have been too small to assess whether or not elderly people's fractures can be reduced by preventing falls, strong evidence exists that exercise, withdrawal from psychotropic drugs, and the use of multifaceted interventions to modify the individual's predisposing and situational risk factors for falls can reduce the risk of falling.(23,24,58–63) Nevertheless, fresh epidemiologic information determining whether the average individual risk of falling has indeed risen (and is yet rising) among our elderly people would help in justifying intensified interventions to prevent falls at the population level. When we know exactly why the age-standardized incidence of low-trauma fractures is rising among elderly populations, we can develop more effective methods and strategies for fracture prevention.

Acknowledgements

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE
  5. TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES
  6. IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION
  7. Acknowledgements
  8. REFERENCES

We thank the Finnish Ministry of Social Affairs and Health, the National Research and Development Center for Welfare and Health, and Statistics Finland for their cooperation. This project was financially supported by the Medical Research Fund of Tampere University Hospital, Tampere, Finland.

REFERENCES

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  2. Abstract
  3. INTRODUCTION
  4. POSSIBLE REASONS FOR THE RISING RISK OF FRACTURE
  5. TESTING THE OSTEOPOROSIS AND FALL HYPOTHESES
  6. IMPLICATIONS OF THE OSTEOPOROSIS AND FALL HYPOTHESES FOR FRACTURE PREVENTION
  7. Acknowledgements
  8. REFERENCES
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