A COMPREHENSIVE FRACTURE PREVENTION STRATEGY IN OLDER ADULTS
J Nutr Health Aging
Volume 20, Number 6, 2016648
half fall over the course of a year (15, 16). More than 80% of
non-vertebral fractures result from a fall (2, 3). Around 10%
of falls result in a fracture (17, 18) and 2% in a hip fracture
(19). The efficacy of falls prevention interventions to reduce
fractures is debated (13, 14), in part because it depends on the
fall risk profile of people and the type of intervention program
(20, 21).
There is no international consensus for assessing the fall
risk profile of older people, even if it is well understood that
people at higher risk of future falls are those aged 75 or older,
those who have fallen during the previous 12 months or those
who have fear of falling or significant gait, muscle strength,
or balance problems (16, 22-28). The fall risk profile is also
dependent on the setting and some other factors, including
cognitive impairment which may be associated with increased
risk-taking. Even though balance, gait, and muscle function
decline increases the risk of falling, the relationship is not
completely linear since those with most problems (i.e. bed-
ridden) usually have a lower falls risk, similar to those without
such problems, presumably due to low exposure to risk (29).
Notwithstanding the lack of consensus in assessing fall risk
profile, there is rather consistent evidence in subjects with
low to moderate falls risk, usually community dwelling, that
multicomponent exercise programs, including progressive,
challenging and regular exercises designed to improve
balance, muscle strength, and protective responses in case of
destabilisation, are effective in the reduction of serious falls
and non-vertebral fractures (21, 24, 30, 31). The studies are
however insufficiently powered to demonstrate a significant
effect on hip fracture risk (21, 24, 30). Single interventions
including treatment of some vision problems or carotid sinus
hypersensitivity, vitamin D supplementation in deficient
patients, gradual withdrawal of psychotropic medication, or
improving the safety of indoor activities and outdoor walking
environments are also effective for suitable patient groups in
the prevention of falls, but the effect on fracture risk is not
clear (21, 32, 33). Multifactorial interventions, a combination
of interventions linked to the individual’s risk profile, seem
no more effective in preventing falls than single targeted
interventions (e.g. community exercise or fall prevention
programs) (21, 34).
In people at high risk of falls single targeted interventions
seem less effective, e.g. in older nursing home residents, the
only single intervention that has reduced falls is vitamin D
supplementation (20). Other interventions have been ineffective
or inconsistent for falls although the rate of recurrent falls
may be reduced (35). A multifactorial and interprofessional
approach, determined by individual assessment of functional,
medical, and social concerns, may be a more appropriate
strategy to prevent falls in older people at high risk of falling
(20, 22-34, 36). Moreover, this tailored approach (37) may
provide opportunities to address previously unidentified health
problems (e.g. impaired cognition, diabetes, Parkinson’s
disease, osteoporosis) (9, 38), conferring benefits beyond
falls prevention (39, 40). People at high risk of fall are most
often frail patients (40) and multifactorial approach in this
population has been shown to improve the ability to live safely
and independently (41).
Taken together, the EUGMS supports 1) the set-up of a
working group that would develop consensus international
operational definitions and diagnostic criteria for assessing
the risk of falling to be used in clinical practice as well as in
research studies, 2) the 2010 American Geriatrics Society /
British Geriatrics Society joint guideline urging practitioners to
screen, at least annually, older patients for risk of falling (42),
3) that above evidenced-based measures, especially evidence-
based community exercise fall prevention programs, should
be widely available to prevent non-vertebral fractures in older
people at low or moderate risk of falling (9), and 4) that people
at high risk should be able to access individually tailored
multifactorial measures based on a comprehensive geriatric
assessment. EUGMS recommends continued and expanded
provision of evidence based fall prevention programmes such
as those being promoted by ProFouND (www.profound.eu.org).
Primary and secondary prevention related to bone health
It is widely recognized that lifestyle measures (regular
weight-bearing exercises, balanced diet, including calcium
intake, avoiding smoking and excessive alcohol consumption)
and measures aimed at reducing adverse effects on bone
of drugs and diseases, including renal diseases, have to be
recommended throughout life in everyone. They are beneficial
in optimizing skeletal development (43-46) and limiting bone
loss during adulthood (47).
Whereas there are well established definitions of
osteoporosis (13, 14), there is much current debate on what
is the target population that may potentially benefit from
treatments acting on bone metabolism (TABM) (13, 14, 48-51).
Osteoporosis is currently defined by bone densitometry
(densitometry osteoporosis) when the bone mineral density
(BMD) is 2.5 SD or more below that of the mean level for a
young-adult reference population (T-score ≤-2.5 at the lumbar
spine or the hip, or at the distal radius when the hip and lumbar
spine cannot be measured or are unusable or uninterpretable)
(52-54). Aortic calcification and osteoarthrosis that increase
progressively with age may be a source of accuracy error in the
measurement of lumbar spine BMD in older people (55, 56).
However, for a given BMD, the risk of major fractures depends
on other risk factors for bone fragility, of which age is the
most important one, which are taken into account in different
fracture prediction tools such as the most used FRAX® tool
(www.shef.ac.uk.FRAX) or the Garvan Fracture Risk calculator
(www.garvan.org.au/bone-fracture) or the Q-fracture Risk
Calculator (www.qfracture.org). Fragility fracture risk should
therefore take into account not only BMD but also other risk
factors of bone fragility, by using fracture prediction tools, and
falls risk (57). Since falls and osteoporosis are independent

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