Skip to main content
SpringerLink
Log in

The Role of Falls in Fracture Prediction

  • Published:
Current Osteoporosis Reports Aims and scope Submit manuscript

Abstract

Close to 75% of hip and non-hip fractures occur among seniors age 65 years and older. Notably, the primary risk factor for a hip fracture is a fall, and over 90% of all fractures occur after a fall. Thus, critical for the understanding and prevention of fractures at later age is their close relationship with muscle weakness and falling. In fact, antiresorptive treatment alone may not reduce fractures among individuals 80 years and older in the presence of nonskeletal risk factors for fractures despite an improvement in bone metabolism. This article will review the epidemiology of falls, and their importance in regard to fracture risk. Finally, fall prevention strategies and how these translate into fracture reduction are evaluated based on data from randomized controlled trials.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Tinetti ME. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319:1701–7.

    Article  PubMed  CAS  Google Scholar 

  2. Campbell AJ, Reinken J, Allan BC, Martinez GS. Falls in old age: a study of frequency and related clinical factors. Age Ageing. 1981;10(4):264–70.

    Article  PubMed  CAS  Google Scholar 

  3. Fatalities and injuries from falls among older adults—United States, 1993–2003 and 2001–2005. MMWR Morb Mortal Wkly Rep. 2006;55(45):1221–4.

  4. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 1998;53(2):M112–9.

    Article  PubMed  CAS  Google Scholar 

  5. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337(18):1279–84.

    Article  PubMed  CAS  Google Scholar 

  6. Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, et al. Risk factors for hip fracture in white women. Study of osteoporotic fractures research group. N Engl J Med. 1995;332(12):767–73.

    Article  PubMed  CAS  Google Scholar 

  7. Pluijm SM, Smit JH, Tromp EA, Stel VS, Deeg DJ, Bouter LM, et al. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos Int. 2006;17(3):417–25. Epub 2006 Jan 17.

    Article  PubMed  CAS  Google Scholar 

  8. EC. European economy: Special Report n° 1/2006. European Commission, Directorate-General for Economic and Financial Affairs. http://urbact.eu/fileadmin/corporate/pdf/news/Focus/Impact_public_finance_DGEco_EN.pdf

  9. Eberstadt N., H. G. Europe’s coming demographic challenge: unlocking the value of health. American Enterprise Institute for Public Policy Research. 2007.

  10. Europe Co. Recent demographic developments in Europe 2005 (2006) European population Committee of the Council of Europe: Strasbourg.

  11. Eurostat. First demographic estimates for 2005: statistics in focus. http://eppeurostateceuropaeu/cache/ITY_OFFPUB/KS-NK-06-001/EN/KS-NK-06-001-ENPDF. 2006.

  12. Lee RD. Global population aging and its economic consequences. Washington, DC: AEI Press, 2007. 2007.

  13. Melton 3rd LJ, Crowson CS, O’Fallon WM. Fracture incidence in Olmsted County, Minnesota: comparison of urban with rural rates and changes in urban rates over time. Osteoporos Int. 1999;9(1):29–37.

    Article  PubMed  Google Scholar 

  14. Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int. 1997;7(5):407–13.

    Article  PubMed  CAS  Google Scholar 

  15. Buchner DM, Hornbrook MC, Kutner NG, Tinetti ME, Ory MG, Mulrow CD, et al. Development of the common data base for the FICSIT trials. J Am Geriatr Soc. 1993;41(3):297–308.

    PubMed  CAS  Google Scholar 

  16. Cummings SR, Nevitt MC, Kidd S. Forgetting falls. The limited accuracy of recall of falls in the elderly. J Am Geriatr Soc. 1988;36(7):613–6.

    PubMed  CAS  Google Scholar 

  17. Kanis JA, Borgstrom F, De Laet C, Johansson H, Johnell O, Jonsson B, et al. Assessment of fracture risk. Osteoporos Int. 2005;16(6):581–9. Epub 2004 Dec 23.

    Article  PubMed  Google Scholar 

  18. Sandhu SK, Nguyen ND, Center JR, Pocock NA, Eisman JA, Nguyen TV. Prognosis of fracture: evaluation of predictive accuracy of the FRAX algorithm and Garvan nomogram. Osteoporos Int.21(5):863–71.

  19. van den Bergh JP, van Geel TA, Lems WF, Geusens PP. Assessment of individual fracture risk: FRAX and beyond. Curr Osteoporos Rep. 2010;8(3):131–7.

    Article  PubMed  Google Scholar 

  20. Cummings SR, Nevitt MC. Non-skeletal determinants of fractures: the potential importance of the mechanics of falls. Study of osteoporotic fractures research group. Osteoporos Int. 1994;4 Suppl 1:67–70.

    Article  PubMed  Google Scholar 

  21. Nguyen ND, Frost SA, Center JR, Eisman JA, Nguyen TV. Development of a nomogram for individualizing hip fracture risk in men and women. Osteoporos Int. 2007;17:17.

    Google Scholar 

  22. Nevitt MC, Cummings SR. Type of fall and risk of hip and wrist fractures: the study of osteoporotic fractures. The study of osteoporotic fractures research group. J Am Geriatr Soc. 1993;41(11):1226–34.

    PubMed  CAS  Google Scholar 

  23. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26(3):189–93.

    Article  PubMed  CAS  Google Scholar 

  24. Arfken CL, Lach HW, Birge SJ, Miller JP. The prevalence and correlates of fear of falling in elderly persons living in the community. Am J Public Health. 1994;84(4):565–70.

    Article  PubMed  CAS  Google Scholar 

  25. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, et al. Effect of risedronate on the risk of hip fracture in elderly women. Hip intervention program study group. N Engl J Med. 2001;344(5):333–40.

    Article  PubMed  CAS  Google Scholar 

  26. Graafmans WC, Ooms ME, Hofstee HM, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol. 1996;143(11):1129–36.

    PubMed  CAS  Google Scholar 

  27. Arden NK, Nevitt MC, Lane NE, Gore LR, Hochberg MC, Scott JC, et al. Osteoarthritis and risk of falls, rates of bone loss, and osteoporotic fractures. Study of osteoporotic fractures research group. Arthritis Rheum. 1999;42(7):1378–85.

    Article  PubMed  CAS  Google Scholar 

  28. Arden NK, Crozier S, Smith H, Anderson F, Edwards C, Raphael H, et al. Knee pain, knee osteoarthritis, and the risk of fracture. Arthritis Rheum. 2006;55(4):610–5.

    Article  PubMed  Google Scholar 

  29. Dufour AB, Roberts B, Broe KE, Kiel DP, Bouxsein ML, Hannan MT. The factor-of-risk biomechanical approach predicts hip fracture in men and women: the Framingham Study. Osteoporos Int. 2011.

  30. Tinetti ME, Inouye SK, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. Jama. 1995;273(17):1348–53.

    Article  PubMed  CAS  Google Scholar 

  31. Mowe M, Haug E, Bohmer T. Low serum calcidiol concentration in older adults with reduced muscular function. J Am Geriatr Soc. 1999;47(2):220–6.

    PubMed  CAS  Google Scholar 

  32. Close J, Ellis M, Hooper R, Glucksman E, Jackson S, Swift C. Prevention of falls in the elderly trial (PROFET): a randomized controlled trial. Lancet. 1999;353:93–7.

    Article  PubMed  CAS  Google Scholar 

  33. Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. Jama. 1995;273(17):1341–7.

    Article  PubMed  CAS  Google Scholar 

  34. Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Am Geriatr Soc. 1996;44(5):489–97.

    PubMed  CAS  Google Scholar 

  35. Oliver D, Connelly JB, Victor CR, Shaw FE, Whitehead A, Genc Y, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. Bmj. 2007;334(7584):82. Epub 2006 Dec 8.

    Article  PubMed  Google Scholar 

  36. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Bmj. 1997;315(7115):1065–9.

    PubMed  CAS  Google Scholar 

  37. • Bischoff-Ferrari HA, Dawson-Hughes B, Platz A, Orav EJ, Stahelin HB, Willett WC, et al. Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture: a randomized controlled trial. Arch Intern Med. 2010;170(9):813–20. The trial tests a simple home exercise program in acute hip fracture patients instructed during acute care compared to standard physiotherapy. The trial also tested 2000 IU vitamin D compared to 800 IU vitamin D per day in a 2x2 factorial design. The higher vitamin D dose resulted in a 39% reduction in hospital re-admission, which was driven by a 60% reduction in fall-related injury. The higher dose of vitamin D did not reduce falls superior to 800 IU vitamin D.

    Article  PubMed  CAS  Google Scholar 

  38. Voukelatos A, Cumming RG, Lord SR, Rissel C. A randomized, controlled trial of tai chi for the prevention of falls: the Central Sydney tai chi trial. J Am Geriatr Soc. 2007;55(8):1185–91.

    Article  PubMed  Google Scholar 

  39. Li F, Harmer P, Fisher KJ, McAuley E, Chaumeton N, Eckstrom E, et al. Tai Chi and fall reductions in older adults: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2005;60(2):187–94.

    Article  PubMed  Google Scholar 

  40. Wolf SL, Sattin RW, Kutner M, O’Grady M, Greenspan AI, Gregor RJ. Intense tai chi exercise training and fall occurrences in older, transitionally frail adults: a randomized, controlled trial. J Am Geriatr Soc. 2003;51(12):1693–701.

    Article  PubMed  Google Scholar 

  41. Lee MS, Pittler MH, Shin BC, Ernst E. Tai chi for osteoporosis: a systematic review. Osteoporos Int. 2007;23:23.

    Google Scholar 

  42. Lundin-Olsson L, Nyberg L, Gustafson Y. Stops walking when talking as a predictor of falls in elderly people. Lancet. 1997;349(9052):617.

    Article  PubMed  CAS  Google Scholar 

  43. de Hoon EW, Allum JH, Carpenter MG, Salis C, Bloem BR, Conzelmann M, et al. Quantitative assessment of the stops walking while talking test in the elderly. Arch Phys Med Rehabil. 2003;84(6):838–42.

    Article  PubMed  Google Scholar 

  44. • Trombetti A, Hars M, Herrmann FR, Kressig RW, Ferrari S, Rizzoli R. Effect of music-based multitask training on gait, balance, and fall risk in elderly people: a randomized controlled trial. Arch Intern Med. 2011;171(6):525–33. Trombetti et al. test a new concept of dual tasking as a music-based coordination. Training in seniors at risk of falling and show a significant benefit on fall reduction in a controlled study design.

    Article  PubMed  Google Scholar 

  45. Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol. 2005;89(1):53–9.

    Article  PubMed  CAS  Google Scholar 

  46. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009;339(1):339:b3692.

    Article  Google Scholar 

  47. Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009;169(6):551–61.

    Article  PubMed  CAS  Google Scholar 

  48. Schott GD, Wills MR. Muscle weakness in osteomalacia. Lancet. 1976;1(7960):626–9.

    Article  PubMed  CAS  Google Scholar 

  49. Bischoff-Ferrari HA, Borchers M, Gudat F, Durmuller U, Stahelin HB, Dick W. Vitamin D receptor expression in human muscle tissue decreases with age. J Bone Miner Res. 2004;19(2):265–9.

    Article  PubMed  CAS  Google Scholar 

  50. • Ceglia L, da Silva Morais M, Park LK, Morris E, Harris SS, Bischoff-Ferrari HA, et al. Multi-step immunofluorescent analysis of vitamin D receptor loci and myosin heavy chain isoforms in human skeletal muscle. J Mol Histol. 2010;41(2–3):137–42. Ceglia et al. confirm earlier findings of the presence of the vitamin D receptor in muscle tissue.

    Article  PubMed  CAS  Google Scholar 

  51. Boland R. Role of vitamin D in skeletal muscle function. Endocrine Reviews. 1986;7:434–47.

    Article  PubMed  CAS  Google Scholar 

  52. Sorensen OH, Lund B, Saltin B, Andersen RB, Hjorth L, Melsen F, et al. Myopathy in bone loss of ageing: improvement by treatment with 1 alpha-hydroxycholecalciferol and calcium. Clin Sci (Colch). 1979;56(2):157–61.

    CAS  Google Scholar 

  53. von Haehling S, Morley JE, Anker SD. An overview of sarcopenia: facts and numbers on prevalence and clinical impact. J Cachex Sarcopenia Muscle.1(2):129–33.

  54. •• Institute of Medicine. Dietary Reference Ranges for Calcium and Vitamin D. http://wwwiomedu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Report-Briefaspx. 2010. The IOM released new recommendations on vitamin D suggesting 600 IU vitamin D in all adults up to age 70 and 800 IU vitamin D per day in seniors age 70 years and older. These recommendations are primarily based on bone health.

  55. •• Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the US. Preventive services task force. Ann Intern Med. 2011;153(12):815–25. The preventive task forced reviewed all evidence from clinical trials and concluded that vitamin D is an effective strategy in fall prevention.

    Google Scholar 

  56. American Geriatric Society/British Geriatric Society Guidelines on Fall Prevention in older Persons. http://wwwamericangeriatricsorg/files/documents/health_care_pros/FallsSummaryGuidepdf. 2010.

  57. •• Dawson-Hughes B, Mithal A, Bonjour JP, Boonen S, Burckhardt P, Fuleihan GE, et al. IOF position statement: vitamin D recommendations for older adults. Osteoporos Int. 2010;21(7):1151–4. The IOF released a position statement of vitamin D in May 2010 and recomments vitamin D supplementation at a dose of 800–1000 IU per day in all adults age 60 years and older to reduce their risk of falls and fracture. The 25(OH)D threshold for optimal fall and fracture prevention, as defined by the IOF, is 75 nmol/l (30 ng/ml).

    Article  PubMed  CAS  Google Scholar 

  58. Graafmans WC, Ooms ME, Hofstee HM, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol. 1996;143(11):1129–36.

    PubMed  CAS  Google Scholar 

  59. Grant AM, Avenell A, Campbell MK, McDonald AM, MacLennan GS, McPherson GC, et al. Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial. Lancet. 2005;365(9471):1621–8.

    Article  PubMed  CAS  Google Scholar 

  60. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. BMJ. 2003;326(7387):469.

    Article  PubMed  CAS  Google Scholar 

  61. Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID. A randomized, controlled trial of quadriceps resistance exercise and vitamin D in frail older people: the Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am Geriatr Soc. 2003;51(3):291–9.

    Article  PubMed  Google Scholar 

  62. Cummings SR, Nevitt MC, Kidd S. Forgetting falls. J Am Geriatr Soc. 1988;36(7):613–6.

    PubMed  CAS  Google Scholar 

  63. • Bischoff-Ferrari HA, Willett WC, Orav EJ, Kiel DP, Dawson-Hughes B. Re: Fall prevention with Vitamin D. Clarifications needed. http://wwwbmjcom/content/339/bmjb3692/reply. 2011. The authors confirm a dose-response association between vitamin D supplementation and fall reduction.

  64. Bischoff-Ferrari HA, Dietrich T, Orav EJ, Dawson-Hughes B. Positive association between 25-hydroxy vitamin d levels and bone mineral density: a population-based study of younger and older adults. Am J Med. 2004;116(9):634–9.

    Article  PubMed  CAS  Google Scholar 

  65. Bischoff-Ferrari HA, Dietrich T, Orav EJ, Hu FB, Zhang Y, Karlson EW, et al. Higher 25-hydroxyvitamin D concentrations are associated with better lower-extremity function in both active and inactive persons aged > =60 y. Am J Clin Nutr. 2004;80(3):752–8.

    PubMed  CAS  Google Scholar 

  66. Wicherts IS, van Schoor NM, Boeke AJ, Visser M, Deeg DJ, Smit J, et al. Vitamin D status predicts physical performance and its decline in older persons. J Clin Endocrinol Metab. 2007;6:6.

    Google Scholar 

  67. Bischoff HA, Stahelin HB, Dick W, Akos R, Knecht M, Salis C, et al. Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial. J Bone Miner Res. 2003;18(2):343–51.

    Article  PubMed  CAS  Google Scholar 

  68. Pfeifer M, Begerow B, Minne HW, Abrams C, Nachtigall D, Hansen C. Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women. J Bone Miner Res. 2000;15(6):1113–8.

    Article  PubMed  CAS  Google Scholar 

  69. Broe KE, Chen TC, Weinberg J, Bischoff-Ferrari HA, Holick MF, Kiel DP. A higher dose of vitamin d reduces the risk of falls in nursing home residents: a randomized, multiple-dose study. J Am Geriatr Soc. 2007;55(2):234–9.

    Article  PubMed  Google Scholar 

  70. Bischoff-Ferrari HA, Orav EJ, Dawson-Hughes B. Effect of cholecalciferol plus calcium on falling in ambulatory older men and women: a 3-year randomized controlled trial. Arch Intern Med. 2006;166(4):424–30.

    Article  PubMed  CAS  Google Scholar 

  71. Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med. 1997;337(10):670–6.

    Article  PubMed  CAS  Google Scholar 

  72. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. Jama. 2005;293(18):2257–64.

    Article  PubMed  CAS  Google Scholar 

  73. Visser M, Deeg DJ, Puts MT, Seidell JC, Lips P. Low serum concentrations of 25-hydroxyvitamin D in older persons and the risk of nursing home admission. Am J Clin Nutr. 2006;84(3):616–22. quiz 71–2.

    PubMed  CAS  Google Scholar 

Download references

Disclosure

Conflicts of interest: H.A. Bischoff-Ferrari: has been a consultant for Novartis, Amgen, DSM, MSD, and Nestlé; and has received grant support from Nestlé, DSM, and MSD.

Author information

Authors and Affiliations

  1. Centre on Aging and Mobility, University of Zurich, Zurich, Switzerland

    Heike A. Bischoff-Ferrari

  2. Department of Rheumatology and Institute of Physical Medicine, University Hospital Zurich, Gloriastrasse 25, 8091, Zurich, Switzerland

    Heike A. Bischoff-Ferrari

Authors
  1. Heike A. Bischoff-Ferrari
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Heike A. Bischoff-Ferrari.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bischoff-Ferrari, H.A. The Role of Falls in Fracture Prediction. Curr Osteoporos Rep 9, 116–121 (2011). https://doi.org/10.1007/s11914-011-0059-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11914-011-0059-y

Keywords

Search

Navigation