1 Osteoporosis Unit, Department of Rheumatology, St George's Hospital, London, SW17 0QT and
2 Department of Rheumatology, St Helier Hospital, Carshalton, Surrey SM5 1AA, UK
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Abstract |
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Methods. Women aged 65 yr and over referred for open access bone densitometry who had femoral neck osteoporosis and a high risk of falling were asked to wear hip protectors.
Results. Eighty five women fulfilled the inclusion criteria of whom 32 (38%) found the hip protectors acceptable and agreed to participate. Reasons given by the remaining 53 (62%) for not finding the hip protectors acceptable included discomfort on wearing, dislike of their personal appearance with the hip protectors on, and disagreement about their fracture risk. Participants were more likely to have a family history of osteoporosis (47 vs 26%, respectively) and hip fracture (16 vs 8%) compared with non-participants. At 12 months only about half of the subjects were wearing hip protectors daily.
Conclusions. Our findings suggest that only a minority of community-dwelling women at high risk of hip fracture will wear hip protectors to reduce fracture risk. Their use should be restricted to highly motivated women who should be carefully identified.
KEY WORDS: Hip protectors, Hip fracture, Community care, Osteoporosis, Compliance.
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Introduction |
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Patients and methods |
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Fall risk assessment was performed as previously described [13]. The tests used have a direct relationship to hip fracture and were: (i) binocular corrected visual acuity (VA), measured using a Snellen chart, (ii) ability to perform four tandem gait steps (heeltoe walking) and (iii) ability to do five stand-ups without arm use.
Women with femoral neck osteoporosis and one or more of the fall risk factors were then given counselling about osteoporosis and falls. Their bone density scans were shown to them and they were given literature about osteoporosis and hip fracture (from the National Osteoporosis Society, UK). The patients were also given the opportunity to try the hip protectors on if they wished.
Those women who consented to participate were issued with diary cards and three pairs of hip protectors (Safehip®, Robinson Healthcare, Chesterfield, S40 1YF, UK). They were asked to wear the hip protectors every day, particularly during waking hours. The diary cards allowed for patients to record the number of hours per day that hip protectors were worn. Patients were asked to return these cards monthly by post. If diary cards were not returned, patients were contacted by phone on two occasions 1 week apart. If this did not result in the diary card being returned, final contact was made to see if the patients wanted to continue to participate. If patients did not wear hip protectors for short periods (less than 2 weeks) for whatever reason, then restarted wearing, we assumed that they were still compliant when analysing the data. Longer periods of not wearing hip protectors were analysed as discontinuation of wear.
Data are presented as mean (S.D.) unless stated. The significance of differences between groups was tested using Student's t-tests or 2-tests where appropriate. A P value of less than 0.05 was considered statistically significant.
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Results |
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The characteristics of the women who chose to wear the hip protectors compared with those who found them unacceptable are shown in Table 1. There was a trend to participants having a family history of osteoporosis compared with non-participants (47 vs 26%, respectively) and participants were twice as likely to have had a hip fracture compared with non-participants (16 vs 8%), but none of these differences reached statistical significance. Compliance with hip protector use and time after initial assessment are shown in Fig. 1
. At 12 months about half of the subjects were wearing hip protectors daily. Based on the diary cards, the majority of the participating women were awake for 1416 h/day and wearing hip protectors for 810 of those hours.
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Discussion |
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Previous hip protector studies have focused on institutionalized older individuals, as residing in an institution is associated with a higher incidence of hip fracture compared with those living in the community [1416]. However, whilst the incidence of hip fracture is high in institutionalized individuals, the majority of fractures actually occur in community-dwelling individuals. Thus, in a recent Dutch population-based study of individuals who sustained a hip fracture, approximately 75% of individuals in the 7079-yr age group were living independently in the community as were about 50% of 8089-yr olds [16]. Similarly, a New Zealand study showed that 58% of hip fractures were sustained by people living in private residences, compared with 42% living in institutions [15]. Therefore, where community-dwelling individuals have been identified as being at high risk of fracture, it seems reasonable to consider all potential interventions to reduce fracture risk, including hip protectors.
Comparison of acceptability and compliance in the present study with previous studies of hip protectors is difficult because of different study methodology and outcome criteria. All the previous studies [9, 1723] have been conducted in nursing homes with study durations varying from 12 weeks to 12 months. The primary endpoint in the majority was hip fracture reduction, although two were assessing compliance prior to larger studies [21, 22]. One important characteristic was that a large number of individuals in these homes (who by virtue of their residence in the homes were at high risk of hip fracture) were excluded from entry for a variety of reasons apart from refusal to consent. Examples of exclusion criteria include dementia [22], mobile only in a wheelchair [19] and assessed as not being at risk of falling [23]. Also the definition and reporting of compliance varied. Thus three studies reported overall compliance of 24% [20], 44% [18] and 48% [9] throughout the study. Other studies have reported between 36 and 74% compliance at periods of 12 weeks to 12 months depending on the duration of the study [1923]. Other than death or leaving the nursing homes, reasons for non-compliance included dementia [16], being bedridden and skin irritation [18], feeling too hot or difficulty in putting on the hip protectors [22], and refusal to continue without specific reasons [9, 23]. In one study, explanations for not using protectors centred on a perceived lack of personal risk (as for some patients in our study) even in subjects with a previous hip fracture [17]. Reasons why the hip protectors were not initially acceptable and subsequent refusal to comply with wearing were not always given [19].
The only statistical difference between participants and non-participants (those who found the hip protectors unacceptable) in our study was that non-participants were about 2 yr older (Table 1). Experience of previous fractures were similar (47% in the participants vs 51% in the non-participants). Previous hip fractures were twice as common in participants compared with non-participants (16 vs 8%, respectively) and a family history of osteoporosis was more common in participants than non-participants (47 vs 26%, respectively), but as the number of patients was small, neither differences reached statistical significance. The number of falls in the last year and presence of fall risk factors were similar. We advised our patients to wear hip protectors during the day, as the majority of hip fractures occur during daylight hours [15, 2427]. This is because we thought that asking these older patients to wear hip protectors at night would reduce compliance (as previously shown) [21]. Previous studies either asked for hip protector wear throughout the 24 h or did not specifiy.
Whilst we believe the findings of this study can be generalized to other centres which provide open access bone densitometry to the community, the findings are probably only applicable to the specific hip protector studied as the protectors vary in design. Other limitations include the bias of returning the diary cards and the reinforcement that contact with the Osteoporosis Unit could have on compliance. Potentially, if women were issued the hip protectors and then no further contact took place, compliance may be lower. Other important issues are that to date there has been no study to show that hip protectors are effective in reducing hip fractures in this population (i.e. community-dwelling women) and therefore calculation of costbenefit is unfeasible. None the less, guidelines for the management of osteoporosis do recommend that hip protectors be considered in those at increased fall risk [28].
In summary we have shown that only a minority (38%) of community-dwelling women at risk of hip fractures find hip protectors acceptable. Apart from discomfort, we found that negative perception of personal appearance with the hip protectors on and the appearance of the actual hip protectors were important to women who did not wish to wear them. Changes in design may improve this, as could different ways of counselling to explain the risk of hip fracture to older women. This is important because whether individuals will find an intervention such as drug treatment or a hip protector acceptable and comply with use will depend on the complex interaction between personal perception of risk, side-effects of the intervention and the ability to administer the intervention. Our findings suggest that only a minority of community-dwelling women at high risk of hip fracture will wear hip protectors to reduce fracture risk. Their use should be restricted to highly motivated women who should be carefully identified.
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Notes |
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References |
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