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## Complete Summary

#### GUIDELINE TITLE

Prevention of hip fracture amongst people aged 65 years and over.

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group (NZGG). Prevention of hip fracture amongst
people aged 65 years and over. Wellington (NZ): New Zealand Guidelines
Group (NZGG); 2003 Jun. 31 p. \[54 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hip fractures

#### GUIDELINE CATEGORY

Prevention

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Internal Medicine\
Orthopedic Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Occupational Therapists\
Patients\
Physical Therapists\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide an evidence-based summary of the clinical aspects of hip
fracture prevention and advice that can effectively reduce the risks of
hip fracture amongst people aged 65 years and over

#### TARGET POPULATION

People in New Zealand aged 65 years and over seen in primary care
settings

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Risk Assessment through:

    -   Detailed medical history

2.  Bone mineral density (BMD) measurement

3.  Fall prevention strategies:

    -   Muscle strengthening and balance training

    -   Multidisciplinary, multifactorial health/environmental
        screening/intervention programmes

    -   Home environment modification

4.  Medication to prevent or reduce progressive bone loss, including
    vitamin D, bisphosphonates, and calcium supplements

    -   Hormone replacement therapy is considered but not recommended.

5.  Hip protectors

#### MAJOR OUTCOMES CONSIDERED

For risk assessment, the guideline developer sought studies which
validated the ability of risk assessment tools to correctly predict
high-risk groups or individuals. For prevention, the primary outcome of
interest was the incidence of hip fractures. Secondary outcomes of
interest were other non-vertebral fractures and incidence of falls
causing significant injury.

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The scope of the guideline and the topics to be researched were
established by consensus within the group, and a search for evidence
conducted. Guidelines developed by other countries and other
organisations and relevant medical literature were reviewed. These were
identified by searching the Internet, and the electronic databases, The
Cochrane Library, MEDLINE, EMBASE, and CINAHL, Healthstar, and Current
Contents, and by reviewing references cited in other guidelines and
identified papers. Identified references were screened for eligibility
according to pre-determined criteria shown below, and the studies
considered eligible were retrieved and underwent critical appraisal
using pre-determined templates.

**Eligibility and Inclusion Criteria**

**Types of Studies**

Systematic reviews and meta-analyses. Descriptive reviews where no
systematic reviews were found, randomised controlled trials (RCTs),
non-randomised controlled clinical trials (CCTs), cohort studies,
case-control studies, and cross-sectional studies.

**Types of Study Participants**

Older people aged 65 years and over

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**1++**

High quality meta-analyses/systematic reviews of randomised controlled
clinical trials (RCTs), or RCTs with a very low risk of bias

**1+**

Well-conducted meta-analyses/systematic reviews, or RCTs with a low risk
of bias

**1-**

Meta-analyses/systematic reviews, or RCTs with a high risk of bias

**2++**

High quality systematic reviews of case-control or cohort studies

High quality case-control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**

Well-conducted case-control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**

Case-control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal

**3**

Non-analytic studies (e.g., case reports, case series)

**4**

Expert opinion

Qualitative material was systematically appraised for quality, but was
not ascribed a level of evidence.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Retrieved studies were obtained and their content reviewed for relevance
to the various topics of the review. Each topic was assigned to two
members of the group who read the retrieved reports, agreed on what
would be included in the guideline, and appraised the included material
using the pathway in the original guideline to filter the included
material (see original guideline supporting material).

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Grades of Recommendation**

**A**

At least one meta-analysis, systematic review, or randomised, controlled
clinical trial (RCT) rated 1++, and directly applicable to the target
population

or

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**

A body of evidence consisting principally of studies rated as 2++,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 1++, or 1+

**C**

A body of evidence consisting principally of studies rated as 2+,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 2++

**D**

Evidence level 3 or 4

or

Extrapolated evidence from studies rated as 2+

#### COST ANALYSIS

**Cost-Effectiveness of Hip Fracture Prevention Strategies**

The cost-effectiveness of hip fracture prevention is the subject of a
recent systematic review, and of modelling.

Considerable uncertainty exists around the cost-effectiveness of
fracture prevention. Estimates are sensitive to individual\'s age at
fracture; age at onset, duration, and other benefits of the prophylactic
regimen; costs of adverse effects; and the costs of the intervention
that vary considerably from country to country.

At present, the differences in cost of different hip fracture prevention
strategies appear to be higher than the apparent differences in
efficacy. Thus, cost-effectiveness ratios will be mainly influenced by
the cost, rather than by the effectiveness.

**Primary Prevention**

Amongst frail older people in residential or nursing home care, economic
modelling based on the results of randomized controlled trials (RCTs)
indicates that the use of calcium and vitamin D supplementation appears
more cost-effective than the use of hip pads.

For primary prevention using hormone replacement therapy (HRT),
potential savings would only exceed costs if used in women aged 70 years
and over (refer to Appendix C in the original guideline document for
caution on HRT use). It is therefore unlikely to be cost-effective in
older women, since acceptance and continuing compliance, even when
scanning has demonstrated low bone mineral density (BMD), may be low.

**Secondary Prevention**

Bisphosphonates used in secondary prevention appear to be less
cost-effective than HRT. However, this conclusion is sensitive to
compliance and other possible positive and adverse effects of HRT (refer
to Appendix C in original guideline document for current advice).
Bisphosphonates may currently be a preferred option.

No studies appear to have measured or modelled the overall
cost-effectiveness of fall-prevention programmes compared with other
fracture prevention strategies.

In community-dwelling older women, the number needed to treat (NNT) to
prevent one hip fracture is estimated at 90 for bisphosphonates,
compared with 300 to 1,000 for fall prevention programmes. However, this
is a crude comparison as the aim and impact of fall prevention
programmes extend beyond hip fracture prevention.

**Tertiary Prevention**

In older people who have already sustained a hip-fracture, modelling
suggests that potential savings from the use of either hip protectors or
bisphosphonates would exceed costs over time, but savings would be less
with bisphosphonates.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

A draft of the guideline was widely circulated to over 30
individuals/organisations for peer review.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the Levels of Evidence (1++ to 4) and Grades of
Recommendation (A to D) are given at the end of the \"Major
Recommendations\" field.

**Risk Assessment for Hip Fracture in Older People**

**B** Women aged 80 years and over and men aged 85 years and over are,
as a group, at high risk of hip fracture.

**B** Women aged 70 years and over and men aged 75 years and over are,
as a group, at high risk of hip fracture:

-   living in institutional care, OR

-   with significant cognitive impairment

**C** Women aged 70 years and over and men aged 75 years and over are at
high risk of hip fracture:

-   with one or more of the following conditions:

    -   visual acuity 0.2 (6/30)

    -   history of a fall with fracture in the previous year

    -   history of frequent falling

    -   type 2 diabetes (evidence available for women only)

-   if currently using any of the following medications;

    -   anticonvulsant therapy

    -   opioids (including propoxyphene containing pain medication)

    -   corticosteroids (doses greater than prednisone 5 mg per day or
        equivalent)

    -   any psychotropic drug

    -   type Ia antiarrhythmics

**C** Women aged 70 years and over with three or all of the following
personal history/lifestyle factors are at high risk of hip fracture:

-   smoking history

-   personal history of any previous fracture

-   history of maternal hip fracture

-   low body mass index

**C** Men aged 75 years and over with any of the following personal
history/lifestyle factors are at high risk of hip fracture:

-   low body mass index

-   smoking history

-   history of fracture of spine, hip or wrist

-   history of stroke should be considered at high risk of hip fracture

**C** Women aged 65 years and over are at high risk if their bone
mineral density (BMD) is 2 SD below normal for age (Z-score \>-2.0), and
75 years and over if BMD is 1 SD below normal for age (Z-score \>-1.0).
The decision on prevention/treatment should take into account Z-score
AND other risk factors.

Men aged 70 years and over are at high risk if their BMD is 2 SD below
normal for age, and 80 years and over if BMD is 1 SD below normal for
age. The decision on prevention/treatment should take into account
Z-score AND other risk factors.

**A** The available evidence does not support the use of BMD measurement
for screening of asymptomatic individuals.

At present, there is only limited evidence that the use of BMD
measurement in selected individuals is effective in reducing the risk of
future fractures.

**Fall Prevention**

**A** A programme of muscle strengthening and balance training,
individually prescribed by a trained health professional in a New
Zealand primary health care setting, reduces the frequency of falls in
high risk community-dwelling older people.

**A** Multidisciplinary, multifactorial health/environmental
screening/intervention programmes reduce the frequency of falls in high
risk community-dwelling older people.

**A** Assessment, advice, and facilitation of home environment
modification, when conducted in an experimental situation by a trained
occupational therapist, reduces the frequency of falls in high risk
community-dwelling older people.

**Medication for Bone Protection**

**A** Daily supplementation with vitamin D~3~ and calcium reduces the
hip fracture rates amongst high-risk older people in institutional care
or who have already sustained a hip fracture.

**A** Bisphosphonates (alendronate, risedronate) reduce hip and other
fracture rates in community-dwelling older women under 80 years of age.

**A** Evidence for the effectiveness of hormone replacement therapy
(HRT) in reducing hip fracture rates in women aged 65 years and over is
conflicting. In view of more recent evidence on the risks of HRT, it is
not recommended for first line prevention of hip fracture. Refer to
Appendix C in the original guideline.

**Hip Protectors**

**A** Hip protectors appear to reduce the incidence of hip fractures in
older people in institutional care provided that compliance/adherence is
achieved.

**Cost-Effectiveness of Hip Fracture Prevention Strategies**

**B** In frail older people in residential or nursing home care, calcium
and vitamin D supplementation appears more cost-effective than the use
of hip pads, although both approaches have similar efficacy.

**B** The cost-effectiveness of bisphosphonates compared with HRT is
sensitive to compliance and the incidence of adverse events and is
unclear (refer to Appendix C in the original guideline for current
advice on HRT).

**B** The overall cost-effectiveness of fall prevention programmes,
compared with other strategies used for hip fracture prevention, is not
known.

**Definitions**:

**Levels of Evidence**

**1++**

High quality meta-analyses/systematic reviews of randomised controlled
clinical trials (RCTs), or RCTs with a very low risk of bias

**1+**

Well-conducted meta-analyses/systematic reviews, or RCTs with a low risk
of bias

**1-**

Meta-analyses/systematic reviews, or RCTs with a high risk of bias

**2++**

High quality systematic reviews of case-control or cohort studies

High quality case-control or cohort studies with a very low risk of
confounding or bias and a high probability that the relationship is
causal

**2+**

Well-conducted case-control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal

**2-**

Case-control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal

**3**

Non-analytic studies (e.g., case reports, case series)

**4**

Expert opinion

Qualitative material was systematically appraised for quality, but was
not ascribed a level of evidence.

**Grades of Recommendations**

**A**

At least one meta-analysis, systematic review, or RCT rated 1++, and
directly applicable to the target population

or

A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results

**B**

A body of evidence consisting principally of studies rated as 2++,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 1++, or 1+

**C**

A body of evidence consisting principally of studies rated as 2+,
directly applicable to the target population, and demonstrating overall
consistency of results

or

Extrapolated evidence from studies rated as 2++

**D**

Evidence level 3 or 4

or

Extrapolated evidence from studies rated as 2+

#### CLINICAL ALGORITHM(S)

The original guideline document provides a summary algorithm for risk
assessment and selection of preventive strategies.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The advice on the prevention of hip fracture amongst people aged 65
years and over given in this guideline is based on epidemiological and
other research evidence, supplemented where necessary by the consensus
opinion of the expert development team based on their own experience.

The evidence supporting the recommendations includes systematic reviews
and meta-analyses, descriptive reviews where no systematic reviews were
found, randomised controlled trials (RCTs), non-randomised controlled
clinical trials (CCTs), cohort studies, case-control studies, and
cross-sectional studies.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

By following the evidence-based recommendations in this guideline, older
people at high risk of hip fracture can adopt effective preventive
strategies to help maintain an independent lifestyle.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

While the guidelines represent a statement of best practice based on the
latest available evidence (at the time of publishing), they are not
intended to replace the health professional\'s judgment in each
individual case.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Implementation**

Adoption and implementation of the recommendations will be a matter for
Accident Compensation Corporation (ACC), District Health Boards (DHBs),
Independent Practitioners´ Associations (IPAs), Primary Healthcare
Organisations (PHOs), and local provider units to consider.

The guideline should provide a basis at local level for protocols,
continuing health professional education, audit, and quality assurance
activities. Suggestions for audit are described below.

**Dissemination**

The guideline will be sent to:

-   ACC

-   colleges and associations representing relevant health professional
    vocational groups

-   members of IPAs

-   PHOs

-   chief executives and chief medical officers of DHBs

-   tertiary education institutions offering health professional
    programmes

-   providers of Aged Care services in the community

-   selected others.

Summary guidelines will also be prepared. The guidelines and summaries
will be posted on the NZGG website
[www.nzgg.org.nz](http://www.nzgg.org.nz/) and on the ACC website
<http://www.acc.co.nz/>.

**Audit and Performance Indicators**

**Quality**

People aged 65 years and over at risk for hip fracture, service
providers and funders of services to people at risk of hip fracture all
have an interest in the preventive strategies for people at high risk of
hip fracture. This places a responsibility on service providers to
collect information relevant to different perspectives. Suggestions
include:

-   a minimum data set for collection relating to each individual at
    risk for hip fracture aged 65 years and over

-   additional data for periodic audit (by an internal or external
    agency)

***Suggested data for routine collection***

-   Basic demographics of people at risk for hip fracture (age, gender,
    ethnicity, height, weight, and body mass index \[BMI\])

-   Current living status (own home -- alone, residential, whanau/family
    support)

-   Maternal history of hip fracture

-   Smoker status. Number of attempts at quitting

-   Diabetes diagnosed. Using insulin?

-   Number of strokes

-   Number of falls in the previous 12 months

-   Previous fractures (hip, wrist, humerus, spine)

-   Current medications and dose levels (anticonvulsants,
    bisphosphonates, corticosteroids, opioids, hormone replacement
    therapy \[HRT\], psychotropic drugs, and type Ia antiarrhythmic)

-   Use of vitamin D supplements and calcium

-   Side effects of medication.

**Audit**

Audit is a systematic, independent and documented process for obtaining
evidence and evaluating it objectively to determine the extent to which
a service, such as a primary health care practice, is meeting best
practice standards. In order to assess hip fracture prevention is being
provided effectively; a register of individuals with risk factors for
hip fracture may be established. In addition, the following performance
indicators may be assessed.

***Suggested performance indicators***

The proportion of people enrolled in the practice who are at high risk
who have had:

-   visual acuity check

-   polypharmacy review

-   vitamin D and calcium supplementation

-   access to hip protectors

-   specific anti-osteoporotic medication (prescribed or prescription
    offered), with details of the type of medication

Proportion of community-dwelling people aged 80 years and over enrolled
in the practice who have had:

-   a formal hip fracture risk assessment including falls assessment

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

New Zealand Guidelines Group (NZGG). Prevention of hip fracture amongst
people aged 65 years and over. Wellington (NZ): New Zealand Guidelines
Group (NZGG); 2003 Jun. 31 p. \[54 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Jun

#### GUIDELINE DEVELOPER(S)

New Zealand Guidelines Group - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

Ministry of Health

#### GUIDELINE COMMITTEE

Guideline Development Team

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Research and Writing Group Members*: William Gillespie, ChM, FRACS,
FRCPEd, Orthopaedic Surgeon, Dean, Hull York Medical School
(*Convenor*); John Campbell, MD, FRACP, Professor of Geriatric Medicine,
University of Otago Medical School; Melinda Gardner, Mphty, PhD,
Physiotherapist, Fall Prevention Research, Northern DHB Support Agency;
Lesley Gillespie, BSc (Soc Sci), MMedSci (Clin Epi), RGN, Trial Search
Coordinator for the Cochrane Musculoskeletal Injuries Group, The
University of York, Orthopaedic Nursing, Clinical Epidemiology; Jan
Jackson, Fractured Neck of Femur Clinical Nurse Specialist, Auckland
District Health Board; Clare Robertson, BSc (Hons), BCom, PhD, Senior
Research Fellow, Fall Prevention Research, Economic Evaluation,
University of Otago Medical School; Jean-Claude Theis, MD, MChOrth, FRCS
Ed, FRACS, Associate Professor of Orthopaedic Surgery, Dunedin School of
Medicine; Raymond Jones, Project Coordinator, Otago District Health
Board

*Consultation Group Members*: Marion Robinson (*Dunedin*); Heather
Thomson (*Opotiki*); Jim Reid (*Dunedin*)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

**Declaration of Competing Interest**

**John Campbell** has received research funding from the Accident
Compensation Corporation (ACC).

#### ENDORSER(S)

Age Concern New Zealand, Inc. - Medical Specialty Society\
College of Nurses Aotearoa NZ - Academic Institution\
Hospitals Association, Inc. (New Zealand) - Professional Association\
New Zealand College of Practice Nurses (NZNO) - Professional
Association\
New Zealand Home and Health Association, Inc. - Professional
Association\
New Zealand Nurses Organization - Professional Association\
New Zealand Orthopaedic Association - Professional Association\
New Zealand Society of Physiotherapists - Professional Association\
NZ Geriatric Society - Professional Association\
Osteoporosis New Zealand - Medical Specialty Society\
Residential Care NZ, Inc. - Professional Association\
Royal New Zealand College of General Practitioners - Medical Specialty
Society\
Women\'s Health Action - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[New Zealand Guidelines Group Web
site](http://www.nzgg.org.nz/guidelines/0006/Hip_Fracture_Prevention_Fulltext.pdf).

Print copies: Available from the New Zealand Guidelines Group Inc.,
Level 10, 40 Mercer Street, PO Box 10 665, The Terrace, Wellington, New
Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail:
<info@nzgg.org.nz>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   New Zealand Guidelines Group (NZGG). Guideline summary. Prevention
    of hip fracture amongst people aged 65 years and over. Wellington
    (NZ): New Zealand Guidelines Group (NZGG); 2003 Jun. 4 p. Available
    from in Portable Document Format (PDF) from the [New Zealand
    Guidelines Group Web
    site](http://www.nzgg.org.nz/guidelines/0006/ACF431.pdf).

-   New Zealand Guidelines Group (NZGG). Search strategy. Prevention of
    hip fracture amongst people aged 65 years and over. Wellington (NZ):
    New Zealand Guidelines Group (NZGG); 2003 Jun. 6 p. Available from
    in Portable Document Format (PDF) from the [New Zealand Guidelines
    Group Web
    site](http://www.nzgg.org.nz/guidelines/0006/Hip_Fracture_Prevention_Methods.pdf).

Print copies: Available from the New Zealand Guidelines Group Inc.,
Level 10, 40 Mercer Street, PO Box 10 665, The Terrace, Wellington, New
Zealand; Tel: 64 4 471 4180; Fax: 64 4 471 4185; e-mail:
<info@nzgg.org.nz>

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 16, 2004. The information
was verified by the guideline developer on July 19, 2004.

#### COPYRIGHT STATEMENT

These guidelines are copyrighted by the New Zealand Guidelines Group.
They may be downloaded and printed for personal use or for producing
local protocols in New Zealand. Re-publication or adaptation of these
guidelines in any form requires specific permission from the Chief
Executive of the New Zealand Guidelines Group.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008