van der Velde N.: Person-centered falls and fracture prevention

I. Falls and fall-related injury, such as fractures, form a major health care problem in older persons (>65yrs), with a yearly fall rate of 33% and an accompanying injury rate of approximately 20%. These numbers double for the over-80yrs group. Worryingly, fall rates in all age categories have been rising over the last decade and the same holds true for (serious) fall-related injuries such as brain injury or hip fracture. In order to diminish this significant and growing disease burden both in terms of quality of life for the individual patients and in terms of health care costs for the society, it is important to minimize the number of fall incidents. The presences of several individual chronic diseases and certain classes of medication have been associated with an increased fall risk. Since fall-risk factors are so numerous, a complex interaction can be expected. Although diseases such as Parkinson and arthritis, as well as the use of certain drugs (psychotropic and cardiovascular) are well known fall-risk factors, little is known about the effects of chronic disease clusters, and its accompanying medication use, on fall- and fall-related-injury risk. Not only combinations of
comorbidity and medication use may affect fall risk and its related injury, but also genetic variations. A person-centered approach in terms of attuning preventive and treatment strategies by incorporating complex patient characteristics will ensue.
II. Cardiovascular disease is a principal contributor to chronic morbidity and loss of wellbeing, and the leading cause of death in older persons. Notwithstanding sufficient evidence that preventive measures in this group are at least as effective as in younger subjects, elderly remain vastly undertreated. Earlier, our group showed that valvular abnormalities, heart-rhythm disorders, poor left-ventricular function, orthostatic hypotension and carotid-sinus hypersensitivity are associated with falls. Cardiovascular disorders are the main cause for unexplained or recurrent falls in elderly. Since standard cardiovascular evaluation is not yet part of the current multifactorial falls guidelines and since studies on how to perform such an analyses effectively in older fallers are currently lacking, it is of highest importance to develop a standardized, evidence-based cardiovascular protocol.
III. Fracture risk is affected by the presence of several individual chronic diseases and classes of medication, which are traditionally assessed individually in the clinical work-up. However, with age, multimorbidity becomes more frequent, together with polypharmacy. Around the age of 65 approximately 55% of community-dwelling older persons have two or more chronic diseases. Nevertheless, up to know, little is known about the effects of chronic disease clusters, and the respective medication use on fracture risk. In addition, the influence of these interactive components on therapeutic response of used medications in fracture care and prevention is unknown. As with falls, again also genetic variations can be expected to influence fracture risk and therapeutic response. Main goal is to develop person-centered, individualized preventive and intervention strategies in fracture care.
IV. Effectiveness of falls and fracture interventions are very much dependent on patient compliance. Incorporating the patient perspective is thus essential. This holds true for geriatric research in general as well as for falls and fracture studies in particular. Especially in this specific group, interventions need to be targeted at optimizing quality of life and thus patient preferences are of great significance. In order to effectively incorporate patient preferences, targeted patient education and emancipation is of major importance. Furthermore, for optimal decision-making in terms of patient preferences, expected effectiveness of particular interventions need to be explicit. Therefore studies specifically addressing the geriatric population are urgently needed in order to gain more knowledge on effectiveness of potential interventions in frail, multimorbid elderly. For patient-centered decision making, time to benefit of the intervention is essential to be included.