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Prescribing Advice for GPs

An NHS Prescribing Advisers' Blog

BMJ targets fall prevention

The British Medical Journal (BMJ) has published several articles discussing approaches to preventing falls and fractures. Fiona Godlee, editor of the BMJ sets the articles in context in Editor's Choice by requesting that risk reductions are expressed as absolute reductions rather than relative reductions.

A research article that aimed to systematically review the evidence supporting multifactorial assessments and interventions to prevent falls examined data from 19 studies of variable quality. There was a trend to a lower fall risk but the result was not significant. Additionally, there were no differences in rates of admission to hospital, emergency department attendance or death.

The authors state that, "any benefits from this type of intervention might be smaller than previously supposed" however due to the limited quality of the studies it remains difficult to assess the impact of these interventions on the number of falls and fall related injuries. More large scale, high quality randomised controlled trials are required.

This edition also contains two analysis articles. The first discusses changing the focus of fracture prevention to fall prevention rather than treating bone mineral density and the second examines the evidence for treating bone mineral density at osteopenic levels rather than waiting for osteoporosis.

The first article notes the unreliable nature of bone densitometry and the fact that over 80% of low trauma fractures occur in people who do not have osteoporosis. The authors recommend that fracture prevention should focus upon prevention of falls rather than treatment of bone density since falling is the strongest risk factor for fractures and not osteoporosis.

The second article questions the marketing of drug treatments to reduce the risk of fracture in women with osteopenia. It is argued that the rationale for this position comes from questionable post-hoc analyses that overstate the benefits and downplay the side effects. It is recommended that treatment decisions are based on an assessment of the absolute risk of fracture. As fracture risk increases with age and falls it would seem that treating postmenopausal women based on the presence of osteopenia alone is inappropriate.

Action: Clinicians who are endeavouring to reduce rates of hip fracture will find these articles a useful summary of the current evidence. Interventions should target absolute fracture risk and include assessment and reduction of falls risk.

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