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 D3 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+
