Hip Protectors Research Articles

Can Hip Protector Use in the Nursing Home Be Predicted?

OBJECTIVES: To identify resident‐ and caregiver‐related factors that influence hip protector (HP) usage.DESIGN: Prospective observational cohort study over 6 weeks.SETTING: A 409‐bed nursing home located in New York City.PARTICIPANTS: Fifty‐two residents and 60 certified nursing assistants (CNAs).INTERVENTION: Free HPs were provided to residents enrolled in the study.MEASUREMENTS: HP adherence (number of hours HPs were worn/shift); HP users (subjects who used HPs for more than 1 hour during any 8‐hour shift as recorded by CNAs in week 6 or who used HPs at checks performed by research staff in week 6 and intended future use); CNAs' scores on a questionnaire quantifying osteoporosis knowledge, opinions on HPs, job satisfaction, and health locus of control.RESULTS: Sixty‐eight percent of residents were HP users. Factors independently associated with this outcome included male sex, age, Parkinson's disease, family involvement, impaired cognition, dependent ambulation, and CNAs' sense that chance affects health outcomes. In multivariate models, anxiety, resistive behaviors, ambulation, and fall history in residents and CNAs' perceptions of HPs and their sense of how chance or other staff determine health outcomes predicted HP adherence.CONCLUSION: Resident‐related factors and CNAs' sense of external controls predicted HP users and HP adherence. CNAs' understanding of osteoporosis and HP affected only HP adherence. Most resident‐related factors were not remediable but might help to target likely HP users. To improve HP adherence, educational programs should be designed to improve CNAs' understanding of osteoporosis and HP. Larger studies are needed to confirm these findings.

Can Hip Protector Use in the Nursing Home Be Predicted?.

To identify resident- and caregiver-related factors that influence hip protector (HP) usage. Prospective observational cohort study over 6 weeks. A 409-bed nursing home located in New York City. Fifty-two residents and 60 certified nursing assistants (CNAs). Free HPs were provided to residents enrolled in the study. HP adherence (number of hours HPs were worn/shift); HP users (subjects who used HPs for more than 1 hour during any 8-hour shift as recorded by CNAs in week 6 or who used HPs at checks performed by research staff in week 6 and intended future use); CNAs' scores on a questionnaire quantifying osteoporosis knowledge, opinions on HPs, job satisfaction, and health locus of control. Sixty-eight percent of residents were HP users. Factors independently associated with this outcome included male sex, age, Parkinson's disease, family involvement, impaired cognition, dependent ambulation, and CNAs' sense that chance affects health outcomes. In multivariate models, anxiety, resistive behaviors, ambulation, and fall history in residents and CNAs' perceptions of HPs and their sense of how chance or other staff determine health outcomes predicted HP adherence. Resident-related factors and CNAs' sense of external controls predicted HP users and HP adherence. CNAs' understanding of osteoporosis and HP affected only HP adherence. Most resident-related factors were not remediable but might help to target likely HP users. To improve HP adherence, educational programs should be designed to improve CNAs' understanding of osteoporosis and HP. Larger studies are needed to confirm these findings.

The Consequences of Falls in Acute and Subacute Hospitals in Australia That Cause Proximal Femoral Fractures

To compare consequences for patients with proximal femoral fractures (PFFs) sustained in the hospital with patients who sustained PFFs in the community. Data were collected from inpatient notes and incident reports of patients admitted to hospitals over a 6-year period. All patients aged 75 and older sustaining a PFF in the hospital were identified and matched according to sex, age, and fracture date with patients who sustained a PFF in the community. Illawarra region hospitals, New South Wales, Australia. Forty-three patients with a hospital-acquired PFF and 43 patients with a community-acquired PFF; mean age was 84.0 (range 75-92), and 67% were women. Outcomes at hospital discharge and circumstances of hospital-acquired PFF. Comparing outcomes of subjects with hospital versus community-acquired PFF revealed that 12 versus four died in the hospital (P=.03), 14 versus five were discharged to long-term nursing care facilities (P=.02), six versus 18 returned to preadmission ambulation (P=.004), and four versus 24 returned to preadmission activity of daily living status (P<.001). The median postfracture length of stay was 46 days for subjects with hospital-acquired PFF versus 32 days for those sustaining a PFF in the community (P<.01). Review of circumstances of the 43 hospital-acquired fractures revealed that 26 occurred in subacute wards, 25 occurred in bedrooms, 25 occurred at night, and 38 occurred while unsupervised. Patients with hospital-acquired PFF have poor outcomes. Adequate supervision, provision of hip protectors in the hospital, and strategies that address fracture circumstances may hold the keys to prevention.

Are hip protectors correctly positioned in use?

There are many designs of hip protectors ranging from small elliptical shaped hard shell designs to large circular soft pads. They are held in position usually by being contained in a close fitting pocket on a garment that patients wear all the time they are at risk of sustaining a fracture of the hip if they fall onto the area of the greater trochanter (GT). It is important for the function of the hip protector that the pad element is positioned over the GT when the subject falls onto a surface such as the floor so as to provide the maximal protection by reducing the large forces transmitted to the femoral neck that lead to the fracture of the bone. In this study, anatomical measurements show where the GT is relevant to the centre of the hip protector, and position and movement studies have shown that generally the hard shell design of the hip protector lies posterior and proximal to the GT both for erect and flexed positions of the hip. The position of the GT relevant to the anterior superior iliac crest was established using ultrasound examinations on control and patients admitted with a fracture of the hip due to a fall. The diagonal surface distance for the three groups of test subjects was approximately 12 cm and a template was developed that could be used to locate the GT. A 'zone' of GT position and movement has been established relative to the anterior superior iliac crest, and designers of garments should ensure that this zone is within the area of protection provided by their hip protector pad design.

Could a policy of provision of hip protectors to elderly nursing home residents result in cost savings in acute hip fracture care? The case of Ontario, Canada

Hip fractures are an important problem in nursing homes. Hip protectors are external devices that decrease the risk of hip fracture in elderly nursing home residents. We estimated the overall healthcare cost savings from a hypothetical strategy of provision of hip protectors to elderly nursing home residents in Ontario, Canada. In a recent meta-analysis, we determined that a strategy of provision of hip protectors decreases the risk of hip fracture in nursing home residents. Our objective was to determine whether the provision of hip protectors to all Ontario nursing home residents aged > or =65 years could result in cost savings, stemming from reductions in initial hospitalizations for hip fracture. We conducted a cost analysis from a Ministry of Health perspective (one year cycle length). The efficacy of the intervention was estimated from a meta-analysis of randomized controlled trials. A strategy of provision of hip protectors to all 60,775 elderly Ontario nursing home residents could result in an overall mean cost savings of 6.0 million Canadian dollars in one year (95% credibility interval, -26.4 million, 39.7 million), with a probability of cost savings of 0.63 (assuming no additional labor costs). In sensitivity analyses, decreasing hip protector price increased cost savings, whereas additional labor expenditures for application for hip protectors decreased cost savings. In conclusion, if hip protectors can be provided to elderly Ontario nursing home residents without additional labor expenditures, there is a reasonable probability that such a strategy may result in healthcare cost savings.

Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review

Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review

Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses

Objectives To evaluate the evidence for strategies to prevent falls or fractures in residents in care homes and hospital inpatients and to investigate the effect of dementia and cognitive impairment....

Do hip protectors decrease the risk of hip fracture in elderly?

Efforts aimed at preventing hip fractures include lifestyle advice for high-risk elderly, interventions to reduce the risk of falls and medication for osteoporosis. Alternative approach is the use of hip protectors. Hip protectors have pads designed to cover the greater trochanter and attenuate or disperse the force of a fall sufficiently to prevent a hip fracture. There are 14 randomized controlled trials (RCTs) included in the Cochrane systematic review until 2005. All RCTs were classified into three groups by the type of randomization; cluster randomized in institutions, individually randomized in institutions and individually randomized in community. There is little evidence to support the use of hip protectors outside the nursing home setting. Further research is required, primarily to produce a device that provide higher compliance, and which will then need to be tested in another RCT.

Effects of unipedal standing balance exercise on the prevention of falls and hip fracture

To prevent hip fracture there are three methods: 1) falls prevention, 2) treatment of osteoporosis and 3) hip protectors. The improvement of the osteoporosis of the proximal hip demands nutrition involved medication as bisphosphonate and mechanical stress. Unipedal standing captures the 2.75 times weight load to the femoral head. Unipedal standing for one minute is equivalent to the amount of integral load gained through walking for approximately 53 minutes. Unipedal standing balance exercise in one minute 3 times per one day is useful to create the proximal femoral bone density and to prevent falls but is not statistically definition to prevent hip fracture. We believe daily unipedal standing balance exercise should contribute toward overcoming prevention of hip fractures.

Prevalence and predictors of osteoporosis treatment in nursing home residents with known osteoporosis or recent fracture.

We studied nursing home residents with osteoporosis or recent fracture to determine the frequency and predictors of osteoporosis treatment. There was wide variation in performance, and both clinical and systems variables predicted use. This study shows that improvement in osteoporosis care is possible and important for many nursing homes. We determined the prevalence and predictors of osteoporosis evaluation and treatment in high-risk nursing home residents. We identified 67 nursing facilities in North Carolina and Arizona with > 10 residents with osteoporosis or recent hip fracture. Medical records (n=895) were abstracted for osteoporosis evaluation [dual-energy X-ray absorptiometry (DXA), vitamin D level, serum calcium), treatment (calcium, vitamin D, osteoporosis medication, hip protectors), clinical, and systems covariates. Data were analyzed at the facility level using mixed models to account for the complex nesting of residents within providers and nursing facilities. Calcium and vitamin D was prescribed for 69% of residents, bisphosphonates for 19%, calcitonin for 14%, other pharmacologic therapies for 6%, and hip protectors for 2%. Overall, 36% received any bone protection (medication or hip protectors), with wide variation among facilities (0-85%). Factors significantly associated with any bone protection included female gender [odds ratio (OR) 2.4, (1.5-3.7)] and nonurban/suburban location [1.5, (1.1-2.2)]. Residents with esophagitis, peptic ulcer disease (PUD), or dysphagia [0.6, (0.4-0.9)] and alcohol abuse [0.2, (0.0-0.9)] were less likely to receive treatment. There is substantial variation in the quality of osteoporosis treatment across nursing homes. Interventions that improve osteoporosis quality of care are needed.

Further exploring hip protector use

Objective: To explore hip protector adherence in high‐risk older people. Methods: In‐depth interviews were conducted with 14 older people (and/or their carers) discharged from hospital with hip protectors. Four outpatients were recruited to supplement numbers. Thematic analysis was carried out on the interview data. Results: Hip protector use largely paralleled daily dressing routines, this contributed to periods of disuse and partial adherence. Another factor in abandoning hip protector use was a fatalistic view of an end of life stage, where injury prevention was not actively sought. Committed carers who demonstrated understanding and support were vital in encouraging ongoing use. Conclusion: Daily routines of a lifetime, reluctance to change, and a readiness to endure the potential risk of hip fracture discouraged use of hip protectors. Family and carer support was vital for continuation. These findings can assist with strategies to improve adherence.

Promoting evidence‐based best practices for hip fracture prevention in residential aged care

Objectives: To evaluate the effect of advice about hip fracture prevention on clinical practice in residential aged care facilities (RACFs) and to survey consumer knowledge. Methods: Cluster randomised trial using modified two‐by‐two factorial design. Clinicians received written advice in three RACFs; online advice in three RACFs; both in three RACFs and three RACFs were controls. Free hip protectors were offered in one RACF from each intervention group. Consumer awareness and attitudes to hip fractures were surveyed. Results: Baseline rate of calcium plus vitamin D prescription was 3.5%. Information provision failed to produce a significant effect on clinical practice during 12‐week follow up. Offering free hip protectors was effective (P &lt; 0.0001), but was associated with lower compliance (P &lt; 0.05). Consumer awareness was low.Conclusions: Low rates of preventative interventions among residents at high risk of hip fracture were not increased by provision of advice to health professionals.

Can Hip Protector Use Cost‐Effectively Prevent Fractures in Community‐Dwelling Geriatric Populations?

To estimate the cost-effectiveness from a societal perspective of a hip protector (HP) program over the remaining lifetime of individuals initially living at home. A state-transition Markov model considering outcomes of HP use in cohorts stratified by age, sex, and functional and residential status. Costs, transition probabilities, HP adherence, and efficacy were derived from published sources. Community and nursing homes in the United States. Hypothetical cohort of individuals aged 65 and older without a hip fracture and initially living at home. HP program. Fractures, life years, and dollars saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER). HP use prevented fractures and increased life expectancy in all cohorts. HP use saved costs and improved QALYs in women initiating HP use at age 80 and in men at age 85. In women initiating HP use at age 75, the HP ICER was 19,000 dollars/QALY. In men initiating HP use at age 80, HP use saved costs but slightly decreased QALYs. In younger cohorts, HP use was neither cost saving nor QALY improving. In sensitivity analyses, if there was no QALY loss from wearing a HP, the ICER was less than 50,000 dollars/QALY for all age and sex cohorts. If HP cost was reduced 50%, HP use was cost saving for women initiating HP use at age 75. In probabilistic sensitivity analyses, the HP ICER was less than 50,000 dollars/QALY in 68% of simulations for women initiating HP use at age 75 and 61% of simulations for men initiating at age 85. HP use saved costs and QALYs for older age cohorts of both sexes. Additional research on the quality-of-life effects and obstacles to wearing HP is warranted.

Examining the efficacy of hip protectors

Hip protectors are suggested as a cheap way to reduce fractures.

Ostéoporose chez le sujet âgé

Osteoporosis is a frequent disease among the elderly and has major consequences in terms of mortality, morbidity and cost. Guidelines for diagnostic procedures are often difficult to apply in frail, elderly patients with multiple comorbidities. Bisphosphonates are the reference treatment for the elderly, combined with vitamin D and calcium supplementation. Vitamin D deficiency must also be treated to prevent falls and fractures. Strontium ranelate is a promising treatment in this population. Fall prevention is a major part of osteoporosis management. The potential benefit of hip protectors is questionable, even in institutionalized patients.

Health Care Provider Awareness and Perceptions of Hip Protectors: Results from a Pilot Survey

Hip fracture is a serious and increasing problem for the elderly population. A variety of currently marketed devices are intended to reduce the risk of hip fracture by shunting the force of a fall away from the greater trochantor. While some of these hip protectors have been evaluated, most have not. Moreover, there are no design standards for the manufacture of hip protectors or criteria for testing their effectiveness, comfort, and durability. Because hip protectors can be purchased without a prescription, it is important that health care providers be in a position to provide informed advice to their elderly patients at risk for falling. To explore health care providers' knowledge and perceptions of hip protectors, we conducted a pilot mailed survey of selected categories of physicians and non-physicians in Rhode Island, eastern Connecticut and southeastern Massachusetts. Our findings suggest that many U.S. health care providers have little or no knowledge of hip protectors, although most believe such devices could have potential benefit for elderly patients.

Prevention of hip fracture with hip protectors

The prevention of fractures amongst older people consists of (i) prevention and treatment of osteoporosis, (ii) prevention of falling and (iii) prevention of fractures using injury-site protection. As the great majority of hip fractures are caused by a sideways fall with direct impact on the greater trochanter of the proximal femur, one approach to prevention is the use of an adequately configured padded, firm-shield external hip protector. With this type of two-part design, the impacting force and energy are, at the time of the fall-impact, first weakened by the padding part of the protector and then diverted away from the greater trochanter by the shield part of the same. Following this line, a series of consecutive studies by the Accident & Trauma Research Center at the UKK Institute, Tampere, Finland, found that a padded, strong-shield hip protector was effective in preventing hip fractures. In the context of the wider literature on hip protectors, these more encouraging results suggest the need for a more rigorous regulation of protector design and characteristics. Alongside inadequacies of design, the other most frequent general problem with hip protectors is compliance. Not all elderly people with a high risk of hip fracture will agree to use hip protectors and in those who do, long-term adherence may decrease. Caregiver motivation and involvement appear therefore to be crucial.

Progress in external hip protectors

Hip fractures are a major cause of disability, impairment and death in elderly people. It has been reported that bisphosphonates significantly reduce the risk of hip fracture among elderly women with confirmed osteoporosis but not among elderly women selected primarily on the basis of risk factors other than low bone mineral density. External hip protectors have been developed as a measure of reducing the impact of the fall and thereby the chance of hip fractures in such high risk people. The results of 14 randomized controlled trials for the prevention of hip fractures by using hip protectors have been reported until 2004. However, Cochrane review of hip protectors has concluded that their effectiveness is uncertain. Although further research is required with different conditions, the most important issue of hip protectors is the low adherence rate.

Hip protectors in the elderly: lack of effectiveness or just suboptimal implementation?

Abstract Hip protectors seemed to be the only non-pharmacological intervention to effectively prevent hip fractures in high-risk populations. In contrast, recently published trials did not find hip fracture reduction through hip protector interventions. An updated Cochrane review concluded that the device is ineffective for community-dwelling elderly and of uncertain effectiveness for institutionalised elderly. However, some primary studies used suboptimal implementation of hip protectors, which has led to low adherence and ineffectiveness of the intervention. Shortcomings in implementation techniques have not been assessed by the Cochrane review. Therefore, reviewers should explicitly assess whether the intervention was well planned and competently administered. As a checklist cannot adequately assess individual, study-specific implementation flaws, we suggest narrative expert review and feedback to the authors of the primary study.

MEASURING EXPECTED OUTCOMES OF FALLS

To the Editor: Commenting on the recent paper “Measuring the Psychological Outcomes of Falling: A Systematic Review,”1 Dr. Lach noted that it is necessary to supplement measures of self-efficacy (in this context, the belief in one's capability to carry out daily activities without falling) with measures of outcome expectancies (such as beliefs about the likely consequences of falling).2 This is quite correct, and we would like to point out that in the systematic review of measures of psychological outcomes of falling, one of the measures described is indeed a measure of outcome expectancies. The “Consequences of Falling” scale3 assesses expectations that falling will result in two types of outcome, which both predict restriction of activity. The first consists of the immediate and psychosocial consequences of falling, such as social embarrassment and indignity, and consequent damage to personal confidence and identity. The second comprises expectations of physical harm and consequent lasting functional disability and loss of independence. The authors of the review suggest that measures of the psychological consequences of falls are a potentially important endpoint for clinical trials of interventions to prevent falls. They note that measures of self-efficacy (such as the Falls Efficacy Scale4 and the Falls Efficacy Scale—International5,6) may be particularly useful, because they are based on Bandura's well-validated Social Cognitive Theory.7 Although Bandura proposes that outcome expectancies are also important, it is likely that clinical interventions will have different effects on these two constructs. Interventions that are intended to reduce the risk of falling can improve self-efficacy8 (i.e., confidence in carrying out daily activities without falling) but may not affect perceived outcomes of falling. Interventions specifically designed to reduce fear of falling9,10 also have the potential to influence outcome expectancies by addressing concerns about the ability to cope with physical and psychosocial consequences of falling. To minimize falls-related disability and fear, it may be beneficial to intervene simultaneously to reduce the risk of falling, which will improve self-efficacy, and to reduce the negative consequences of falling, which will improve outcome expectancies. Interventions such as strength and balance training, Tai Chi, and home hazard reduction have the potential to reduce falls risk and increase self-efficacy. Interventions such as hip protectors, dietary supplements to maintain bone strength, and training in rising after a fall have the potential to reduce the negative consequences of falling and improve outcome expectancies. Financial Disclosure(s): None. Author Contributions: Both authors contributed to writing this letter. Sponsor's Role: None.