USPSTF Draft Recommendations Address Falls, Fractures

September 28, 2017 04:22 pm Chris Crawford

One out of three adults ages 65 and older falls at least once a year, which can lead to moderate to severe injuries, including fractures, decreased mobility and even death.  

[Older adults exercising]

On Sept. 26, to address this issue, the U.S. Preventive Services Task Force (USPSTF) posted two draft recommendation statements and draft evidence reviews on the prevention of falls and fractures in older adults.

Interventions to Prevent Falls

First, the USPSTF issued a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on interventions to prevent falls in community-dwelling older adults.

Based on its review of the evidence, for adults ages 65 and older who live at home and are at increased risk of falls, the task force recommended that  

Story highlights
  • On Sept. 26, the U.S. Preventive Services Task Force (USPSTF) posted two draft recommendation statements and draft evidence reviews on the prevention of falls and fractures in older adults.
  • Based on its review of the evidence, for adults ages 65 and older who live at home and are at increased risk of falls, the USPSTF recommended exercise and that physicians selectively offer multifactorial interventions based on the balance of benefits and harms for a patient.
  • In a separate draft recommendation, the task force said there wasn't enough evidence about the benefits and harms of vitamin D and calcium supplementation, alone or combined, to prevent fractures in men or premenopausal women or to recommend for or against supplementation with higher doses of vitamin D and calcium in community-dwelling, postmenopausal women.  
  • patients exercise -- a "B" recommendation(www.uspreventiveservicestaskforce.org); and
  • physicians selectively offer multifactorial interventions based on the balance of benefits and harms for a patient, considering prior falls, presence of comorbid conditions and the patient's preference -- a "C" recommendation.

For adults ages 65 and older who live at home but aren't necessarily at increased risk of falls, the USPSTF recommended against vitamin D supplementation to prevent falls -- a "D" recommendation.

"Falls can cause significant injuries in older adults, so preventing falls is important to maintaining their physical well-being. We found that exercise can help prevent falls," said USPSTF member Alex Krist, M.D., M.P.H., in a news release(www.uspreventiveservicestaskforce.org).

The task force found five good-quality and 16 fair-quality studies reporting on various exercise interventions to prevent falls, with more than half recruiting populations at high risk for falls. Six studies were conducted exclusively in women.

"Physical function/mobility limitation problems" was the most common risk factor used to identify participants at high risk. Studies included from 55 to 1,635 participants with a mean age range of 68-88 years. Collectively, these studies found that exercise improved several fall-related outcomes.

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that exercise to prevent falls doesn't have to be strenuous, cardiovascular exercise. Rather, the focus should be on improving strength and balance.

For the draft recommendation on multifactorial interventions to prevent falls in adults ages 65 and older at increased risk for falls, Frost said the evidence supporting multifactorial interventions showed a small reduction in the number of falls per individual, but not a decrease in total individuals experiencing falls.

"More importantly, it didn't show any reduction in the number of falls causing injury," she said. "An older person who has experienced multiple falls might benefit from multifactorial interventions, but they would have a limited impact for most older adults."

Finally, the draft evidence report supporting the recommendation against vitamin D supplementation to prevent falls in adults ages 65 and older who live at home included multiple studies that evaluated whether vitamin D supplementation reduced the risk of falls.

"Only one of these studies showed a reduction in falls, five studies showed no reduction and one study showed an increase in falls," Frost said. "When all of the data was pooled, there was no effect on falls with vitamin D supplementation."

This draft recommendation statement updates the USPSTF's 2012 final recommendation statement. The recommendations for exercise and multifactorial interventions are consistent with the previous final recommendations; however, based on the current evidence, the task force now recommends against taking vitamin D to prevent falls.

Supplementation to Prevent Fractures

Separately, the USPSTF issued a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on supplementation for the primary prevention of fractures in community-dwelling adults who have no history of fractures related to osteoporosis.

Based on its review of the evidence, the task force found there was insufficient evidence to recommend for or against

  • vitamin D and calcium supplementation, alone or combined, to prevent fractures in men or premenopausal women -- an "I" statement; and
  • supplementation with higher doses of vitamin D and calcium (greater than 400 IU of vitamin D and greater than 1,000 mg of calcium) in community-dwelling, postmenopausal women – also an "I" statement.

Additionally, the USPSTF recommended against daily supplementation at lower doses (400 IU or less of vitamin D and 1,000 mg or less of calcium) for the primary prevention of fractures in community-dwelling, postmenopausal women -- a "D" recommendation.

The task force reviewed evidence from eight randomized, controlled trials on vitamin D, calcium or combined supplementation for the primary prevention of fractures. Four of these evaluated vitamin D supplementation, two evaluated calcium supplementation and two evaluated combined vitamin D and calcium supplementation.

Four studies represented data from 5,900 men and four were limited to women, with almost 42,000 women analyzed across all eight studies. The mean age of study participants ranged from 53-80 years.

"We need more research to understand whether taking higher doses of vitamin D or calcium helps to prevent fractures in women who have gone through menopause -- or at any dose for men or younger women," said USPSTF member Carol Mangione, M.D., M.S.P.H., in the release. "We do know that lower doses of these supplements do not prevent fractures in women who have gone through menopause."

This draft recommendation statement is consistent with the USPSTF's 2013 final recommendation.

Up Next

The USPSTF is inviting comments on its draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on interventions for fall prevention in community-dwelling older adults.

The task force also is inviting comments on its draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) for supplementation for the primary prevention of fractures in adults.

The public comment window for the draft recommendations and draft evidence reviews is open until 8 p.m. EDT on Oct. 23. All comments received will be considered as the task force prepares its final recommendation.

The AAFP will review the USPSTF's draft recommendation statements and supporting evidence and provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.

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