COCHRANE CORNER
Hip Protectors for Preventing Hip Fractures in Older People Cindy Stern
REVIEW QUESTION: Do external hip protectors reduce the risk of hip fracture in older people?
Nursing Implications Hip fracture, resulting from a fall, occurs more frequently in older people primarily because of factors associated with aging. The combination of the hip fracture and other medical problems can lead to serious morbidity and mortality. Hip protectors can be used as a preventive measure to minimize the risk of a hip fracture.
Study Characteristics This is a summary of a recently updated Cochrane systematic review containing 19 randomized or quasirandomized controlled trials (nine were cluster randomized) comprising approximately 17,000 people. Participants were older people (generally defined as 65 years or older) living either in residential care or in the community setting. The mean age range was 78–86 years. The intervention of interest was the use of hip protectors (either hard or soft that were commonly situated in specially designed underwear). These were compared to controls (people not provided with hip protectors). Trials including the use of hip protectors that were just one component of a larger program aimed to reduce hip fractures were excluded. The primary outcomes were risk of sustaining a hip fracture, risk of sustaining a pelvic fracture, overall rate of pelvic and other fractures, and rate of fall events. Secondary outcomes were acceptance and adherence to the hip protector, complications, and economic outcomes. Most studies were undertaken in Europe and Australia. Follow-up was measured at up to 28 months, but most outcomes were measured at 1 year. Generally selection bias, attrition bias, and reporting bias were considered at low risk. Performance bias (blinding) was obviously an issue and as such had a high risk of bias. Meta-analysis was undertaken where possible. • Summary of key evidence 䡬 A small decrease in hip fracture risk was demonstrated with the use of hip protectors in 14 studies of participants from residential care settings (risk ratio [RR] = 0.82; 95% confidence © 2014 by National Association of Orthopaedic Nurses
intervals [CI] [0.67, 1.00]). It was noted that the CIs included both no effect and a benefit of the intervention. The reviewers went on to calculate an absolute effect of 11 per 1,000 that suggests that 11 fewer people per 1,000 will have a hip fracture when provided with hip protectors. 䡬 There was no significant reduction in hip fracture risk in participants living in the community (five trials). 䡬 There was a nonsignificant increase in pelvic fractures (RR = 1.27; 95%CI [0.78, 2.08]; nine trials). In terms of absolute effect, this was 1 per 1,000. 䡬 There was also no significant difference between interventions and controls regarding falls (16 trials) or other fractures besides the hip or pelvis (six trials). 䡬 Adverse events were reported in 12 studies and included skin irritation (0%–5% reported). Adherence to wearing hip protectors was reported in 19 studies and ranged from 24% to 80%. • Best practice recommendations Current evidence suggests that the provision of hip protectors is likely to slightly reduce the risk of hip fracture in older people living in residential care settings. There seems to be little or no effect on falls, other fractures, and adverse events. The risk of pelvic fractures may slightly increase; however, this is based on lowquality evidence. The use of hip protectors in the community seems to have little or no effect on hip fracture. Adherence to long-term use is an issue.
REFERENCE Santesso, N., Carrasco-Labra, A., & Brignardello-Petersen, R. (2014). Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews, (3), Art. No.: CD001255. DOI: 10.1002/1465 1858.CD001255.pub5. The full text can be viewed at http://onlinelibrary.wiley.com/doi/10.1002/14651858 .CD001255.pub5/abstract Cindy Stern, BHSc (Hons), PhD, Senior Research Fellow, The School of Translational Health Science, The University of Adelaide, Adelaide, Australia. Cindy Stern is the coordinator of the Cochrane Nursing Care Field (CNCF). The author has disclosed no conflicts of interest. DOI: 10.1097/NOR.0000000000000079
Orthopaedic Nursing
•
September/October 2014
•
Volume 33
• Number 5 297
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ725_LR 297
9/13/14 10:45 AM
Hip Protectors for Preventing Hip Fractures in Older People Cindy Stern
REVIEW QUESTION: Do external hip protectors reduce the risk of hip fracture in older people?
Nursing Implications Hip fracture, resulting from a fall, occurs more frequently in older people primarily because of factors associated with aging. The combination of the hip fracture and other medical problems can lead to serious morbidity and mortality. Hip protectors can be used as a preventive measure to minimize the risk of a hip fracture.
Study Characteristics This is a summary of a recently updated Cochrane systematic review containing 19 randomized or quasirandomized controlled trials (nine were cluster randomized) comprising approximately 17,000 people. Participants were older people (generally defined as 65 years or older) living either in residential care or in the community setting. The mean age range was 78–86 years. The intervention of interest was the use of hip protectors (either hard or soft that were commonly situated in specially designed underwear). These were compared to controls (people not provided with hip protectors). Trials including the use of hip protectors that were just one component of a larger program aimed to reduce hip fractures were excluded. The primary outcomes were risk of sustaining a hip fracture, risk of sustaining a pelvic fracture, overall rate of pelvic and other fractures, and rate of fall events. Secondary outcomes were acceptance and adherence to the hip protector, complications, and economic outcomes. Most studies were undertaken in Europe and Australia. Follow-up was measured at up to 28 months, but most outcomes were measured at 1 year. Generally selection bias, attrition bias, and reporting bias were considered at low risk. Performance bias (blinding) was obviously an issue and as such had a high risk of bias. Meta-analysis was undertaken where possible. • Summary of key evidence 䡬 A small decrease in hip fracture risk was demonstrated with the use of hip protectors in 14 studies of participants from residential care settings (risk ratio [RR] = 0.82; 95% confidence © 2014 by National Association of Orthopaedic Nurses
intervals [CI] [0.67, 1.00]). It was noted that the CIs included both no effect and a benefit of the intervention. The reviewers went on to calculate an absolute effect of 11 per 1,000 that suggests that 11 fewer people per 1,000 will have a hip fracture when provided with hip protectors. 䡬 There was no significant reduction in hip fracture risk in participants living in the community (five trials). 䡬 There was a nonsignificant increase in pelvic fractures (RR = 1.27; 95%CI [0.78, 2.08]; nine trials). In terms of absolute effect, this was 1 per 1,000. 䡬 There was also no significant difference between interventions and controls regarding falls (16 trials) or other fractures besides the hip or pelvis (six trials). 䡬 Adverse events were reported in 12 studies and included skin irritation (0%–5% reported). Adherence to wearing hip protectors was reported in 19 studies and ranged from 24% to 80%. • Best practice recommendations Current evidence suggests that the provision of hip protectors is likely to slightly reduce the risk of hip fracture in older people living in residential care settings. There seems to be little or no effect on falls, other fractures, and adverse events. The risk of pelvic fractures may slightly increase; however, this is based on lowquality evidence. The use of hip protectors in the community seems to have little or no effect on hip fracture. Adherence to long-term use is an issue.
REFERENCE Santesso, N., Carrasco-Labra, A., & Brignardello-Petersen, R. (2014). Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews, (3), Art. No.: CD001255. DOI: 10.1002/1465 1858.CD001255.pub5. The full text can be viewed at http://onlinelibrary.wiley.com/doi/10.1002/14651858 .CD001255.pub5/abstract Cindy Stern, BHSc (Hons), PhD, Senior Research Fellow, The School of Translational Health Science, The University of Adelaide, Adelaide, Australia. Cindy Stern is the coordinator of the Cochrane Nursing Care Field (CNCF). The author has disclosed no conflicts of interest. DOI: 10.1097/NOR.0000000000000079
Orthopaedic Nursing
•
September/October 2014
•
Volume 33
• Number 5 297
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ725_LR 297
9/13/14 10:45 AM
