Risk for Hip or Femur Fracture Doubled in Stroke Patients
Risk for Hip or Femur Fracture Doubled in Stroke Patients
August 6, 2009 — A new study suggests that the risk for fracture of the hip or femur is doubled among patients with a history of stroke, compared with matched individuals with no stroke history. The risk was highest for patients who were younger than 71 years, for women, and for those whose stroke had occurred within the previous 3 months, the authors report.
"Our findings imply that it is important to conduct fracture risk assessment immediately after a patient is hospitalized for stroke," senior author Frank de Vries, PharmD, PhD, from the University of Utrecht in the Netherlands, and colleagues conclude.
"We know from other studies that bone loss starts rapidly after stroke," Dr. de Vries told Medscape Neurology. Evidence supports the use of strategies, including bisphosphonates, vitamin D, and increased mobility, to retain motor function, he said, as well as fall-prevention programs and the judicious use of drugs such as hypnotics or antihypertensive agents that may increase the risk for falls in these patients, he added.
Their report is published online August 6, and is scheduled to appear in the October issue of Stroke.
Osteoporosis a Serious Complication
Osteoporosis has been recognized as a serious complication after stroke, the authors write. Stroke has been associated with an increase in hip fractures up to 4-fold in various studies, and studies of bone-mineral density (BMD) after stroke have shown a rapid onset of significant bone loss on the paretic side, particularly for those with the most severe functional deficits.
Previous studies, however, haven't examined the time course of this increased risk for fracture after stroke, have adjusted for only a limited number of confounders, and didn't distinguish between ischemic and hemorrhagic stroke.
To look at this question, the authors carried out a case–control study using the Dutch PHARMO Record Linkage System database. A total of 6763 patients with a first fracture of the hip or femur were identified, and they were matched for age, sex, and region of residence with up to 4 control subjects without such fractures.
After adjustment for a variety of confounding risk factors for fracture, an increased risk for hip and femur fractures was seen in patients who had had a stroke any time before the index date, defined as the date of first hospital admission for a first hip or femur fracture, compared with control subjects, they report.
The risk was highest for patients who had sustained a stroke within 3 months of their first hip/femur fracture admission, and was higher for female patients and those younger than 71 years.
Risk for Hip/Femur Fracture Associated With Stroke
Although it is not clear why younger stroke patients have a higher fracture risk, the authors speculate that older patients have other competing risk factors for hip fracture. "It's likely, therefore, that the overall contribution of stroke to hip fracture risk declines with age," Dr. de Vries said.
There was also a tendency for those with hemorrhagic stroke to have a higher hip/femur fracture risk than those with ischemic stroke, they note, but this difference did not reach statistical significance.
"Fall-prevention programs, BMD measurements, and use of bisphosphonates may be necessary to minimize hip fractures in the elderly during and after stroke rehabilitation," Dr. de Vries and colleagues conclude. Bisphosphonates have been shown in a randomized trial in an Asian population to reduce bone loss and hip fracture risk at 1 year when begun immediately after stroke, he added.
Vitamin D supplementation, increasing mobility, and correcting deformities that limit normal gait should also be considered, along with fall-prevention strategies such as use of a walking aid, choosing shoes with broad heels and nonslip soles, and minimizing obstacles around the home, he said. "In general, all treatments should be started as soon as possible," he concluded.
Figures from the National Osteoporosis Foundation show that almost 300,000 people have a hip fracture in the United States each year, and of those, 20% die within a year of the fracture, according to a release from the American Heart Association/American Stroke Association. In this study, the authors weren't able to assess whether mortality risk was higher for fracture patients with or without stroke, they note. In addition, stroke patients were included whether or not they had hemiplegia, which has previously been shown, perhaps not surprisingly, to affect fracture risk.
Not on the Radar
Asked for comment on these findings, Philip B. Gorelick, MD, MPH, director of the Center for Stroke Research at the University of Illinois College of Medicine in Chicago, pointed out that stroke patients are already substantially burdened by functional limitations, cognitive complications, psychological sequelae, and economic consequences of their illness.
"This very large case–control study . . . from the Netherlands provides evidence that stroke patients may be saddled with an additional burden — the risk of fracture of the hip and femur," Dr. Gorelick said. This risk might not be clear to many healthcare professionals, he noted.
"Whereas stroke patients are considered at risk for falls, the reality of the possibility of hip and femur fracture may not be on the healthcare professionals' radar screen," he told Medscape Neurology. "Development of hip and femur fracture prevention programs for stroke patients should be considered, and the possible beneficial role of bone-mineral-density screening and use of interventions, such as drug or other bone-fracture preventatives, should be considered for rigorous scientific study."
The Department of Pharmacoepidemiology and Pharmacotherapy that employs the authors has received unrestricted funding for pharmacoepidemiological research from GlaxoSmithKline, Novo Nordisk, the private-public-funded Top Institute Pharma, which includes cofunding from universities, government, industry, the Dutch Medicines Evaluation Board, and the Dutch Ministry of Health. Dr. de Vries and coauthor Dr. Tjeerd van Staa work for the General Practice Research Database, which is owned by UK Department of Health.
Stroke. Published online before print August 6, 2009.
August 6, 2009 — A new study suggests that the risk for fracture of the hip or femur is doubled among patients with a history of stroke, compared with matched individuals with no stroke history. The risk was highest for patients who were younger than 71 years, for women, and for those whose stroke had occurred within the previous 3 months, the authors report.
"Our findings imply that it is important to conduct fracture risk assessment immediately after a patient is hospitalized for stroke," senior author Frank de Vries, PharmD, PhD, from the University of Utrecht in the Netherlands, and colleagues conclude.
"We know from other studies that bone loss starts rapidly after stroke," Dr. de Vries told Medscape Neurology. Evidence supports the use of strategies, including bisphosphonates, vitamin D, and increased mobility, to retain motor function, he said, as well as fall-prevention programs and the judicious use of drugs such as hypnotics or antihypertensive agents that may increase the risk for falls in these patients, he added.
Their report is published online August 6, and is scheduled to appear in the October issue of Stroke.
Osteoporosis a Serious Complication
Osteoporosis has been recognized as a serious complication after stroke, the authors write. Stroke has been associated with an increase in hip fractures up to 4-fold in various studies, and studies of bone-mineral density (BMD) after stroke have shown a rapid onset of significant bone loss on the paretic side, particularly for those with the most severe functional deficits.
Previous studies, however, haven't examined the time course of this increased risk for fracture after stroke, have adjusted for only a limited number of confounders, and didn't distinguish between ischemic and hemorrhagic stroke.
To look at this question, the authors carried out a case–control study using the Dutch PHARMO Record Linkage System database. A total of 6763 patients with a first fracture of the hip or femur were identified, and they were matched for age, sex, and region of residence with up to 4 control subjects without such fractures.
After adjustment for a variety of confounding risk factors for fracture, an increased risk for hip and femur fractures was seen in patients who had had a stroke any time before the index date, defined as the date of first hospital admission for a first hip or femur fracture, compared with control subjects, they report.
The risk was highest for patients who had sustained a stroke within 3 months of their first hip/femur fracture admission, and was higher for female patients and those younger than 71 years.
Risk for Hip/Femur Fracture Associated With Stroke
| Group | Odds Ratio | 95% CI |
| Any stroke prior to index date | 1.96 | 1.65 - 2.33 |
| Stroke within 3 months of index date | 3.35 | 1.87 - 5.97 |
| Female stroke patients | 2.12 | 1.73 - 2.59 |
| Stroke patients younger than 71 years | 5.12 | 3.00 - 8.75 |
Although it is not clear why younger stroke patients have a higher fracture risk, the authors speculate that older patients have other competing risk factors for hip fracture. "It's likely, therefore, that the overall contribution of stroke to hip fracture risk declines with age," Dr. de Vries said.
There was also a tendency for those with hemorrhagic stroke to have a higher hip/femur fracture risk than those with ischemic stroke, they note, but this difference did not reach statistical significance.
"Fall-prevention programs, BMD measurements, and use of bisphosphonates may be necessary to minimize hip fractures in the elderly during and after stroke rehabilitation," Dr. de Vries and colleagues conclude. Bisphosphonates have been shown in a randomized trial in an Asian population to reduce bone loss and hip fracture risk at 1 year when begun immediately after stroke, he added.
Vitamin D supplementation, increasing mobility, and correcting deformities that limit normal gait should also be considered, along with fall-prevention strategies such as use of a walking aid, choosing shoes with broad heels and nonslip soles, and minimizing obstacles around the home, he said. "In general, all treatments should be started as soon as possible," he concluded.
Figures from the National Osteoporosis Foundation show that almost 300,000 people have a hip fracture in the United States each year, and of those, 20% die within a year of the fracture, according to a release from the American Heart Association/American Stroke Association. In this study, the authors weren't able to assess whether mortality risk was higher for fracture patients with or without stroke, they note. In addition, stroke patients were included whether or not they had hemiplegia, which has previously been shown, perhaps not surprisingly, to affect fracture risk.
Not on the Radar
Asked for comment on these findings, Philip B. Gorelick, MD, MPH, director of the Center for Stroke Research at the University of Illinois College of Medicine in Chicago, pointed out that stroke patients are already substantially burdened by functional limitations, cognitive complications, psychological sequelae, and economic consequences of their illness.
"This very large case–control study . . . from the Netherlands provides evidence that stroke patients may be saddled with an additional burden — the risk of fracture of the hip and femur," Dr. Gorelick said. This risk might not be clear to many healthcare professionals, he noted.
"Whereas stroke patients are considered at risk for falls, the reality of the possibility of hip and femur fracture may not be on the healthcare professionals' radar screen," he told Medscape Neurology. "Development of hip and femur fracture prevention programs for stroke patients should be considered, and the possible beneficial role of bone-mineral-density screening and use of interventions, such as drug or other bone-fracture preventatives, should be considered for rigorous scientific study."
The Department of Pharmacoepidemiology and Pharmacotherapy that employs the authors has received unrestricted funding for pharmacoepidemiological research from GlaxoSmithKline, Novo Nordisk, the private-public-funded Top Institute Pharma, which includes cofunding from universities, government, industry, the Dutch Medicines Evaluation Board, and the Dutch Ministry of Health. Dr. de Vries and coauthor Dr. Tjeerd van Staa work for the General Practice Research Database, which is owned by UK Department of Health.
Stroke. Published online before print August 6, 2009.
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