Elsevier

Bone

Volume 90, September 2016, Pages 116-122
Bone

Review Article
Frailty as a predictor of fractures among community-dwelling older people: A systematic review and meta-analysis

https://doi.org/10.1016/j.bone.2016.06.009Get rights and content

Highlights

  • Fractures can cause detrimental physical and psychological impacts on older people.

  • Frailty may predict fracture, sharing various risk factors with osteoporosis.

  • The associations between frailty and fractures in the literature are inconsistent.

  • This study showed that frailty and prefrailty are significant predictors of fractures.

  • Treating frailty and prefrailty may lead to lowering the fracture risks.

Abstract

Purpose

To identify prospective studies examining associations between frailty and fractures and to combine the risk measures to synthesize pooled evidence on frailty as a predictor of fractures among community-dwelling older people.

Methods

A systematic literature search was conducted using five databases: Embase, MEDLINE, CINAHL Plus, PsycINFO, and the Cochrane Library for prospective studies on associations between frailty and fracture risk published from 2000 to August 2015 without language restriction. Odds ratios (OR) and hazard ratios (HR) extracted from the studies or calculated from available data were combined to synthesize pooled effect measures using random-effects or fixed-effects models. Heterogeneity, methodological quality, and publication bias were assessed. Meta-regression analyses were performed to explore the cause of high heterogeneity.

Results

Of 1305 studies identified, six studies involving 96,564 older people in the community were included in this review. Frailty and prefrailty were significantly associated with future fractures among five studies with OR (pooled OR = 1.70, 95% confidence interval (95% CI) = 1.34–2.15, p < 0.0001; pooled OR = 1.31, 95% CI = 1.18–1.46, p < 0.00001, respectively) and four studies with HR (pooled HR = 1.57, 95% CI = 1.31–1.89, p < 0.00001; pooled HR = 1.30, 95% CI = 1.12–1.51, p = 0.0006, respectively). High heterogeneity was observed among five studies with OR of frailty (I2 = 66%). The studies from the United States were found to have a higher fracture risk than from those from other countries in a meta-regression model (regression coefficient = 0.39, p = 0.04). No evidence of publication bias was identified.

Conclusions

This systematic review and meta-analysis showed evidence that frailty and prefrailty are significant predictors of fractures among community-dwelling older people. Treating frailty may potentially lead to lowering fracture risks.

Introduction

Fractures are becoming more prevalent as the population ages and the number and proportion of older people grow worldwide [1], [2], [3]. Approximately 50% of women and 20% of men aged 50 years and older are estimated to have a fracture during the rest of their lives [2]. Fractures can have detrimental impacts physically and mentally on older people and contribute to healthcare burden and costs. In particular, those who sustain hip fractures are often hospitalized for treatment including surgery, which is frequently followed by reduced mobility, functional disabilities, increased dependence, nursing home placement, chronic pain, and high mortality [4]. Fractures have been a major public health concern due to their substantial morbidity and mortality as well as the economic costs.

Osteoporosis is a well-known major risk factor for fragility fractures. Osteoporosis is characterized by low bone mass and microarchitectural deterioration of bone tissue, increasing bone fragility and predisposing older people to an increased fracture risk [5]. Osteoporosis is diagnosed by the presence of fragility fractures or if the bone mineral density of the spine, hip, or wrist is 2.5 standard deviations or more below the reference mean based on the WHO criteria [5].

Frailty, another age-related geriatric syndrome of decreased resistance to stressors and vulnerability to adverse health outcomes due to multisystem impairment [6], [7], [8], [9], [32], [33], shares various risk factors and physiological pathways with osteoporosis, including advanced age, low body weight, low physical activity, sarcopenia, inflammation, and vitamin D deficiency [6], [10], [11]. Although the relationship between frailty and osteoporosis is not clear, and they may be merely distinct age-related phenomena, some studies showed possible associations [10], [11], [12]. Fried et al. defined frailty as having three or more of the five criteria: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity in the Cardiovascular Health Study (CHS) [13]. Whereas fracture was not examined in this study, several studies have later investigated associations between frailty and fractures and inconsistently shown significant and non-significant results [14], [15], [16], [17], [18], [19], [20], [21]. These studies used various frailty criteria and different types of fractures, which makes it difficult to reach the conclusions on frailty as a predictor of fractures. To the best of my knowledge, no systematic review or meta-analysis on associations between frailty and fractures has been conducted. Thus, the objectives of this study were to conduct a systematic search of the literature for prospective cohort studies examining frailty as a predictor of fractures among community-dwelling older people and to perform a meta-analysis to combine the risk measures to synthesize pooled estimates.

Section snippets

Data sources and search strategy

A literature search was systematically conducted in accordance with a protocol developed within the scope of Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) [22] and Meta-analysis of Observational Studies in Epidemiology (MOOSE) [23] statements. Five electronic databases: Embase, CINAHL Plus, MEDLINE, PsycINFO, and the Cochrane Library, were searched in August 2015 without language restriction for prospective cohort studies examining associations between frailty and a

Selection processes

The systematic search of the literature using the five electronic databases identified 1304 studies, and one study was found from another source. Among them, 458 studies were excluded because they were duplicates, and 822 studies were excluded through title and abstract screening, leaving 25 studies for full-text review. Of these studies, 19 were excluded because they were letters, comments, editorials, or conference abstracts (n = 9), used the same cohorts (n = 5), used non-validated frailty

Discussion

The pooled data from the six studies involving 96,564 community-dwelling older people suggested that both frailty and prefrailty were significant predictors of fractures. It was suggested that study location may have had an effect on the degree of fracture risks.

No international consensus has been reached regarding a definition of frailty [6]. A wide array of definitions and criteria have been developed and used in clinical and research settings [26]. The CHS criteria are frequently used

Conclusion

This systematic review and meta-analysis provide evidence that frailty is a significant predictor of future fractures among community-dwelling older people. Given that frailty and prefrailty can be reversed or improved by interventions [6], [31], treating frailty and prefrailty may lead to lowering fracture risks.

Conflict of interest

None.

Acknowledgment

This research received no specific financial support from any funding agency in the public, commercial, or not-for-profit sectors.

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