In older adults, does a recent hip fracture increase the risk of subsequent falls?

Does a Recent Hip Fracture Increase the Risk of Falls?

Yes, a recent hip fracture substantially increases the risk of subsequent falls, with over half of older adults experiencing at least one fall within 6 months after hospital discharge.

Magnitude of Fall Risk After Hip Fracture

The evidence demonstrates a markedly elevated fall risk following hip fracture:

• 53.3% of community-dwelling older adults reported one or more falls within 6 months after hospitalization for hip fracture 1
• 11.8% of patients fell during the rehabilitation period itself, with risk peaking in the middle of the second week when patients gain mobility but lack adequate stability 2
• This represents a substantially higher fall rate compared to age-matched controls who have not experienced hip fracture 3

Why Hip Fracture Patients Are at Higher Risk

Hip fracture patients demonstrate multiple physiological impairments that directly increase fall risk:

Physical Function Deficits

• Markedly reduced quadriceps strength compared to non-fallers, which is the most important distinguishing factor 3
• Increased postural sway on both firm and compliant surfaces, with body sway on compliant surfaces being a critical predictor 3
• These two variables alone (quadriceps strength and postural sway) correctly classified 92% of hip fracture cases versus controls 3

Functional Decline

• Greater declines in independence with activities of daily living (ADL) among those who fall post-discharge 1
• Lower performance on balance and mobility measures at 6 months post-fracture 1
• Decline in unaffected limb quadriceps muscle endurance is a crucial predictor of falls in the first postoperative year 4

Additional Risk Factors

• Prefracture fall history is a strong predictor of postdischarge falls 1
• Use of gait devices predicts subsequent falls 1
• Advanced age and more severe depressive symptoms predict multiple falls rather than single falls 4
• Nocturnal urinary incontinence increases fall risk during rehabilitation 2

Clinical Implications and Management

Risk Assessment Framework

According to current guidelines, initial fall risk assessment in adults at high risk of fragility fracture should focus on 5:

• Any history of falls within the past 12 months
• Fear of falling
• Feeling unsteady while walking or standing

A positive response in any of these areas mandates a multifactorial falls-risk assessment incorporating evaluation of gait, mobility (e.g., Timed Up and Go test), balance, lower limb strength, medication review, cognitive capacity, footwear, and environmental factors 5

Evidence-Based Interventions

Multicomponent exercise interventions incorporating progressive resistance training, strength, and balance training are essential 5:

• Structured exercise interventions following hip fracture surgery result in small but significant improvements in mobility and physical function 5
• Multicomponent exercise incorporating dynamic weight-bearing, strength, and balance training undertaken 2-3 days per week for at least 10 weeks reduces fall risk 5
• These interventions should be supervised and progressive 5

Multifactorial Fall Prevention

Non-physician health professionals should offer multicomponent interventions including nutrition, multifactorial fall prevention initiatives, and education, along with supervised progressive weight-bearing, strength, and balance training to patients at high risk of falls following fragility fracture 5

The USPSTF recommends exercise interventions to prevent falls in community-dwelling older adults at increased risk, which includes those with a history of falls or mobility problems 6. History of prior falls is adequate and appropriate for determining high risk 6.

Critical Timing Considerations

The risk of falling increases particularly in the middle of the second week of rehabilitation, when frailer patients gain mobility and ability to walk independently but are not yet stable enough 2. This represents a critical window requiring heightened vigilance and protective interventions.

Common Pitfalls to Avoid

• Do not overlook the unaffected limb: Decline in unaffected limb quadriceps endurance is a crucial predictor of falls 4
• Do not delay rehabilitation: Early postoperative lower extremity muscular endurance rehabilitation must be provided 4
• Do not focus solely on the hip: Engagement in ADLs is a crucial predictor for falls during the first to second postoperative years 4
• Do not ignore psychological factors: Depression status significantly predicts multiple falls 4

Coordination of Care

Patients with fragility fractures should be referred to a Fracture Liaison Service (FLS) or an adequate, coordinated, multidisciplinary post-fracture prevention program 5. Non-physician health professionals should be included in orthogeriatric services and coordinated multidisciplinary care 5.