Validation of a 4-Item Score Predicting Hip Fracture and Mortality Risk Among Elderly Women

Falls are a frequent problem amongst elderly people and fractures a serious consequence. There are now well tested strategies for decreasing both falls and fractures; the issue is how to use those strategies in the most effective manner not only for individual patients but also as a public health measure.

Albertsson and colleagues, in an elegant study, have developed a simple to use index to identify those elderly people most at risk of fracture. Not only was the FRAMO index a good predictor of fracture it also had strong predictive value for mortality. This raises the interesting question as to whether this index, which may well catch on as a quick clinical screening tool, should be used to identify those who need specific intervention to prevent fracture or used as a marker of frailty and more general risk of dependency and death.

If the FRAMO index is used to screen large numbers of those likely to fracture then subsequent assessments and treatments should be kept simple and easy to implement so that health services can cope with the demand. The FRAMO index identifies osteoporosis through the history of fracture, and strength and balance impairment through the chair rise. Subsequent interventions may include calcium, vitamin D and a bisphosphonate for the bones and a proven strength and balance retraining program for fall prevention. The strength and balance retraining may be done at home ( 1 ) or in groups ( 2 ). There is no evidence that such a program is effective in those with cognitive impairment ( 3 ).

The mortality in those with four risk factors was high and a more comprehensive assessment of this group may identify remediable problems. In a high proportion their weakness and poor nutritional state will reflect end stage physical illnesses such as dementia and chronic respiratory disease. In others, though, these problems may respond to improved nutrition, medication review and an exercise program. A future study to identify the scope for improvement in this frail group would be of considerable interest. The FRAMO index may well have a future in identifying those elderly people who are just coping at home but where any minor illness or injury may have a catastrophic effect on their independence. Early identification and intervention may prevent this decline.

1) Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997; 315: 1065-9.

2) Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community- based group exercise improves balance and reduces falls in at-risk older people: a randomised controlled trial. Age Ageing 2003; 32: 407-14.

3) Shaw FE, Bond J, Richardson DA et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ 2003; 326: 73.

A John Campbell Professor of Geriatric Medicine Dunedin School of Medicine University of Otago Dunedin New Zealand

Competing interests:   None declared