One of our pet peeves in primary care is that physicians readily order bone densitometry tests and prescribe drugs for osteoporosis yet almost never do fall risk assessments on those patients. CMS even uses ordering the bone densitometry test or prescribing the drugs in their quality measures yet also does not assess whether fall risk assessments were done. In that population, our real goal is to prevent fractures so why would you just look for osteoporosis and skip the fall risk assessment?
There are obviously many factors that predispose patients to falls (drugs, orthostatic hypotension, neuropathies with loss of proprioception, other neurological diseases, and multiple sensory deficits, among others) and there are numerous fall risk assessment tools out there.
But a recent paper noted the value of the time up-and-go test (yes, the same one we just described earlier in this month’s What’s New in the Patient Safety World column “Timed Up-and-Go Test and Surgical Outcomes”). Zhu and colleagues (Zhu 2011) looked at bone densitometry and the timed up-and-go test (“TUG”) in a cohort of women aged 70-85 who were followed for 5 years in a randomized clinical trial of calcium supplementation to prevent fractures. They found that the TUG (using a cutoff of 10.2 seconds) was an independent predictor of nonvertebral fracture.
The TUG is a measure incorporated into several frailty indices. For those of you unfamiliar with the TUG, you simply time a patient standing up from a chair, walking 10 feet, returning to the chair and sitting down.
The TUG costs nothing and takes almost no time to complete so it can be easily integrated into almost any practice setting.
The editorial accompanying the Zhu article (Bauer 2011) notes that some good existing algorithms to predict fracture, such as WHO’s FRAX, also lack inputs that assess fall risk and could be significantly improved by inclusion of such a variable. He notes that such a variable should be easy to measure, reproducible, and strongly predictive of fracture independent of bone density and other factors and notes that the timed up-and-go test has many of those attributes. Though advocating further studies to formally assess that combination, he suggests that adding the TUG to the FRAX tool may prove to be very useful.
Sometimes it’s remarkable how we overlook useful things that are right in front of us!
Zhu K, Devine A, Lewis JR, et al. "'Timed Up and Go' Test and Bone Mineral Density Measurement for Fracture Prediction. Arch Intern Med. 2011; 171(18): 1655-1661
Bauer DC. FRAX, Falls, and Fracture Prediction: Predicting the Future: Comment on " ‘Timed Up and Go’ Test and Bone Mineral Density Measurement for Fracture Prediction". Arch Intern Med. 2011;171(18):1661-1662
WHO’s FRAX algorhithm and scoring tool