Falls and bone health in Parkinson’s disease

by Dr Sowjanya PotturuFalls are common in Parkinson’s disease and are a common cause of hip fracture. Prospective studies have shown that 46% of PD patients fall within three months of follow up¹. Multiple factors increase falls risk in PD, including motor dysfunction (freezing, postural reflex loss), impaired cognition, sarcopenia and postural hypotension. PD guidelines lack detail regarding the assessment and management of bone health.A median duration of four years has been reported between Parkinson’s diagnosis and first hip fracture¹. Retrospective studies¹ indicate that PD is associated with a doubling of fracture risk and a tripling of hip fracture risk in early diagnosis. Several case control studies have shown that PD patients have a lower bone mineral density than controls due to lower physical activity level, sarcopenia and under-nutrition¹. Fractured neck of femur is associated with an 8.2 % one-month and a 25 % 12-month mortality in non-PD patients. This is not known for PD patients.There is a lack of guidance for assessing fracture risk and managing bone health in PD. NICE PD guidelines⁵ acknowledge fracture risk as a complication and recommend risk assessment but no detail is given on how to do this. NICE Osteoporosis guidance³ recommends using FRAX or QFracture to identify patients at risk of falls in the general population.

Aims

We aimed to audit fracture risk assessments in patients attending an outpatient PD clinic. We sought to identify patients with a high fracture risk and audit whether appropriate bone protection had been given, or appropriate investigations performed.

Methods

Ninety patients' case notes, from a 400-patient cohort with a confirmed diagnosis of PD or Parkinsonism and attending the medical day hospital Parkinson’s clinic, were audited using an in-house tool. Particular consideration was given for falls, fractures, osteoporosis, past medical history, polypharmacy, postural hypotension, BMI, smoking status and alcohol consumption. QFracture scores were retrospectively calculated for these patients. Details of bone protection measures taken were recorded.

Results

Fifty of the 90 patients studied had fallen in the previous six months. The major risk factors for falls included postural hypotension (30%), polypharmacy (66%), dementia (20%) and multiple co-morbidities (54%).The factors associated with increased fracture risk were low BMI (38%) and a history of previous fractures (27%). Forty-three out of 90 (48%) patients had QFracture scores of ≥20% for major osteoporotic fractures. Only four patients (9%) were on Alendronate.

Discussion

Lyell and colleagues recently proposed guidance suggesting how to assess and manage fracture risk in patients with Parkinson's disease¹. They recommended that patients over 75 years of age with QFracture scores of ≥20% for major osteoporotic fractures should be considered for bone protection without the need for a DEXA scan. In our cohort of PD patients, falls were common and multiple patients had risk factors for falls and fractures. Despite this, only a few patients were on any kind of bone protection. We found no clear documentation for the assessment of fracture risk in the notes.

Recommendations

Our audit highlights a clear need for further guidance on the assessment, prevention and treatment of falls and fractures in Parkinson’s disease. We have presented these results to the multidisciplinary team looking after our PD patients to increase awareness and understanding of fracture risk. Our aim now is to develop a pathway assessing fracture risk in patients with PD attending our clinics. We now routinely identify patients at risk of fractures by calculating QFracture scores and, where appropriate, suggest treatment options to the patient's GP.

References

1. Veronica Lyell1, Emily Henderson2, Mark Devine1 and Celia Gregson1,3 Assessment and management of fracture risk in patients with Parkinson's disease Age Ageing (2015) 44 (1): 34-41. doi: 10.1093/ageing/afu122 First published online: September 18, 2014
2. Hippisley-Cox (2012) Derivation and validation of updated Qfracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study BMJ 344:e3427 doi: 10.1136/bmj.e3427
3. NICE (2012) Clinical guideline 146 Osteoporosis: assessing the risk of fragility fracture
4. NICE clinical guideline 161 Falls: assessment and prevention of falls in older people
5. NICE (2006) Parkinson’s disease: national clinical guideline for diagnosis and management in primary and secondary care National Collaborating Centre for Chronic Conditions

Authors : Dr.Sowjanya Potturu, Jordana Freemantle, Bernadette GoodburnWith thanks to Dr Sally Jones, Dr Lucy StrensClick here to see the presentation slides for this audit