Characterization of first ever stroke patients : functional status with special reference to risk of falls and fracture

Introduction. The costs for falling accidents in Sweden are very high. There is now evidence that assessments and intervention programmes are effective in reducing the risk of falling. It is important to identify which patients have a risk of falling and therefore would benefit most from fall prevention measures. Patients with stroke have a high risk of falling. The falls may result in fear of falling again and fractures. Hip fractures constitute one of the most serious ones. Compared with the general population, stroke survivors have an increased risk of hip fracture. The risk is up to four times higher than for age-matched control subjects. The most likely explanations are an increased risk of falling and reduced bone density.

Aims. Our aims in the present study were to determine if certain test instruments can identify fallers and predict hip fractures, determine the relationship between fear of falling and functional characteristics, describe the circumstances that prevailed when the patients sustained their hip fractures, compare bone mineral density in patients with stroke and hip fracture and to investigate side differences in bone mineral density in patients with stroke alone.

Methods. Patients with first ever stroke treated in the stroke unit at Örebro University Hospital during one year were included in the present study. One hundred and sixty-two of the 218 patients who were included participated in the follow-up after six or twelve months. Nine of the patients fractured their hip within two years after stroke. Bone mineral density was measured in eight of them, as well as in 76 control subjects.

Results. The results of Berg Balance Scale (BBS), Stops Walking When Talking (SWWT) and Timed Up & Go (TUG) differed between fallers and non-fallers. Previous falls as well as using sedatives and impaired vision was associated with falling. Impaired physical function was significantly associated with scoring low fall-related self-efficacy, both for fallers and non-fallers. All patients who subsequently sustained hip fracture had their fractures indoors when they were performing everyday activities. Hip fracture was associated with previous fractures, impaired vision and impaired cognition. Bone mineral density in patients with hip fracture tended to be lower whether they had a stroke or not. Side differences may occur even in patients who can walk independently at stroke onset and all patients who fractured their hip did not have osteoporosis.

Conclusions. BBS, SWWT, TUG and Falls Efficacy Scale - Swedish version could add useful information in a multidisciplinary fall risk analysis. The same factors were associated with an increased risk of falling and having a hip fracture in patients with stroke as for people in general. For a frail, elderly person who already has very small margins, the onset of stroke may mean the difference between falling or not falling, having a hip fracture or not.

List of scientific papers

I. Åsa G. Andersson, Kitty Kamwendo, Åke Seiger, Peter Appelros. How to identify potential fallers in a stroke unit: validity indexes of 4 test methods. Journal of Rehabilitation Medicine. 2006; 38(3):186-91.
https://doi.org/10.1080/16501970500478023

II. Åsa G. Andersson, Kitty Kamwendo, Peter Appelros. Fear of falling in stroke patients: relationship to previous falls and functional characteristics. International Journal of Rehabilitation Research. 2008; 31(3):261-4.
https://doi.org/10.1097/MRR.0b013e3282fba390

III. Åsa G. Andersson, Åke Seiger, Peter Appelros. Hip fractures in patients with stroke. [Submitted]

IV. Åsa G. Andersson, Åke Seiger, Peter Appelros. Bone density in patients with stroke and hip fracture. A case-control study. [Submitted]