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Long-term effects of functional impairment on fracture risk and mortality in postmenopausal women

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Abstract

Summary

Our findings imply that simple functional tests can predict both hip fracture risk and excess mortality in postmenopausal women. Since the tests characterize general functional capacity (one-legged stance, squatting down, and grip strength), these simple measures should have clinical utility in the assessment of women at risk of falls and fragility fracture.

Introduction

Functional impairment is associated with the risk of fall, which is the leading cause of hip fracture. We aimed to determine how clinical assessments of functional impairment predict long-term hip fracture and mortality.

Methods

A population-based prospective cohort involved 2815 Caucasian women with the average baseline age of 59.1 years. The mean follow-up time in 1994–2014 was 18.3 years. Three functional tests and their combinations assessed at baseline were treated as dichotomous risk factors: (1) inability to squat down and touch the floor (SQ), (2) inability to stand on one leg for 10 s (SOL), and (3) having grip strength (GS) within the lowest quartile (≤ 58 kPa, mean 45.6 kPa). Bone mineral density (BMD) at the proximal femur was measured by DXA. Fractures and deaths were verified from registries. Hazard ratios were determined by using Cox proportional models. Age, body mass index (BMI), and BMD were included as covariates for fracture risk estimates. Age, BMI, and smoking were used for mortality.

Results

Altogether, 650 (23.1%) women had 718 follow-up fractures, including 86 hip fractures. The mortality during the follow-up was 16.8% (n = 473). Half of the women (56.8%, n = 1600) had none of the impairments and were regarded as the referent group. Overall, women with any of the three impairments (43.2%, n = 1215) had higher risks of any fracture, hip fracture, and death, with hazard ratios (HR) of 1.3 ((95% CI) 1.0–1.5, p < 0.01), 2.4 (1.5–3.4, p < 0.001), and 1.5 (1.3–1.8, p < 0.001), respectively. The strongest single predictor for hip fracture was failing to achieve a one-leg stand for 10 s (prevalence 7.1%, n = 200), followed by inability to squat down (27.0%, n = 759) and weak grip strength (24.4%, n = 688), with their respective HRs of 4.3 (2.3–8.0, p < 0.001), 3.1 (2.0–5.0, p < 0.001), and 2.0 (1.2–3.4, p < 0.001). In addition, age, lower BMD, BMI, and smoking were significant covariates.

Conclusions

These findings suggest that functional tests provide long-term prediction of fracture and death in postmenopausal women. Whether reversal of these impairments is associated with a reduction in adverse outcomes is an area for future trials.

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Funding

American Society of Bone and Mineral Research (Young Investigator Award), Sigrid Juselius Foundation, and Finnish Cultural Foundation (The North Savo Regional Fund) have financially supported this study.

Author information

Authors and Affiliations

  1. Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Yliopistonranta 1b, PL 1627,, 70211, Kuopio, Finland

    T. Rikkonen, R. Sund, R. Honkanen & H. Kröger

  2. Addenbrookes’ Hospital, Box 157, Hills Road, Cambridge, CB2 0QQ, UK

    K. Poole

  3. Department of Orthopaedics, Traumatology and Handsurgery, Kuopio University Hospital, Puijonlaaksontie 2, PL 100, 700029, Kuopio, Finland

    J. Sirola & H. Kröger

Authors
  1. T. Rikkonen
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  2. K. Poole
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Corresponding author

Correspondence to T. Rikkonen.

Ethics declarations

The study has been approved by the Kuopio university hospital ethics committee on October 28, 1986, and is performed in accordance with the ethical standards by the Declaration of Helsinki. Oral and written information have been provided before the onset of data collection.

Disclosures

TR received grants for the study from American Society of Bone and Mineral Research (Young Investigator Award), Sigrid Juselius Foundation, and North Savo Regional Fund of the Finnish Cultural Foundation. KP acknowledges the support of the Cambridge NIHR Biomedical Research Centre. The funding body had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

KP has within the last 5 years undertaken scientific advisory board work and educational lectures for Amgen, UCB, Radius, and Lilly through Cambridge Enterprise, the consultancy arm of the University of Cambridge. In accordance with the Ethics Commission, KP gifts all fees for these activities anonymously to various charities. JS reports grant from Finnish Cultural Foundation (The North Savo Regional Fund) and personal fees from Zimmer, Depuy Synthes, and Astra Zeneca. HK reports lecture and advisory board fees from Amgen Ltd. and Eli Lilly Ltd.

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Rikkonen, T., Poole, K., Sirola, J. et al. Long-term effects of functional impairment on fracture risk and mortality in postmenopausal women. Osteoporos Int 29, 2111–2120 (2018). https://doi.org/10.1007/s00198-018-4588-4

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  • DOI: https://doi.org/10.1007/s00198-018-4588-4

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