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Fall-Related Hip Fracture: Predisposing and Precipitating Factors
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

A physically inactive lifestyle is a predisposing risk factor for fall-related hip fracture. The circumstances, or precipitating factors, surrounding hip fractures are, however, not well understood, a factor of relevance for Swedish adults who have one of the highest hip fracture risks in the world. The aims of this thesis, therefore, were: to explore perceptions of physical activity (PA) among older adults, to describe the circumstances surrounding hip fracture events and the health characteristics of those who experience them.

Four observational studies were conducted involving qualitative, epidemiological and mixed method designs. Participants in study I were recruited from community settings in Stockholm and Dublin (n=30). Studies II-IV (sample sizes, n=484, n=125, n=477) were based on a population-based sample of people admitted to Uppsala University hospital due to hip fracture. Study IV also incorporated the background population of Uppsala county in 2010 (n=117 494).

Analysis of PA perceptions in study I revealed that PA which is functional nature is perceived as most meaningful among certain participants. The uptake of PA in later years was a means of creating a new self-identify and being active in outdoor environments was an important culture-specific motivator to PA among Swedish participants. Analysis of hip fractures patterns in studies II-III showed that: hip fractures among psychotropic drug users were twice as likely to occur during night-time hours compared to those occurring among people not receiving these drugs. Additionally, the fall-related hip fractures of community dwellers with poorest health and function tended to occur indoors during positional changes. In study IV, all categories of disease (according to the International Classification of Diseases, 10th Revision) were seen to be positively associated with hip fracture.  Cardiovascular disease and previous injury (including previous fracture) posed the highest relative and absolute fracture risks.

Detailed investigation of hip fracture circumstances reveal patterns in health and functional characteristics, which provide information regarding predisposing and precipitating factors for these events. This knowledge, in combination with findings regarding PA perceptions, can be used when identifying individuals at high risk for hip fracture and when tailoring fracture prevention at an individual level to those at risk. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 84 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1082
Keyword [en]
Co-existing disease, Epidemiology, Fall circumstances, Hip fracture, In-depth interviews, Mixed methods, Physical activity perceptions, Psychotropic drugs, Qualitative
National Category
Medical and Health Sciences
Research subject
Orthopaedics; Epidemiology; Geriatrics; Physiotherapy
URN: urn:nbn:se:uu:diva-247286ISBN: 978-91-554-9202-1OAI: oai:DiVA.org:uu-247286DiVA: diva2:796142
Public defence
2015-05-07, Rosénsalen, Ingång 95/96, Akademiska Sjukhuset, Uppsala, 09:15 (English)
Available from: 2015-04-13 Created: 2015-03-17 Last updated: 2015-04-17
List of papers
1. "Not ready to throw in the towel": perceptions of physical activity held by older adults in Stockholm and Dublin
Open this publication in new window or tab >>"Not ready to throw in the towel": perceptions of physical activity held by older adults in Stockholm and Dublin
2010 (English)In: Journal of Aging and Physical Activity, ISSN 1063-8652, Vol. 18, no 2, 219-236 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this qualitative study was to explore and describe the perceptions of physical activity held by older urban Swedish and Irish adults. Qualitative interviews were carried out with 30 people age 65 years and older (mean age 74.5), of whom 15 were living in Dublin and 15 were living in Stockholm. The "thematic framework" approach was used to analyze the data. Three central themes were identified regarding people's perceptions of physical activity: physical activity as self-expression, physical activity as interaction, and physical activity as health promotion. Participants' perceptions of physical activity tended to relate to their perceived level of physical activity, regardless of their cultural background. Certain culture-specific motivators and barriers to exercise were also identified. Less active Irish men were more likely to underestimate the health-promoting benefits of exercise.

elderly, motivators, barriers, qualitative interviews
National Category
Medical and Health Sciences
urn:nbn:se:uu:diva-144812 (URN)000276503300007 ()20440032 (PubMedID)
Available from: 2011-02-02 Created: 2011-02-02 Last updated: 2015-04-17Bibliographically approved
2. When and where do hip fractures occur?: A population-based study
Open this publication in new window or tab >>When and where do hip fractures occur?: A population-based study
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2013 (English)In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 24, no 9, 2387-2396 p.Article in journal (Refereed) Published
Abstract [en]


We investigated the effects of socio-demographic and health factors on timing and location of hip fracture among 484 subjects. Time of fracture varied between community dwellers and residential care facility dwellers, and in relation to subjects' psychotropic drug status. Indoor hip fracture incidence increased on snow-covered days.


This paper aims to describe the timing and whereabouts of hip fracture cases in a population-based setting and to relate these factors with residential and health status, seasonal variation, and snow-covered ground.


We consecutively included 484 incident hip fracture events (age ≥50 years) admitted to a Swedish orthopedic department during a 1-year period. Data concerning socio-demographic details, fall location, time of fracture, comorbidity, and medications were collected from in-patient medical records and through patient or caregiver interviews.


The expected peak in fracture occurrence during daytime was observed among community dwellers but not among subjects living in residential care. Hip fracture was twice as likely to occur during nighttime hours among psychotropic drug users (adjusted odds ratio (Adj. OR), 2.20; 95 % confidence interval (CI), 1.12-4.30) compared to those not receiving these medications. Subjects without dementia, taking psychotropic drugs, were also more likely to fracture during nighttime hours (Adj. OR, 2.91; 95 % CI, 1.40-6.0). We observed an increase in indoor hip fracture incidence on snow-covered days among community dwellers (incidence rate ratio, 1.34; 95 % CI, 1.02-1.74). We observed only a weak seasonal trend in hip fracture incidence, based on month, among community dwellers who fractured indoors.


Special attention and possibly fall-preventive efforts should be directed not only toward those living in residential care facilities but also toward community-dwelling subjects taking psychotropic drugs since these groups have a higher incidence of nighttime hip fracture. Further research aiming to explain the seasonal variation of indoor fracture incidence among community dwellers is warranted.

National Category
Medical and Health Sciences
urn:nbn:se:uu:diva-199982 (URN)10.1007/s00198-013-2333-6 (DOI)000323062700002 ()23532356 (PubMedID)
Available from: 2013-05-17 Created: 2013-05-17 Last updated: 2015-04-17Bibliographically approved
3. The fall descriptions and health characteristics of older adults with hip fracture: a mixed methods study
Open this publication in new window or tab >>The fall descriptions and health characteristics of older adults with hip fracture: a mixed methods study
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2015 (English)In: BMC Geriatrics, ISSN 1471-2318, Vol. 15, no 1, 40Article in journal (Refereed) Published
Abstract [en]


In light of the multifactorial etiology of fall-related hip fracture, knowledge of fall circumstances may be especially valuable when placed in the context of the health of the person who falls. We aimed to investigate the circumstances surrounding fall-related hip fractures and to describe fall circumstances in relation to participants' health and functional characteristics.


The fall circumstances of 125 individuals (age ≥ 50 years) with hip fracture were investigated using semi-structured interviews. Data concerning participants' health (comorbidities and medications) and function (self-reported performance of mobility, balance, personal activities of daily living and physical activity, previous falls and hand grip strength) were collected via medical records, questionnaires and dynamometry. Using a mixed methods design, both data sets were analysed separately and then merged in order to provide a comprehensive description of fall events and identify eventual patterns in the data.


Fall circumstances were described as i) Activity at the time of the fall: Positional change (n = 24, 19%); Standing (n = 16, 13%); Walking (n = 71, 57%); Balance challenging (n = 14, 11%) and ii) Nature of the fall: Environmental (n = 32, 26%); Physiological (n = 35, 28%); Activity-related indoor (n = 8, 6%) and outdoor (n = 8, 6%); Trips and slips on snow (n = 20, 16%) and in snow-free conditions (n = 12, 10%) and Unknown (n = 10, 8%). We observed the following patterns regarding fall circumstances and participants' health: those who fell i) during positional change had the poorest functional status; ii) due to environmental reasons (indoors) had moderate physical function, but high levels of comorbidity and fall risk increasing medications; iii) in snow-free environments (outdoors) appeared to have a poorer health and functional status than other outdoor groups.


Our findings indicate that patterns exist in relation to the falls circumstances and health characteristics of people with hip fracture which build upon that previously reported. These patterns, when verified, can provide useful information as to the ways in which fall prevention strategies can be tailored to individuals of varying levels of health and function who are at risk for falls and hip fracture.

Hip fracture, Fall circumstances, Health and functional characteristics
National Category
Clinical Medicine
Research subject
Geriatrics; Orthopaedics
urn:nbn:se:uu:diva-247421 (URN)10.1186/s12877-015-0036-x (DOI)000354249000001 ()25887407 (PubMedID)
Available from: 2015-03-18 Created: 2015-03-18 Last updated: 2015-06-16Bibliographically approved
4. The Impact of Disease on Hip Fracture Risk
Open this publication in new window or tab >>The Impact of Disease on Hip Fracture Risk
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(English)Manuscript (preprint) (Other academic)
Co-existing disease, Hip fracture, Relative risk, Absolute risk
National Category
Medical and Health Sciences
Research subject
Epidemiology; Orthopaedics
urn:nbn:se:uu:diva-247425 (URN)
Available from: 2015-03-18 Created: 2015-03-18 Last updated: 2015-04-17

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