Can flooring and underlay materials reduce hip fractures in older people?

Falls resulting in fracture of the hip in older people are a major health problem worldwide, but the rate of fractures varies geographically from 100 plus per 100,000 in the USA to fewer than five for the South African Bantu. The UK rate is 63 per 100,000 (Nevitt et al 1991). Clearly the home environment is a major consideration in accounting for the large difference in these figures, and one factor in this may be the place where falls occur – for example, in homes with hard floors and stairs (Tinetti et al 1994). The people at high risk of a fracture are more likely to be over 75, unwell with multiple pathology, fall indoors, and have fallen before. People aged 65 and over are likely to fall as a result of external environmental hazards, and overall more than 50 per cent of fractures are due to falls from tripping at home (Nevitt et al 1993). Flooring which is slippery and unsuitable footwear are other major factors contributing to the onset of fractures in the home, and building design should incorporate measures to minimise the risk of falls (RCP 1989). Even a small percentage reduction in the incidence of hip fractures would save several million pounds in healthcare costs. Flooring can be modified using a honeycomb structure, such as that developed at Penn State University (Casalena et al 1998), under the surface to reduce the peak impact forces on the femur, but this requires major structural changes to be incorporated at the building stage and is an impractical solution in homes or hospitals already built. There is guidance and practical advice for disabled and older people on how to make their homes safer and more suitable for both their present and future needs, including advice about anti-slip mats and avoiding trip hazards (Lacey 2002). NHS Estates, on behalf of the Centre for Accessible Environments, has produced an extensive guide on principles of design in residential environments and care homes for older people (CAE 1998). This includes relevant legislation and useful organisations, but no data on the materials and characteristics of shock-absorbing underlays. The Royal Society for the Prevention of Accidents has a section on home safety, which contains advice on preventing falls, in its Saving Lives newsletters. Although the likelihood of hip fracture can be reduced by hip protectors (Lauritzen et al 1993, Meyer et al 2003), there are problems associated with these (Hayes 2004, Witchard 2004) and many falls occur at night when hip protector garments are not worn (van Schoor et al 2003). The risk of hip fracture is significantly influenced by floor covering (Healy 1994). Gardner et al (1998) indicated that thicker carpet (7mm) gave a four-fold decrease in fracture incidence over a vinyl floor covering, although the trial was small and no information on underlay was given. A recent study by the same group showed that carpet over a wooden floor substantially reduces the number of fractures of the hip occurring from a floor with no carpet, although the existence and role of the underlay was not recorded (Simpson et al 2004). The peak force from an object dropping onto a hard surface may be substantially reduced by selecting an appropriate floor covering (Maki and Fernie 1990), but no work has been undertaken on the effect of underlays on the reduction of hip fracture from a fall. The legislation and appropriate standards are in place for safety flooring in children’s playgrounds. In particular the British Standard Falls in the elderly