Determinants of recovery 12 months after hip fracture: the importance of psychosocial factors.

The independent contributions to recovery from hip fracture of psychosocial factors including depression, personality, social connectedness, and self-rated health were studied in 219 women age 59 and older (mean age 78.5) who were community dwelling prior to fracture. Initial assessments were conducted shortly after surgery and follow up assessments 2, 6, and 12 months later. By 12 months, 15 patients had died and 15 had entered a nursing home. Substantial declines in physical functioning though not psychosocial status were observed. Only 21 per cent (compared to 81 per cent prefracture) reported walking independently; fewer than 30 per cent had regained reported prefracture levels of physical function. The proportion with elevated depression scores at 12 months was 20 per cent, down from 51 per cent following surgery; 64 per cent rated their health excellent or good at 12 months, up from 43 per cent after surgery. Poor cognitive status and post-surgical self-rated health were predictive of mortality. Among survivors, age, prefracture physical functioning, and cognitive status were associated with recovery in physical function but not psychosocial status. High post-surgery depression scores, but not the other psychosocial factors, were associated with poorer recovery in both functional and psychosocial status. These findings demonstrate the importance of depressive symptoms as one determinant of recovery from hip fracture and support the need to attend to the affective status of hip fracture patients following surgery.     

Factors related to occurrence of hip fracture during a fall on the hip

Recently, it has been shown that hip fractures can be effectively prevented by use of hip protectors. To determine who would gain most benefit from use of hip protectors, we conducted a study with the aim to clarify factors that contribute to the occurrence of fracture in individuals who fall on their hip. Hip fracture patients were compared with individuals who had fallen on their hip without sustaining a fracture. The study group consisted of 123 consecutive hip fracture patients aged 70 years or over (mean age 82 years, female 82 years and male 80 years). The control group comprised 132 individuals (mean age 81 years, female 81 years and male 80 years) obtained from a prospective study on falls, who had experienced a fall that caused a visible soft tissue injury (bruise or wound) at the hip or gluteal region without sustaining a fracture. Patients were questioned about associated diseases, medications, place of residence, walking ability, need for locomotor aids and some activities in daily living (ADL). Patients who sustained a hip fracture were more likely to be women, living in long-term institutional care, using neuroleptics, dependent in ADL and had more history of previous stroke with hemiparesis, more Parkinsonism and lower body mass indexes (BMI) than those who did not sustain a fracture on fall on the hip. According to a logistical regression model, institutional residence, low BMI and history of stroke with hemiplegic status differed between fracture cases and controls. Institutional residence, low BMI and history of hemiplegic stroke discriminate hip fracture patients from fallers who sustain a soft tissue injury on the hip region. In clinical practice, patients who have these characteristics would be potential candidates to use hip protectors and other preventive measures.     

Changes in functional status attributable to hip fracture: a comparison of hip fracture patients to community-dwelling aged

Disability attributable to hip fracture regarding activities of daily living was evaluated by comparing 594 hip fracture patients entering eight hospitals in Baltimore, Maryland, in 1990-1991 with community-dwelling aged from the Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort matched on age, sex, and walking ability. Subjects were assessed at baseline (prefracture report for patients), 12 months, and 24 months. At baseline, 26% of both groups had walking disability, 12-14% had transferring disability, and 6-8% evidenced grooming disability. At 12 and 24 months, about 50% of hip fracture patients were walking disabled compared with 21-29% of EPESE respondents after the authors controlled for age, sex, comorbidities, and functional status (excess disability attributable to hip fracture, i.e., attributable disability, of 26 additional cases of disability per 100 persons in the hip fracture cohort during follow-up). Likewise, hip fracture patients experienced more disability regarding transferring (38-39% vs. 10-18%; attributable disability, approximately 22 cases per 100 persons) and grooming (17-19% vs. 7-15%; attributable disability, approximately six cases per 100 persons). Thus, results showed that hip fracture patients had substantially more activities of daily living disability than that explained by aging over 24 months.     

Survival experience of aged hip fracture patients.

Hip fracture has long been considered a major threat to survival in aged populations. This report describes the survival experience of 814 aged, community dwelling hip fracture patients treated in seven Baltimore hospitals between 1984 and 1986: 4.3 per cent died during hospitalization; 8.2, 12.6, and 17.4 per cent died within three, six, and 12 months after fracture, respectively. The mortality rate for the entire population approaches expected mortality approximately six months post-fracture, but varies by age and sex. The most important factors predicting mortality are presence of serious concomitant illness and marked delirium (in the absence of dementia) at the time of hospital admission. The authors suggest that medical factors that may contribute to patient disorientation be investigated and treated, when possible, in an effort to improve the survival status of hip fracture patients.     

Functional ability after hip fracture among patients home-dwelling at the time of fracture

The aim of the study was to assess the change in function and residential status four months after hip fracture in patients over 50 years of age and living independently at home at the time of fracture. All consecutive hip fracture patients treated at Oulu University Hospital during 1989--1999 were followed up. Data collection was done on standardized hip fracture forms, which were filled in at admission and at four months postoperatively. The forms included demographic data, place of residence, locomotor ability, use of walking aids, data on the fracture and its treatment, hospital stay, place of discharge and pain. At four months, 16.0% of the men and 14.3% of the women were permanently institutionalized. Preoperatively, 81.1% of the patients had been able to walk out of doors either alone or accompanied, while at 4 months, less than half of the patients (149 men, 391 women) were able to do so. Two thirds of the hip fracture patients had been able to walk without walking aids before the fracture, the corresponding proportion being one fifth at four months after the fracture. Cumulative mortality at 4 months was 9.9%, being higher among the male (15.5%, n=53) than the female patients (7.9%, n=75). The original study population was also divided into two subgroups operated at different period of time (1989--92 and 1993--99), the functional results seemed to improve with time. Hip fracture leads to the institutionalization of every seventh patient able to live at home at the time of fracture and impairs markedly one's functional capacity. To restore the pre-fracture status as well as possible and to reduce the burden of the consequences of hip fracture, it might be beneficial to evaluate and improve the existing rehabilitation system.     

Replacement of the femoral head due to fracture of the hip: prognostic factors for the duration of hospitalisation, institutionalisation and mortality

OBJECTIVE: To identify preoperative factors affecting length of hospital stay, residential status and mortality after replacement of the femoral head for a hip fracture. DESIGN: Prospective. METHOD: Of the 146 consecutive patients who had hemiarthroplasty for a displaced femoral neck fracture in the period 1996-1998, data were recorded on age, sex, the residential situation, ambulation, ADL dependency, the presence of dementia and the classification according to the American Society of Anesthesiologists (ASA). The operations were carried out in the IJsselland Hospital, Capelle aan den IJssel, the Netherlands. The study was terminated in October 2001. With the aid of uni- and multivariate analysis, the relationship was determined between the pre-operative factors and the length of hospital stay, need for institutional care, and mortality within 3 years after the operation. RESULTS: The study population consisted of 146 patients: 33 men and 113 women with an average age of 82 years (range: 60-98). The length of hospital stay averaged 21 days (range: 2-98). Independent pre-operative predictors for a longer period of hospitalisation were ADL dependency (OR: 1.3; 95% CI: 1.1-15.2), residence at home (0.7; 0.6-0.8), and poor ambulation (1.1; 1.0-1.3). The predictors for permanent institutionalisation were: prior stay in an institution (4-7; 1.1-19.5) and the presence of dementia (3.9; 1.0-1.5). Compared to the general Dutch population of the same age and sex, there was a significant excess mortality during the 3 years after the operation and especially during the first 12 months. Unfavourable prognostic factors for mortality within 3 years after the operation were: poor ambulation before the fracture (3.1; 1.8-5.3), an ASA classification of 3 or 4 (2.0; 1.2-3.1) and an age over 80 years (2.0; 1.2-3.3). CONCLUSION: The risk factors for a longer stay in hospital, placement in an institution or decreased survival in patients who underwent hemiarthroplasty as part of the treatment of a hip fracture can already be identified at the time of admission. The patients with these risk factors should be given special attention during the period of hospitalisation and after-care.     

Falls and hip fracture in Hong Kong Chinese

The risk factors for hip fracture were studied in four hundred patients and eight hundred community and hospital controls. Falling was found to be important as a direct cause of fracture. A history of falls was a significant risk factor for hip fracture in men and women younger than 70, but was less important in older men and women. Medical conditions and treatments did not occur more frequently in hip fracture patients with a history of falls than in patients without, and the patients with a history of falls was not less ambulant than patients without. Regular weight-bearing exercise programmes are recommended as a practical preventive measure for falls and hip fractures.     

Hospitalization with vertebral fracture among the aged: a national population-based study, 1986-1989.

Whereas fractures related to osteoporosis have become a pressing public health concern, relatively few epidemiologic studies have focused on vertebral fractures. To shed further light on the occurrence of this injury, we collected data from the Health Care Financing Administration on 151,986 discharges listing a diagnosis of vertebral fracture over a 4-year period. After adjusting for age, white women experienced the highest rates of discharge, at 17.1 per 10,000 per year, followed by white men (9.9 per 10,000), black women (3.7 per 10,000), and black men (2.5 per 10,000). Among white women, discharge rates rose exponentially from 5.3 discharges per 10,000 population at age 65 to nearly 47.8 per 10,000 at age 90. White men, black women, and black men experienced less dramatic age-related increases in discharge rates. The similarity of these patterns to discharge rates for hip fracture suggests that the race-sex differences in vertebral fracture discharge rates may be due to differences in the incidence of vertebral fracture.     

Hip fracture incidence in an urban area in Northeast Brazil

Hip fractures involve high morbidity and mortality and extensive treatment costs and are thus considered an important public health issue. Hip fracture incidence varies greatly between countries and even between cities in the same region. This study aimed to determine hip fracture incidence in Fortaleza, Ceará State, Brazil. Hip fracture cases were identified prospectively in patients aged 45 and over attending private and public hospitals in Fortaleza from July 2001 to June 2002. The study identified 673 patients with hip fractures, 382 of whom from Fortaleza. Annual hip fracture incidence in Fortaleza for patients over 60 years was 21.7/10,000 inhabitants (13.0/10,000 for men and 27.7/10,000 for women). Hip fractures were more frequent among women and with advancing age. Hip fracture incidence in Fortaleza was very low compared to rates reported from other parts of the world.     

Outcome in ambulatory status immediately following hip fracture surgery in the acute setting: a comparison of nursing home residents and community older adults

OBJECTIVE: To compare the ambulatory status following hip fracture surgery in the acute setting between older adults from long-term care facilities (LTCF) and the community. SETTING: A 650-bed, urban, inner city, university-affiliated teaching hospital. METHODS: One hundred forty hip fracture patients (60-97 years) from long-term care facilities and the community were examined. Ambulatory status before and after surgery was categorized four ways based on the degree of independence in ambulation: A1 = independent ambulation (with or without an assisting device), A2 = assistance of another person required, A3 = predominant use of a wheelchair, and A4 = bed-bound. Change in ambulatory status was designated as "moderate" if the deterioration was one status level only (A1 to A2, A2 to A3, and A3 to A4) or "major" if the deterioration was more than one status level (A1 to A3/A4 or A2 to A4). Additional variables such as age, sex, risk factors, length of stay, history of drug use, and laboratory results also were examined. RESULTS: Hip fracture patients from LTCF were older (P = 0.0160) and had more overall risk factors for hip fracture (P = 0.0039) than community patients. They also had higher rates of dementia (P < 0.000), arrhythmia (P = 0.025), delirium (P = 0.0016) and anxiolytics use (P = 0.019) than patients from the community. On admission, LTCF patients had lower serum calcium (P = 0.0003), phosphorus (P = 0.0210), and albumin (P = 0.0004) than community patients. Before hospitalization they also were less ambulatory (P = 0.002) than community patients. Post surgery, ambulatory status declined in both groups. However, a "major" change (decline) in ambulatory status occurred more often in LTCF patients (P = 0.001). CONCLUSIONS: A greater decline in ambulatory status is seen in patients from LTCF than in community patients, immediately following hip fracture surgery. Compared with community patients, LTCF patients are also older, sicker (higher total risk score) and have an increased risk for a decline in functional status.     

Predicting place of discharge from hospital for patients with a stroke or hip fracture on admission

OBJECTIVES: To determine the predictive power of patient and service characteristics on place of discharge following hospital admission for an acute stroke and for hip fracture. METHODS: Prospective cohort of 440 acute stroke and 572 hip fracture patients aged 65 years or over admitted from home to six district general hospitals and associated community hospitals, three in the North and three in the South of England. RESULTS: Age, marital status, living arrangements, mental health status at admission, pre-admission self-rated disability, pre-admission use of home-care services, post-admission staff assessments of functional dependency as measured by Barthel Index and of confusion as measured by the modified Crichton Royal Behavioural Rating Scale and nursing staffs' expectation of place of discharge are all significantly related to place of discharge for stroke and hip fracture participants. Logistic regression correctly predicted discharge destination for 87% of stroke patients from data available at time of admission and 83% of hip fracture patients. Of the 30% of stroke patients discharged to an institution, the model correctly predicted 73%. However, of the 19% of hip fracture patients discharged to an institution, only 28% were correctly predicted. CONCLUSIONS: Data about older patients admitted to hospital with an acute condition should be routinely collected by hospital staff to inform clinical management and to permit risk-adjusted audit.     

A clinically meaningful difference was generated for a performance measure of recovery from hip fracture

BACKGROUND AND OBJECTIVE: The Lower Extremity Gain Scale (LEGS) is a performance measure of tasks that are often impaired in hip fracture patients. This study was designed to determine a clinically meaningful difference in LEGS. METHODS: The population was 139 female patients (age >65 years) admitted to Baltimore hospitals. Recovery levels were estimated by fitting trajectory curves for the cohort for the 12 months post fracture. The clinically meaningful difference was evaluated using an anchor-based approach, examining the relationship between the LEGS recovery level and age. A second, distribution-based method used an effect size of .20. RESULTS: According to our model, a difference of 5 years in age corresponded to a difference of 1.6-3.6 points in LEGS scores. The standard deviation for LEGS at 12 months was 8.0; thus, Cohen's effect size of 0.2 would equate to a difference of 1.6 points. CONCLUSION: This suggests that a clinically meaningful difference in the LEGS scores for a population in this age range would be 2-3 points.     

Consequences of a Hip Fracture in Activity Performance and Life Satisfaction in an Elderly Swedish Clientele

The purpose of the study was to explore whether activity performance in elderly people changed following a hip fracture and whether the change influenced life satisfaction. The sample consisted of 29 patients, 23 women and 6 men aged between 65 and 100. In an initial interview at the hospital a questionnaire about daily living activities before the fracture and an ADL taxonomy were used. In a second interview three to four months later at their homes the same questionnaires was used and the subjects were asked about satisfaction with life as a whole. After the fracture many had difficulties in conducting hobby activities and in making social contacts outside the home. Grooming and washing were other activities that few could manage. A large number wanted to perform most of the activities that they did not have the ability to do. A hip fracture is a hazardous event in the life of an elderly person, and may lead to a permanently more restricted life. It is apparent also that this influenced how satisfied these people were with their life in general.     

In-hospital case-fatality of aged patients with hip fracture in Catalonia, Spain

Hip fracture case-fatality in patients aged 65 years or older was studied in patients admitted to acute care hospitals in Catalonia over a 1-year period. 1222 femoral neck fractures and 1648 pertrochanteric fractures were identified. Women (76.9%) were most frequently and significantly older than men. Average age in pertrochanteric fracture was significantly higher than cervical fracture. The overall in-hospital case-fatality rate was 6.8%. Male gender, advanced age, pertrochanteric fracture and conservative management were associated with a significantly higher case-fatality rate. Multivariate logistic regression analyses demonstrated that previously seen associations showed univariate analysis. However, because interaction was observed, association within fracture and case-fatality was studied separately by gender. Men with pertrochanteric fracture showed the greatest association for in-hospital case-fatality (OR, 3.3; 95% CI: 2–5.5) compared with women with femoral neck fractures. In models with in-hospital case-fatality or no autonomy at discharge or in-hospital case-fatality or no autonomy at discharge or readmission as dependent variables, the odds ratio of death for conservative management of hip fracture were 3.7 (95% CI: 2.3–6) and 3.1 (95% CI: 1.9–4.9), respectively. This information should be taken into consideration for further analyses for long-term outcome and resource consumption by patients with hip fracture.     

Evaluation of fracture risk in osteoporosis

Osteoporotic fractures are associated with excess mortality. Effective treatment options are available, which reduce the risk of vertebral and non-vertebral fractures, but the identification of patients with high fracture risk is problematic. Low bone mineral density (BMD)--the basis for the diagnosis of osteoporosis--is an important, but not the only determinant of fracture risk. Several clinical risk factors are know that operate partially or completely independently of BMD, and affect the fracture risk. These include age, a prior fragility fracture, a parental history of hip fracture, use of corticosteroids, excess alcohol intake, rheumatoid arthritis, and different types of diseases which can cause secondary bone loss. The FRAX? tool integrates the weight of above mentioned clinical risk factors for fracture risk assessment with or without BMD value, and calculates the 10-year absolute risk of hip and major osteoporotic (hip, vertebral, humerus and forearm together) fracture probabilities. Although the use of data is not yet uniform, the FRAX? is a promising opportunity to identify individuals with high fracture risk. The accumulation of experience with FRAX? is going on and it can modify current diagnostic and therapeutic recommendations in Hungary as well.     

老年人髋部骨折术后认知障碍临床分析

目的研究高龄患者术后认知功能障碍的临床特点及治疗方法。方法凹顾性分析笔者所在医院2004年6月至2009年6月12例高龄患者髋部骨折术后出现认知障碍的原因,临床表现及其治疗方法。所有病例术后随访3—12个月。结果所有患者住院期间无死亡,经对症处理及上述治疗后,10例患者术后1周内好转,1例术后2周内好转,1例术后随访半年仍有认知功能障碍,但较住院期间明显好转。结论老年患者髋部骨折术后认知功能障碍发病率高,危害大,应早期诊治,加强围手术期处理,纠正各种生理紊乱,加强护理,提高老年患者的生活质量。     

Quality of life: a possible health index for the elderly

To assess whether quality of life (QOL) could be employed as an outcome measure of health programs for elderly populations, we evaluated the relationship between subjective assessment of QOL ("morale scale") and objective constituents of active life such as activities of daily living (ADL), instrumental ADL (IADL) and work status along with determination of active life expectancy (ALE) in a rural district in Japan (n = 13,529). The QOL scale was positively correlated with ADL, IADL and work status but not with age. Validity and test-retest reliability were satisfactory as regards the small subsamples of respondents. ALE of the elderly aged 60 to 64 was 15.2 years, while their life expectancy was 27.1 years. Factors associated with lower ADL included age, lower IADL and joblessness. The QOL measurement and the objective variables can be incorporated into an assessment of the health status of the elderly in addition to conventional indices based on mortality.     

人工髋关节置换术治疗陈旧性股骨颈骨折相关因素及疗效评价

目的 探讨人工髋关节置换术治疗陈旧性股骨颈骨折的技术措施及临床疗效.方法 对2000年1月至2008年4月采用人工髋关节置换术治疗陈旧性股骨颈骨折且获得完整资料的61例患者进行回顾性研究.伤后曾行内固定术治疗者11例.应用Harris评分标准及x线片测量行术前、术后疗效评价.结果 随访时间3个月至8年.Harris评分由术前(17.5±8.4)分恢复到随访时的(78.1±8.5)分(P＜0.05).术前患肢缩短(2.52±1.09)cm,术后缩短(0.81±0.73)cm,偏心距手术前、后较对侧缩小值分别为(2.34±0.72)cm及(0.78±0.57)cm,差异均有统计学意义(P＜0.05).结论 人工髋关节置换术对治疗老年性或既往治疗失败的陈旧性股骨颈骨折疗效确切.对骨折后病程较长者的疼痛症状缓解更为明显,但随着病程延长,人工髋关节置换术对肢体缩短的矫正能力有所局限.     

The Burden of Osteoporosis and the Case for Disease Management

Currently, osteoporosis, defined as low bone mineral density (BMD), affects 30% of postmenopausal women and 8% of men >50 years old in Western society and these percentages are likely to increase as our elderly population expands. Osteoporosis-related fractures increase with age and reductions in BMD, with the greatest increase in hip, followed by vertebral, and then wrist fractures. Osteoporosis is associated with significant mortality and for each 1 SD decrease in BMD there is a 1.5-fold increase in mortality risk. Following a hip fracture, 25–30% of patients will die within 3–6 months and in some populations hip fractures account for 1.5% of all deaths. Osteoporosis and related fractures are associated with significant morbidity, with loss of independence, psychological effects, and an overall decreased quality of life.The current financial cost of osteoporosis in the US is $US14 billion and in the UK just over £1 billion, and these costs will increase 3- to 8-fold over the next 50 years. Treatments are available that have been shown to significantly increase BMD, decrease bone turnover, and as a result decrease fracture incidence. For reductions in both vertebral and fracture, the evidence is strongest for the use of the bisphosphonates alendronate and risedronate; while for vertebral fracture, effective treatments include raloxifene, etidronate, calcitonin, and calcium plus vitamin D. Recent data suggest that hormone replacement therapy (HRT) can prevent hip and vertebral fractures, but long-term use, or commencement in elderly women of some continuous combined preparations, is no longer recommended.It has been recognized that bone turnover and bone quality contribute to fracture risk and, therefore, biochemical assessment of bone resorption and formation may increase the clinical and cost effectiveness of treatment. Using a conservative estimate of fracture reduction (35%) over a 5-year period, an intervention costing $US500 (£333) per year is cost effective when targeted to women with osteoporosis who are ≥65 years of age. It has been calculated that the lower the intervention cost and the higher the effectiveness of treatment the lower the age at which the treatment would be cost effective. The increasing healthcare burden and effective treatments make osteoporosis an excellent candidate for disease management programs.     

Effects of long-term fluoride in drinking water on risks of hip fracture of the elderly: an ecologic study based on database of hospitalization episodes]

OBJECTIVES: Fluoridation of drinking water is known to decrease dental caries, particularly in children. However, the effects of fluoridated water on bone over several decades are still in controversy. To assess the risk of hip fracture related to water fluoridation, we evaluated the hip fracture-related hospitalizations of the elderly between a fluoridated city and non-fluoridated cities in Korea. METHODS: Cheongju as a fluoridated area and Chungju, Chuncheon, Suwon, Wonju as non-fluoridated areas were chosen for the study. We established a database of hip fracture hospitalization episode based on the claims data submitted to the Health Insurance Review Agency from January 1995 to December 2002. The hip fracture hospitalization episodes that satisfied the conditions were those that occurred in patients over 65 years old, the injuries had a hip fracture code (ICD-9 820, ICD-10 S72) and the patients were hospitalized for at least 7days. A total of 80,558 cases of hip fracture hospitalization episodes were analyzed. RESULTS: The admission rates for hip fracture increased with the age of the men and women in both a fluoridated city and the non-fluoridated cities (p<0.01). The relative risk of hip fracture increased significantly both for men and women as their age increased. However, any difference in the hip fracture admission rates was not consistently observed between the fluoridated city and the nonfluoridated cities. CONCLUSIONS: We cannot conclude that fluoridation of drinking water increases the risk of hip fracture in the elderly.