Heterogeneity in hip fracture patients: age, functional status, and comorbidity

OBJECTIVES: To examine unidentified heterogeneity in hip fracture patients that may predict variation in functional outcomes. DESIGN: Observational, longitudinal, multisite cohort study. SETTING: Three separate cohorts from five hospitals in the metropolitan New York area and eight hospitals in Baltimore. PARTICIPANTS: Two thousand six hundred ninety-two hip fracture patients treated at one of 13 hospitals and followed for 6 months postfracture. MEASUREMENTS: A mobility measure with three categories (independent (walks independently or with a device), limited independence (needs human assistance or supervision to walk 150 feet or one block or able only to walk indoors), and unable to walk) was developed for use with all three cohorts. A similar measure was developed for the other activities of daily living (ADLs): bathing, dressing, feeding, and using the toilet. Cluster analysis was used to form homogenous groups of patients based on baseline demographic characteristics, comorbid conditions, and baseline mobility and ADL independence. RESULTS: Seven homogeneous subgroups were identified based on prefracture age, health, and functional status, with measurably different 6-month functional outcomes. At least 90% of patients could be correctly classified into the seven groups using simple decision rules about age, ADLs, and dementia status at baseline. Dementia was the only comorbid condition that segmented the groups. CONCLUSION: The heterogeneous hip fracture population can be grouped into homogenous patient clusters based on prefracture characteristics. Differentially targeting services and interventions to these subgroups may improve functional status outcomes.     

Adjusted mortality after hip fracture: From the cardiovascular health study

OBJECTIVES: To estimate the risk of death associated with hip fracture (HFx), stratifying by sex and time since fracture. DESIGN: Prospective cohort study compared participants with and without hip fracture, matched on sex, age, race, recruitment period, and time since enrollment. SETTING: The Cardiovascular Health Study, a more-than-15-year longitudinal study of 5,888 older individuals from four U.S. sites. PARTICIPANTS: Three hundred seventy-nine individuals with HFx were compared with 1,134 without HFx. MEASUREMENTS: Extended Cox models were used to estimate mortality hazard ratios (HRs) for different periods after fracture, adjusting for prefracture health. RESULTS: Age- and race-adjusted excess mortality was 9% in women and 24% in men 1 year after fracture, and 24% in women and 26% men 5 years postfracture. Multivariable-adjusted HRs of mortality associated with HFx in women were 7.1 (95% confidence interval (CI) = 2.3-21.5), 2.1 (95% CI = 1.0-4.1), 1.4 (95% CI = 1.1-2.0), and 1.0 (95% CI = 0.6-1.5) for 0 to 1 months, 2 to 6 months, 7 months to 4 years, and 5 to 8 years, respectively, after index date. In men, respective HRs for the same time periods were 39.9 (95% CI = 5.2-308.7), 3.8 (95% CI = 1.4-10.3), 1.1 (95% CI = 0.7-1.8), and 1.0 (95% CI = 0.3-2.7). HRs adjusted for age and race were 20% to 40% higher. CONCLUSION: The risk of mortality was highest in the first 6 months after HFx. In men, the risk of death approximated that of men without HFx after 6 months; in women, a moderately greater risk persisted through the fourth year. Although the mortality pattern was different in women and men, excess mortality 5 years postfracture was similar for both sexes.     

Effect of hip fracture on mortality in elderly women: the EPIDOS prospective study

OBJECTIVES: To assess whether the occurrence of a hip fracture is associated with an increased risk of mortality even after taking into account age and prefracture health status and whether this increased risk of mortality persists beyond the first 6 months after the fracture. DESIGN: A prospective study of risk factors for hip fracture. SETTING: Five French areas: Amiens, Lyon, Montpellier, Paris, and Toulouse. PARTICIPANTS: The cohort consisted of 7,512 volunteer ambulatory women aged 75 and older who were recruited from voter registration lists. Women who had a history of hip fracture or bilateral hip replacement were excluded. MEASUREMENTS: The baseline examination included a functional and clinical examination and a questionnaire on life style and treatments. Thereafter, women were followed every 4 months for 4 years to record the occurrence of fractures and deaths. A multivariable proportional hazards model was used to determine the association between hip fracture (treated as a time-dependent variable) and mortality, after adjustment for age and baseline health status. RESULTS: During a mean+/-standard deviation follow-up of 3.9+/-0.9 years, 338 women had a first hip fracture, and their postfracture mortality rate was 112.4 per 1,000 woman-years, compared with 27.3 per 1,000 woman-years for the 6,115 women who did not have any fracture (P<.001). After adjusting for age and baseline health status, women with hip fracture were more than twice as likely to die (95% confidence interval (CI)=1.6-2.8). This increased risk appeared more pronounced in the first 6 months (relative risk (RR)=3.0, 95% CI=1.9-4.7) than after (RR=1.9, 95% CI=1.6-2.2) (P=.09). CONCLUSION: In ambulatory elderly women, the occurrence of a hip fracture is associated with an increased risk of death, even after prefracture health status is taken into account. Although the effect of the fracture is stronger in the first 6 months, it persists for several years thereafter, which suggests that prevention of hip fracture and improved care after the fracture may contribute to increase life expectancy in addition to preserving quality of life.     

Physical therapy and mobility 2 and 6 months after hip fracture

OBJECTIVES: To examine the relationship between early physical therapy (PT), later therapy, and mobility 2 and 6 months after hip fracture. DESIGN: Prospective, multisite observational study. SETTING: Four hospitals in the New York City area. PARTICIPANTS: Four hundred forty-three hospitalized older patients discharged after surgery for hip fracture in 1997-98. MEASUREMENTS: Patient demographics, fracture type, comorbidities, dementia, number of new impairments at discharge, amount of PT between day of surgery and postoperative day (POD) 3, amount of therapy between POD4 and 8 weeks later, and prefracture, 2-, and 6-month mobility measured using the Functional Independence Measure. RESULTS: More PT immediately after hip fracture surgery was associated with significantly better locomotion 2 months later. Each additional session from the day of surgery through POD3 was associated with an increase of 0.4 points (P=.032) on the 14-point locomotion scale, but the positive relationship between early PT and mobility was attenuated by 6 months postfracture. There was no association between later therapy and 2- or 6-month mobility. CONCLUSION: PT immediately after hip fracture surgery is beneficial. The effects of later therapy on mobility were difficult to assess because of limitations of the data. Well-designed randomized, controlled trials of the effect of varying schedules and amounts of therapy on functional status after hip fracture would be informative.     

Does functional recovery in elderly hip fracture patients differ between patients admitted from long-term care and the community?

BACKGROUND: It is largely unknown whether functional recovery following hip fracture differs between long-term care (LTC) and community-dwelling residents. Our primary purpose was to compare recovery between these patients 6 months following hip fracture, controlling for known prognostic factors. Secondarily, we examined the contribution of residential status, in addition to patient characteristics, to functional recovery. METHODS: We studied a population-based inception cohort of 451 hip fracture patients >/= 65 years old admitted to one Canadian health region hospital between July 1999 and September 2000. Participants completed the Modified Barthel Functional Index (MBI) in hospital and again via telephone interviews 6 months postoperatively. Data were also collected on surgery and rehabilitation timing, length of hospital stay (LOS). and discharge destination. Relative change from prefracture function adjusting for known prognostic factors, and the proportion of participants returning to prefracture function were compared between the LTC and community-dwelling residents. RESULTS: LTC residents (n = 115) were older, with lower function prefracture, more comorbidities, and increased dementia than community-dwelling residents (n = 336). Six months postfracture, 17 (22%) LTC and 180 (71%) community-dwelling residents had regained prefracture function (p <.001). LTC residents had 33% lower (-40.6, -27.2) and community-dwelling residents 11.6% lower (-14.8, -8.4) 6-month MBI scores relative to prefracture scores after risk adjustment. Residential status was significantly associated with risk-adjusted functional recovery (p <.001). Median LOS was 4 days less for LTC than for community-dwelling residents (p <.001). Twelve (10%) LTC and 266 (79%) community-dwelling residents were discharged to inpatient rehabilitation (p <.001). CONCLUSION: Following hip fracture, most LTC residents do not regain prefracture function irrespective of known prognostic factors. Further investigation is needed as to the extent to which personal and environmental characteristics contribute to outcome after hip fracture.     

Subsequent fracture in nursing home residents with a hip fracture: a competing risks approach

OBJECTIVES: To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death. DESIGN: Dynamic cohort study. SETTING: Hebrew Rehabilitation Center, a 725‐bed, long‐term care facility in Boston, Massachusetts. PARTICIPANTS: Long‐term care residents with a surgically repaired hip fracture (1999–2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site. MEASUREMENTS: Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture. RESULTS: The study included 184 residents with a baseline hip fracture. Thirty‐nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow‐up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture. CONCLUSION: Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.     

Effect of fracture on the health care use of nursing home residents

BACKGROUND: Osteoporotic fractures result in increased health care use. Care following fracture has been characterized for community dwellers but not for nursing home residents, whose fracture rates are as much as 11 times higher than those of age-matched community dwellers. Knowing the amount of care following fracture may help determine the effects of fracture prevention on use and costs in this population. METHODS: A prospective cohort study was conducted, with 18 months of follow-up, of 1427 randomly selected white, female nursing home residents 65 years and older from 47 randomly selected nursing homes in Maryland. RESULTS: After controlling for age, comorbidities, and mobility, nursing home residents who experienced a fracture were hospitalized more than 15 times as often as those who did not in the month following the fracture (relative rate, 15.35; 95% confidence interval, 12.27-19.21) and at a higher rate from 3 through 12 months postfracture. Rates in the first month were higher for persons with a hip fracture (relative rate, 31.01; 95% confidence interval, 26.52-36.24). Rates of emergency department use and contacts with physicians and therapists were increased, the latter two for 12 months following fracture. Also, before the fracture, patients who experienced a fracture visited the emergency department and had more physician contacts; for those with a hip fracture, there were fewer prefracture hospitalizations. CONCLUSIONS: Health care use remained elevated through 1 year postfracture. Comparisons with community patients suggest that this care may be less than what would be provided in other settings. For patients who fractured a hip, higher use decreased after 6 months, similar to community cohorts. Nursing home residents who visit the emergency department may warrant special screening for a fracture.     

Mortality and institutionalization following hip fracture

OBJECTIVES: To identify determinants of mortality and institutionalization after hip fracture and to identify those older hip fracture patients at high risk of death or institutionalization after hip fracture. DESIGN: Population-based prospective inception cohort study of hip fracture patients; patients were assessed in the hospital and at 3 months following the hip fracture. SETTING: Edmonton area hip fracture patients admitted to one of two Edmonton, Alberta, Canada, acute care centers between July 10, 1996, and August 31, 1997. PARTICIPANTS: Patients were residents of the Edmonton area and over the age of 64. Those who had previously fractured the same hip within the past 5 years or had some pathological condition underlying the hip fracture were excluded. Of 610 eligible patients, 558 contributed some baseline information and were included in the mortality analysis; the institutionalization analysis was restricted to the 338 patients who lived in the community before fracture, survived the 3-month period postfracture, and had completed a 3-month follow-up interview. MEASUREMENTS: The baseline interview was done in the hospital to assess mental status, prefracture physical function, prefracture health perception, and prefracture social support. The 3-month follow-up interview was done by phone to assess physical function, health perception, and social support 3 months postfracture. Demographic and comorbidity information was collected from medical records. RESULTS: Low mental status in hospital was found to increase the chances of mortality and institutionalization, and male gender was found to increase mortality risk fourfold. Each additional 10 years of age increased the risk of institutionalization approximately 2.5 times. Patients with lower postfracture physical function had at least five times the risk of institutionalization compared to patients with high postfracture physical function. CONCLUSIONS: Cognitive impairment, older age, and gender were associated with increased risk of poor outcome following hip fracture. The socioeconomic variables--social support and health perception--did not contribute significant additional information in explaining mortality or institutionalization risk. While demographic factors cannot be modified, physical function 3 months postfracture may be amenable to intervention and may reduce the risk of institutionalization. Intervening to increase postfracture physical function may be particularly beneficial to older patients, or to those who are cognitively impaired.     

Gender differences in functioning after hip fracture

BACKGROUND: Hip fracture is a significant health problem for men and women; between 25 and 30 percent of all hip fractures are sustained by men. Relatively little is known about gender differences in functional outcomes after hip fracture. The purpose of the current study is to compare post-hip fracture functional recovery of men and women. METHODS: A sample of 674 patients age 65 or older were recruited as part of the Baltimore Hip Studies and were followed longitudinally for 1 year following fracture. Information on prefracture status and hospital course of treatment was collected as well as functional data at baseline, 2, 6, and 12 months postfracture. Data were analyzed longitudinally using Generalized Estimating Equations (GEEs). RESULTS: Men in the study were generally younger and suffered greater comorbidity at time of fracture. Men further suffered higher mortality in the year following fracture. Among survivors, little difference between men and women was seen in patterns of recovery of function following fracture. CONCLUSIONS: Hip fracture is not a problem affecting just women. Recovery following fracture for men is probably no better than that for women, even after mortality differentially eliminates the frailest male participants. However, psychosocial factors, greater comorbidity, and higher rates of certain complications among men may require adjustments to interventions designed to restore function. Further research into the consequences of hip fracture for men and women is needed.     

Prefracture syndrome of the hip fracture: a case control study

BACKGROUND: Hip fractures result from both bone fragility and trauma, more often a sideways fall. Spontaneous hip fractures have been described; in such cases, patients reported pain ("prefracture" syndrome) in the hip region for weeks before the fracture. OBJECTIVES: To identify the proportion of patients who had a pain in the hip region before a hip fracture, to compare this proportion to the one observed in controls and to describe the characteristics of this pain. PATIENTS AND METHODS: For a period of 6 months, each subject (>65 years) treated for hip fracture was prospectively recruited in an orthopaedic surgery department. Exclusion criteria were: alterations of cognitive functions (defined by a mini mental state <20), refusal, and fractures related to bone metastasis or multiple myeloma. Subjects were compared to sex-matched controls consulting in an acute care geriatrics unit. They were asked about the occurrence of pain in hip region before the fracture and its characteristics.RESULTS:Thirty-eight patients (31 women, 7 men, mean age 83.1 [+/-7.6]) were included and were compared to 38 sex-matched controls (31 women, 7 men, mean age 82.7 [+/-6.9]). Among the 38 patients with hip fracture, 10 (26.3%) reported a pain in the hip region, compared with 2 (5.3%) in the control group (p=0.01). CONCLUSION: A better recognition of "prefracture" pain in the elderly may allow adequate management and treatment of patients, in order to avoid a proportion of hip fractures.     

Delirium is independently associated with poor functional recovery after hip fracture

OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status. DESIGN: Prospective cohort study. SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow-up extending into rehabilitation hospitals, nursing homes, and the community. PARTICIPANTS: One hundred twenty-six consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini-Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement. RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, and those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved. CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture.     

More than half of hip fracture patients do not regain mobility in the first postoperative year

Aim: To measure functional recovery and determine risk factors for failure to return to the prefracture level of mobility of hip fracture patients 1 year postoperatively. Methods: A prospective cohort follow‐up study of 390 hip fracture patients aged 65 years and older was carried out. Patients were stratified in categories based on prefracture mobility: mobile without aid, with aid in‐ and outdoors, or only mobile indoors. Immobile patients were excluded. Risk factors for not regaining prefracture mobility were identified. Results: Nearly half of all patients regained their prefracture level of mobility after 1 year. Mobile patients without an aid were less likely to return to their prefracture mobility level compared with patients who were mobile with aid or mobile indoors. After 1 year, 18.7% of all patients had become immobile. Most important independent risk factors for failure to return to the prefracture level of mobility were a limited prefracture level of activities of daily living and a delirium during admission. Conclusions: The risk not to regain prefracture mobility is highest in mobile patients without an aid. The risk of becoming immobile is higher in those having a lower prefracture mobility. Activities of daily living dependence and delirium were the main risk factors for not regaining mobility. Geriatr Gerontol Int 2013; 13: 334–341 .     

Self-rated health, activities of daily living, and mobility limitations among black and white stroke survivors

Objective. To explore racial differences in self-rated health (SRH) and its relationship to activities of daily living (ADLs) and mobility limitations among stroke survivors. Method. Data from 580 Black and White participants of the North Carolina Established Populations for Epidemiologic Studies of the Elderly (EPESE) were used to assess relationships between SRH, ADLs, and mobility variables. Fisher's exact tests, t tests, and logistic regression with backward selection (p < .20) were used. Results. No racial difference in SRH was found. SRH was significant in predicting ADL status among Whites only (OR = 0.23; CI = 0.08-0.69; p < .01). Participants older than 75 years had a greater likelihood of being in the lowest functioning ADL categories (OR = 2.31; CI = 1.48-3.60; p < .01). Discussion. Though no racial differences in SRH were found, the relationship between SRH, ADLs, and mobility status was moderated by race. SRH was predictive of limitations in Whites only. Observed differences suggest SRH construct may differ by race.     

Do clinical characteristics and outcome in nonagenarians with a hip fracture differ from younger patients?

Aim: To compare clinical characteristics and outcome of nonagenarian hip fracture patients with younger patients aged 65–89 years. Methods: This was a cohort follow‐up study of admissions for a hip fracture between 2005–2010 (mean follow up of 3.5 years) in two teaching hospitals in the Netherlands; 230 nonagenarians and 1014 patients aged 65–89 years were included. Clinical characteristics, adverse events, mobility and mortality were compared. Results: Nonagenarians were more likely to be female and anemic (both P < 0.001), and had more trochanteric fractures (P = 0.005). The number of American Society of Anesthesiologists III/VI classified patients did not differ between the two groups. During the hospital stay, adverse events were more frequently observed in nonagenarians compared with younger patients (P < 0.001). The length of stay was significantly longer in nonagenarians (P < 0.001), and the 90‐day readmission rate was similar. Absolute mortality was higher in nonagenarians (P < 0.001), excess mortality, however, was comparable. Before admission, 40.0% of the nonagenarians lived in their own home, and 40.9% had returned 3 months postfracture. The rate of returning to their own home was lower compared with younger patients (P < 0.001). Prefracture mobility was worse in nonagenarians compared with the younger group, but 3 months after discharge, the number of patients that regained prefracture mobility was comparable in both age groups. Conclusions: Nonagenarian hip fracture patients differ significantly from younger patients aged 65–89 years with respect to clinical characteristics and long‐term outcome. However, almost half of the nonagenarians returned to their own home and more than half regained their prefracture level of mobility. Given these findings, prevention strategies for hip fracture and adverse events during hospital stay that focus particularly on frail nonagenarians are highly recommended. Geriatr Gerontol Int 2013; 13: 190–197.     

Change in muscle mass and muscle strength after a hip fracture: relationship to mobility recovery

BACKGROUND: Hip fracture in elderly persons has a serious impact on long-term physical function. This study determines the change in muscle strength and muscle mass after a hip fracture, and the associations between these changes and mobility recovery. METHODS: Ninety community-dwelling women aged 65 years and older who had recently experienced a fracture of the proximal femur were included in the study. At 2 to 10 days after hospital admission, the women's grip strength, ankle dorsiflexion strength, and regional muscle mass (by dual-energy x-ray absorptiometry) were measured, and the prefracture level of independence for five mobility function items was assessed. All measurements were repeated at 12 months. RESULTS: At follow-up, only 17.8% of the women had returned to their prefracture level of mobility function for all five items. Mobility function recovery was not related to change in skeletal muscle mass of the nonfractured leg or the arms. However, women who lost grip strength (mean loss of -28.7%, SD = 16.9%), or who lost ankle strength of the nonfractured leg (mean loss of -21.5%, SD = 14.7%), had a worse mobility recovery compared with those who gained strength (p = .04 and p = .09, respectively). In addition, chronic disease (p = .03), days hospitalized (p = .04), and self-reported hip pain (p = .07) were independent predictors of decline in mobility function. CONCLUSIONS: The results suggest that loss of muscle strength, but not loss of muscle mass, is an independent predictor of poorer mobility recovery 12 months after a hip fracture. When confirmed by other studies, these findings may have implications for rehabilitation strategies after a hip fracture.     

Excess mortality or institutionalization after hip fracture: men are at greater risk than women

OBJECTIVES: To assess 2-year excess mortality or institutionalization risk associated with hip fracture in community-dwelling people aged 60 and over. DESIGN: Cohort study. SETTING: Auckland, New Zealand, from July 1991 to February 1996. PARTICIPANTS: Five hundred sixty-five community-dwelling older people recently hospitalized with a hip fracture and 782 randomly selected controls, frequency matched for age and gender, living in the same catchment area as the cases. MEASUREMENTS: Two-year mortality or institutionalization status. RESULTS: Over half (52.1%) of male hip fracture cases and 12.4% of male controls were dead or institutionalized, compared with 39.2% of female hip fracture cases and 19.7% of female controls. The odds ratio, adjusted for baseline demographic characteristics, medical status, and physical function, for death or institutionalization was 6.89 (95% confidence interval (CI) = 2.75-17.27) for men and 1.48 (95% CI = 1.02-2.19) for women. CONCLUSIONS: For both men and women who incur a hip fracture, the risks of dying or being institutionalized within 2 years are higher than for their peers. The independent effect of hip fracture on this outcome was significantly greater for men than women. The marked influences of prefracture health status, physical limitations, and gender on outcome have important implications for preventative strategies.     

Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes

BACKGROUND: Hip fracture patients are at increased risk of confusion or delirium due to the trauma associated with the injury and the rapid progression to hospitalization and surgery, in addition to the pain and loss of function experienced. Hip fracture patients who develop delirium may require longer hospital stays, are more often discharged to long-term care, and have a generally poor prognosis for returning home or regaining function in activities of daily living (ADL). METHODS: The present study examines the impact of delirium present on hospital admission in a sample of 682 non-demented, aged hip fracture patients residing in the community at the time of their fracture. In-hospital assessments designed to assess both prefracture and postfracture functioning, as well as follow-up interviews at 2, 6, 12, 18, and 24 months postfracture, were obtained from participants. RESULTS: Analyses indicate that baseline or admission delirium is an important prognostic predictor of poor long-term outcomes in persons without known cognitive impairment, after controlling for age, gender, race, comorbidity, and functional status. Delirium at admission (i.e., prior to surgery) was associated with poorer functioning in physical, cognitive, and affective domains at 6 months postfracture and slower rates of recovery. Impairment and delays in recovery may be further exacerbated by increased depressive symptoms in confused patients over time. Delirium on hospital admission was not a significant predictor of mortality after adjustment for confounding factors. CONCLUSIONS: The present findings further emphasize the significance of immediate detection and treatment of delirium in hip fracture patients to ameliorate the short and long-term effects of acute confusion on functional outcomes.     

Mortality and causes of death after hip fractures in The Netherlands.

The mortality rate and causes of death after a hip fracture were studied in 493 consecutive patients with a hip fracture. All patients were treated in three hospitals in Utrecht, The Netherlands. The mortality rate following hip fractures is high and age dependent. Forty-five patients, 38 women and 7 men, died during the period of hospitalization (9.1%). One year after the date of hip fracture 23.6% of the women had died and 33.0% of the men. Four years after the date of hip fracture the mortality rates in women and men were 44.4% and 55.3%, respectively. Male sex, concomitant illnesses and in-hospital complications are negative determinants of survival. The in-hospital mortality was due to: cerebrovascular accident (n = 7), cardiac decompensation (n = 12), myocardial infarction (n = 4), pulmonary infection (n = 6), intestinal bleeding (n = 1) and sepsis (n = 5). From the registration of death causes we learned that 54 deaths were directly due to the hip fracture, 4 due to bed sores, 34 due to infectious diseases, 62 due to cardiovascular disease, 22 due to cerebrovascular accidents, 14 due to diabetes mellitus, and 33 due to neoplasm. The high mortality rate within the first 8 weeks after the date of hip fracture was mainly attributed to the hip fracture.     

Quality of life, morbidity, and mortality after low trauma hip fracture in men

BACKGROUND: Osteoporotic hip fractures have been extensively studied in women, but they have been relatively ignored in men. OBJECTIVE: To study the mortality, morbidity, and impact on health related quality of life of male hip fractures. METHODS: 100 consecutive men aged 50 years and over, with incident low trauma hip fracture, admitted to Royal Cornwall Hospital, UK during 1995-97, were studied. 100 controls were recruited from a nearby general practice. Mortality and morbidity, including health status assessed using the SF-36, were evaluated over a 2 year follow up period. RESULTS: Survival after 2 years was 37% in fracture cases compared with 88% in controls (log rank test 62.6, df = 1, p = 0.0001). In the first year 45 patients died but only one control. By 2 years 58 patients but only 8 controls had died. Patients with hip fracture died from various causes, the most common being bronchopneumonia (21 cases), heart failure (9 cases), and ischaemic heart disease (8 cases). Factors associated with increased mortality after hip fracture included older age, residence before fracture in a nursing or residential home, presence of comorbid diseases, and poor functional activity before fracture. Patients with fracture were often disabled with poor quality of life. By 24 months 7 patients could not walk, 12 required residential accommodation, and the mean SF-36 physical summary score was 1.7SD below the normal standards. CONCLUSIONS: Low trauma hip fracture in men is associated with a significant increase in mortality and morbidity. Impaired function before fracture is a key determinant of mortality after fracture.     

Hip fracture in men-survival and subsequent fractures: a cohort study with 22-year follow-up

OBJECTIVES: To evaluate the influence of age on survival and risk of subsequent fracture in men with hip fracture, applying a residual lifetime perspective. DESIGN: Retrospective cohort study with 22‐year follow‐up. SETTING: Skåne University Hospital, Malmö, Sweden. PARTICIPANTS: Men aged 60 and older (N=226) with an index hip fracture during 1984/85. MEASUREMENTS: Twenty‐two‐year survival (mortality) and risk of new fractures evaluated in 5‐year age bands and age groups (<75, 75–84, ≥85). RESULTS: Mean age was 78±9. Mortality at 22 years was 98%. Survivors were all younger than 75 at inclusion. Mortality was dependent on age at all time points (18%, 38%, 69% at 1 year, increasing to 71%, 93%, 100% by 10 years in <75, 75–84, ≥85, respectively). Median survival was 5.4 years, 2.0 years, and 3 months, respectively, in these age groups, and 33%, 27%, and 13% of each age‐group sustained subsequent fractures, generally within 5 years. Overall 10‐year fracture risk was 29% (95% confidence interval (CI)=19–38%), increasing to 44% (95% CI=30–58%) when adjusted for mortality. Residual lifetime risk of new fracture was 33% (95% CI=23–43%), and mortality‐adjusted risk was 63% (95% CI=45–81%). Participants younger than 75 at index hip fracture were at greatest risk of new fracture (hazard ratio=2.7, 95% CI=1.1–6.4, P=.03). CONCLUSION: Almost one‐third of men with hip fracture have subsequent fractures during their remaining lifetime. Time at risk is highly dependent on age. Most new fractures occur in relatively younger men and within 5 years, whereas most aged 75 and older die before experiencing a new fracture.