Clinical outcomes and treatment of hip fractures

Lack of association between mortality and timing of surgical fixation in elderly patients with hip fracture: results of a retrospective population-based cohort study

BACKGROUND

Conventional wisdom suggests high-quality care for most patients with hip fractures is surgical fixation within 24 hours to reduce mortality and complications, although there is little evidence to support this standard.

OBJECTIVES

We sought to determine the relationship between timing of hip fracture surgery and early mortality.

DESIGN AND SUBJECTS

This was a retrospective population-based cohort study of 3981 patients with hip fractures>60 years of age that were admitted to hospitals in one Canadian health region from 1994-2000.

METHODS

We collected sociodemographic, prefracture comorbidity, and postoperative complication data. Timing of surgery was classified as within 24 hours ("early surgery," the referent group for all analyses), 24-48 hours, and beyond 48 hours. Main outcome was in-hospital mortality. We used multivariable logistic regression methods, including adjustments with propensity scores and a validated hip fracture-specific mortality index, to determine the independent association between early versus later surgery and mortality.

RESULTS

Median age of patients was 82 years, 71% were women, and 26% had >4 prefracture comorbidities. Unadjusted in-hospital mortality was 6%; it was 5% for those who had surgery within 24 hours or from 24 to 48 hours, 10% for surgery beyond 48 hours, and 21% for patients that did not have surgery. Compared with those who had surgery within 24 hours, there was no independent association between timing of surgery and in-hospital mortality (24-48 hours, adjusted odds ratio 0.89, 95% confidence interval 0.62-1.30, P=0.55; beyond 48 hours 1.30, 95% confidence interval 0.86-2.00], P=0.21).

CONCLUSIONS

The timing of surgical fixation of hip fracture was not associated with early mortality in carefully adjusted analyses, and the use of "surgery within 24 hours" as a measure of high quality care may be inappropriate.

Using a collaborative approach to reduce postoperative complications for hip-fracture patients: a three-year follow-up

BACKGROUND

To reduce perioperative complications for hip fracture, (1) patients were assigned admitting service using a simple clinical algorithm, (2) evidence-based guidelines and order sets were implemented for perioperative care; (3) a nurse specialist facilitated adherence to evidence-based interventions and mobility goals; and (4) patients and families were given an educational brochure highlighting the daily hospital course.

METHODS

A case series with pre/post intervention comparison was conducted for all patients with hip fracture (preintervention n = 97, postintervention n = 589) at 9 months before and 33 months after the intervention.

RESULTS

The algorithm assigned approximately one-third of patients to each of the three general services, with few to subspecialty services. Miscellaneous complications were almost eliminated, and significant reductions were observed in the proportion of patients with iatrogenic complications and postprocedure hemorrhage and hematoma. The percentage of patients with any postoperative complication fell from almost 60% to less than 10% by the end of the study.

CONCLUSIONS

This study provides preliminary data from which to investigate the effectiveness of collaborative approaches to management on the outcomes of care for medically complex and geriatric surgical patients.

Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems?

BACKGROUND

Adverse outcomes for patients with isolated hip fracture have been documented when preoperative delay is longer than 48 hours. An efficient system will have the capacity to repair all hip fractures within 48 hours. We hypothesized that in an efficient system, there would be a medical justification for a delay greater than 48 hours. The purpose of this study was to identify the causes and outcome of delay for hip surgery in an efficient system.

METHODS

All patients with isolated hip fracture admitted to a regional trauma center from April 1993 to March 2003 were reviewed. Demographics, presence of comorbidity, preoperative delay, complications, and mortality were collected. Univariate and multivariate analysis were carried out.

RESULTS

The cohort included 977 patients. Overall mortality was 12.2%. Surgery was performed within 24 hours in 53% of cases and within 48 hours in 87% of cases. The presence of comorbidity partly explained longer (>48 hours) surgical delays. Multivariate analysis revealed that age greater than 65, male sex, and the presence of pulmonary and cardiac comorbid conditions or an active cancer but not surgical delay were associated with mortality and complications. However, surgical delay was associated with longer postsurgical hospital stay, independently of the presence of comorbidity or increasing age.

CONCLUSIONS

Preoperative delay does not entail adverse outcomes when the surgery is delayed to allow for treatment of comorbid medical conditions. Preoperative delay is associated with a longer hospital stay. The presence of comorbidity only partly explains preoperative delay and adverse outcomes. A prospective study coding for the severity of comorbid conditions and the justification of the preoperative delay will be required to fully elucidate the link between delay and outcome.

Mortality associated with delay in operation after hip fracture: observational study

OBJECTIVE

To estimate the number of deaths and readmissions associated with delay in operation after femoral fracture.

DESIGN

Analysis of inpatient hospital episode statistics.

SETTING

NHS hospital trusts in England with at least 100 admissions for fractured neck of femur during the study period. Patients People aged > or = 65 admitted from home with fractured neck of femur and discharged between April 2001 and March 2004.

MAIN OUTCOME MEASURES

In hospital mortality and emergency readmission within 28 days.

RESULTS

There were 129,522 admissions for fractured neck of femur in 151 trusts with 18,508 deaths in hospital (14.3%). Delay in operation was associated with an increased risk of death in hospital, which was reduced but persisted after adjustment for comorbidity. For all deaths in hospital, the odds ratio for more than one day's delay relative to one day or less was 1.27 (95% confidence interval 1.23 to 1.32) after adjustment for comorbidity. The proportion with more than two days' delay ranged from 1.1% to 62.4% between trusts. If death rates in patients with at most one day's delay had been repeated throughout all 151 trusts in this study, there would have been an average of 581 (478 to 683) fewer total deaths per year (9.4% of the total). There was little evidence of an association between delay and emergency readmission.

CONCLUSIONS

Delay in operation is associated with an increased risk of death but not readmission after a fractured neck of femur, even with adjustment for comorbidity, and there is wide variation between trusts.

Inpatient rehabilitation outcome after hip fracture surgery in elderly patients: a prospective cohort study of 946 patients

OBJECTIVE

To identify the factors associated with inpatient rehabilitation outcome after surgical repair of hip fracture in elderly patients.

DESIGN

A noninterventional prospective cohort study.

SETTING

Geriatric inpatient rehabilitation center in a tertiary university medical center in southern Israel.

PARTICIPANTS

Patients (N=946) aged 65 years of age or older who were hospitalized for rehabilitation after surgery for hip fracture.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional studies by the FIM instrument and a broad spectrum of clinical, demographic, and social variables. Stepwise multiple regression was used to assess the relative contribution of the variables to the variance of the percentage change in the FIM score during the course of rehabilitation in relation to the severity of the functional impairment at its inception.

RESULTS

Eight variables were significantly and independently associated with rehabilitation outcome. Prefracture FIM scale (standardized regression coefficient in multiple regression [beta]=.261, P<.001), serum albumin at discharge (beta=.222, P<.001), Folstein Mini-Mental State Examination (beta=.174, P<.001), visual impairment (beta=-.089, P=.002), dyspnea at mild exertion (New York Heart Association class III) (beta=-.080, P=.005), age (beta=-.080, P=.007), poststroke motor impairment (beta=-.072, P=.011), and decreased serum folic acid (beta=-.055, P=.047). The total percentage of the explained variance of the primary rehabilitation outcome measure accounted for by these 8 variables (adjusted R(2)) was 31.9%.

CONCLUSIONS

The outcome of rehabilitation of elderly patients after surgical repair of hip fracture is associated with 4 clinical and nutritional correctable parameters. The other 4 variables that are associated with the process cannot be corrected but may help predict outcomes and adjust expectations.

Body mass index and functional recovery after hip fracture: a survey study of 510 women

BACKGROUND AND AIMS

Low body mass index (BMI) is associated with high risk of osteoporosis and fractures, but its impact on functional recovery after fractures is unknown. Our aim was to investigate the association between BMI and both functional recovery and period of rehabilitation in hip-fractured women.

METHODS

510 out of 580 Caucasian women with hip fracture, admitted consecutively to a rehabilitation hospital, were investigated in this retrospective study. Functional recovery was assessed using the Barthel index score.

RESULTS

In the 510 women, BMI was 22.8 +/- 4.1 kg/m2 (mean +/- SD). After adjustment for age, femur bone mineral density, and the Barthel index assessed on admission to rehabilitation, a significant negative association was found between BMI and both the Barthel index score after rehabilitation and changes in it resulting from rehabilitation (p < 0.001). After adjustment for age and the Barthel index assessed on admission to rehabilitation, a significant positive association was found between BMI and period of rehabilitation (p < 0.001). The results were similar when BMI was evaluated either as individual values or after categorization according to World Health Organization criteria.

CONCLUSIONS

In a sample of hip-fractured women, BMI was negatively associated with Barthel index scores and positively associated with period of rehabilitation. BMI may affect function after hip fracture, apart from hip fracture risk: subjects with higher BMI and low hip fracture risk may have poorer functional recovery in case of hip fracture, despite prolonged rehabilitation. Conversely, subjects with lower BMI and high hip fracture risk may have better functional recovery in case of hip fracture.

The effectiveness of orthopaedic trauma theatres in decreasing morbidity and mortality: a study of 701 displaced subcapital hip fractures in two trauma centres

In countries with universal health care systems patients frequently wait days for their "emergency" surgery. A general trend in orthopaedic traumatology is the advent of daily, dedicated orthopaedic trauma theatres. Availability of trauma theatres is believed to decrease morbidity and mortality, but this remains unproven. A retrospective review comparing morbidity and mortality outcomes between two similar level-one trauma centres (one without a dedicated trauma room system) was undertaken. We reviewed 701 elderly patients receiving hemiarthroplasties for displaced subcapital hip fractures over a 76-month period. Patients were similar between centres in terms of age, gender ratio and comorbidities. Statistically significant differences were found favouring the dedicated trauma room system with approximately half the operative delay and post-operative morbidity. A trend towards decreased mortality was also seen. This study supports the use of regular orthopaedic trauma theatres in tertiary care institutions.

Factors affecting ambulatory status and survival of patients 90 years and older with hip fractures

This study was done to assess the long-term functional outcome of very elderly patients with hip fractures, to determine whether bone mineral density and prevalent vertebral fractures could affect mortality and ambulatory status, and to examine which patient characteristics reported in the literature are predictive of patient mortality and ambulatory status. Seventy-four patients 90 years and older with hip fractures were analyzed and followed up for at least 4 years or until death. The mean age of the patients was 92.8 years and all were treated surgically. Walking ability before injury was better than at discharge; walking ability decreased during the first year after discharge, but thereafter reached a plateau. The predictors of survival were the preoperative American Society of Anesthesiologists score, walking ability, fracture type, type of surgery, and the number of prevalent vertebral fractures on admission. Dementia and the number of prevalent vertebral fractures were predictors of the recovery of walking ability. Type of surgery and fracture type are collinear variables, and because it is difficult to separate the effects of one versus the other, additional well-designed, randomized studies on the effect of the type of surgery and fracture type on outcome are needed.

LEVEL OF EVIDENCE

Prognostic study, Level II-1 (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Early diagnosis of occult hip fractures MRI versus CT scan

OBJECTIVE

We compared Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) in diagnosis of a painful hip in elderly patients after trauma. We report on accuracy, efficiency and benefits.

DESIGN

We assessed 13 patients, average age 73 years, after fall with plain X-rays showing no evidence of fracture. There were two groups: Group A (six patients) underwent CT and MRI; Group B underwent MRI only.

RESULTS

In Group A where all of the six patients underwent CT and MRI, four of the CT images resulted in misdiagnosis due to inaccuracy. In Group B where all the seven patients underwent only MRI, all the results were accurate and enabled a precise and fast diagnosis.

CONCLUSIONS

MRI was found to be a more accurate modality than CT scan for obtaining early diagnosis of occult hip fractures. These results point out the advantage of immediate MRI imaging in patients with occult hip fracture enabling a more effective treatment, a shorter hospitalisation period entailing decreased medical costs.

The effect of type of hip protector and resident characteristics on adherence to use of hip protectors in nursing and residential homes—an exploratory study

OBJECTIVES

To investigate the factors influencing the acceptability of hip protectors to residents of nursing and residential homes, especially the effect of hip protector type, and resident characteristics.

DESIGN

A randomised controlled trial with 12 weeks follow-up. Participants were randomised to receive either Safehip or HipSaver hip protectors.

SETTING/PARTICIPANTS

109 residents aged 61 to 98 years from seven residential homes and two nursing homes in Northern Ireland.

MAIN OUTCOME MEASURES

Percentage day-time use of the hip protectors over 12 weeks and ongoing use at 12 weeks.

RESULTS

42% (119/285) of residents invited to enter the study agreed to take part, and 109 started to wear the hip protectors. 43.1% (47/109) were still using them at 12 weeks. Mean percentage day-time use for all residents during 12 weeks was 48.6%. There was no significant difference in percentage day-time use (p=0.40), or use at 12 weeks (p=0.56) between the residents wearing Safehip and HipSaver protectors. Greater percentage daytime use of hip protectors was associated with being resident in a home for the elderly mentally infirm (75.1%, p<or=0.0005), having a low (12 or less) Barthel score (61.1%, p<or=0.0005), and having been injured in a fall in the last 12 months (57.3%, p=0.012).

CONCLUSIONS

The type of hip protector appeared to make no difference to their continued use by residents. Residents with a history of a fall and those who are physically and mentally incapacitated appear to be more likely to wear hip protectors. These residents, who are at high risk of falling, are also highly dependent on nursing staff. Efforts to increase hip protector use in residential and nursing home should focus on staff, who are in the best position to advise and influence residents and their relatives.

Nutritional supplementation for hip fracture aftercare in older people

BACKGROUND

Fractures of the hip are an important cause of later ill health and mortality in older people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital.

OBJECTIVES

This review assesses the effects of nutritional interventions in older people recovering from hip fracture.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 3, 2004), MEDLINE (1966 to October week 1 2004), Nutrition Abstracts and Reviews, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, the National Research Register and reference lists. We contacted investigators and handsearched four nutrition journals.

SELECTION CRITERIA

Randomised and quasi-randomised trials of nutritional interventions for mainly older people (aged over 65 years) with hip fracture.

DATA COLLECTION AND ANALYSIS

Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from all trialists, and pooled data for primary outcomes.

MAIN RESULTS

Eighteen randomised trials involving 1306 participants were included. Overall trial quality was poor; specifically in terms of allocation concealment, assessor blinding and intention-to-treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Eight trials evaluated oral multinutrient feeds: these provided non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84). Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97), but the studies were heterogeneous regarding case mix. There was insufficient information for other outcomes. The specific effect of protein given in an oral feed was tested in three trials. There was no evidence for an effect on mortality (RR 1.38, 95% CI 0.82 to 2.34). Protein supplementation may have reduced the number of long term complications and days spent in rehabilitation wards. Two trials, testing intravenous thiamin (vitamin B1) and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either vitamin supplement.

AUTHORS' CONCLUSIONS

While some evidence exists for the effectiveness of oral protein and energy feeds, overall the evidence for the effectiveness of nutritional supplementation remains weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.

Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures

Our objectives were to better define the rates and determinants of in-hospital and 1-year mortality after hip fracture. We studied a population-based cohort of 3981 hip fracture patients. Using multivariable regression methods, we identified risk factors for mortality (older age, male sex, long-term care residence, 10 prefracture co-morbidities) and calculated a hip fracture-specific score that could accurately predict or risk-adjust in-hospital and 1-year mortality. Our methods, after further validation, may be useful for comparing outcomes across hospitals or regions.

INTRODUCTION

Hip fractures in the elderly are common and associated with significant mortality and variations in outcome. The rates and determinants of mortality after hip fracture are not well defined. Our objectives were (1) to define the rate of in-hospital and 1-year mortality in hip fracture patients, (2) to describe co-morbidities at the time of fracture, and (3) to develop and validate a multivariable risk-adjustment model for mortality.

MATERIALS AND METHODS

We studied a population-based cohort of 3981 hip fracture patients > or =60 years of age admitted to hospitals in a large Canadian health region from 1994 to 2000. We collected sociodemographic and prefracture co-morbidity data. Main outcomes were in-hospital and 1-year mortality. We used multivariable regression methods to first derive a risk-adjustment model for mortality in 2187 patients treated at one hospital and then validated it in 1794 patients treated at another hospital. These models were used to calculate a score that could predict or risk-adjust in-hospital and 1-year mortality after hip fracture.

RESULTS AND CONCLUSIONS

The median age of the cohort was 82 years, 71% were female, and 26% had more than four prefracture co-morbidities. In-hospital mortality was 6.3%; 10.2% for men and 4.7% for women (adjusted odds ratio, 1.8; 95% CI, 1.3-2.4). Mortality at 1 year was 30.8%; 37.5% for men and 28.2% for women (adjusted p < 0.001). Older age, male sex, long-term care residence, and 10 different co-morbidities were independently associated with mortality. Risk-adjustment models based on these variables had excellent accuracy for predicting mortality in-hospital (c-statistic = 0.82) and at 1 year (c-statistic = 0.74). We conclude that 1 in 15 elderly patients with hip fracture will die during hospitalization, and almost one-third of those who survive to discharge will die within the year. The determinants of mortality were primarily older age, male sex, and prefracture co-morbidities. Our hip fracture-specific risk-adjustment tool is pragmatic and reliable, and after further validation, may be useful for comparing outcomes across different hospitals or regions.

Serum levels of 25-Hydroxyvitamin D and functional recovery after hip fracture

OBJECTIVE

To evaluate the association between serum levels of 25-hydroxyvitamin D (25[OH]D(3)) and functional recovery after hip fracture.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

A total of 350 white hip-fracture patients consecutively admitted to a rehabilitation hospital. Thirty-five patients were excluded because their hip fracture was caused by major trauma or cancer affecting the bone or they could not complete rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients underwent 25(OH)D(3) assessment at a mean +/- standard deviation of 21.3+/-8.1 days after the hip fracture. Functional recovery was evaluated by using Barthel Index scores.

RESULTS

Low levels of 25(OH)D(3) were found (median, 6.9 ng/mL). By using the Spearman rank correlation test, a significant positive correlation was observed between serum 25(OH)D(3) and Barthel Index score assessed on admission (rho=.218, P <.001) and discharge (rho=.198, P <.001), but not with the change in Barthel Index score attributable to rehabilitation. Linear multiple regression showed that the association between 25(OH)D(3) and Barthel Index score was independent of 11 confounding variables: age, sex, hip-fracture type, pressure ulcers, cognitive impairment, neurologic impairment, infections, time between fracture occurrence and 25(OH)D(3) evaluation, comorbidity, surgical procedure type, and previous hip fractures.

CONCLUSIONS

In the study population, serum 25(OH)D(3) was an independent predictor of functional recovery assessed by Barthel Index score after hip fracture but not of the change in the functional score resulting from rehabilitation.

The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly

The optimal time for the operation of hip fractures in elderly is not clear. Most of the data indicate that early operation is associated with better prognosis and improved health quality. We aimed to investigate the effect of timing of surgical intervention on the frequency of post-operative complications, recovery of weight bearing ability, total hospitalization time and activities of daily living (ADL) scores. Sixty five patients subjected to surgical repair were followed up. All were evaluated for their ADL before fracture, post-operative 1st, 3rd, 6th and 12th month. The patients operated within 5 days after hospitalization constituted the early group (n = 38, 24 females, 14 males; mean age = 76.16 +/- 7.08 years), and the patients operated after the fifth day served as the late group (n = 27, 18 females, 9 males; mean age = 75.81 +/- 7.50). Time of recovery of weight bearing ability and total hospitalization time were significantly higher in the late group (P < 0.05). ADL scores in 1st, 3rd and 6th month after surgery were significantly lower (P < 0.05), and death rates on post-operative 1st and 12th month were significantly higher in the late group (P < 0.05). Elderly, operated within 5 days of the hip fracture have increased survival time and better life quality than those operated after the fifth day of the admission. The data supports the previous reports which indicate the necessity of the early operation of elderly hip fractures.

Hip fractures in centenarians

The centenarian population is increasing yet there is little about their morbidity and mortality rates following hip fracture. The aim was to review centenarians treated for proximal femoral fractures in Edinburgh describing treatment outcomes in relation to mortality, walking ability and residential status comparing centenarians with a the more typical hip fracture population. In this retrospective review, 18 centenarians sustaining hip fractures in Edinburgh between 1998 and 2002 were compared to 18 randomly selected "normal" hip fracture patients aged 75-83 years. Centenarian in-hospital, 1 and 4 month mortality was 11.1, 33.3 and 50%, respectively, versus 0, 0 and 5.6% in the normal group. Centenarian 4 month mortality was significantly greater than that of the normal group (Fisher's Exact Test, P = 0.00723). A total of 22.2% of centenarians regained pre-fracture walking ability compared to 58.8% of the normal patients. A total 28.6% of centenarians could continue living independently post-fracture compared to 69.2% of the normal group.

Functional recovery and length of stay after hip fracture in patients taking corticosteroids

OBJECTIVE

To evaluate the functional recovery and the length of stay after hip fracture in patients receiving corticosteroids.

DESIGN

A total of 796 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 36 of 796 were currently treated with either oral (n = 23) or inhaled (n = 13) corticosteroids.

RESULTS

No significant differences were shown between corticosteroid users and controls for Barthel index score at admission or discharge, change in Barthel index score resulting from rehabilitation, and length of stay. Multiple regression, including 11 confounding variables, showed that several factors, but not the treatment with corticosteroids, were significantly associated with the Barthel index score or the length of stay. The results were similar when the two subgroups of patients receiving corticosteroids were evaluated separately. In the subgroup of the patients receiving oral corticosteroids, no meaningful correlations were observed between the daily dose (milligrams of prednisone equivalent) and the Barthel index score, the change in the Barthel index score attributable to rehabilitation, or the length of stay.

CONCLUSIONS

After hip fracture, neither the functional recovery nor the length of stay were significantly affected by the current treatment with corticosteroids.

Can functional status, after rehabilitation, independently predict long-term mortality of hip-fractured elderly patients?

BACKGROUND AND AIMS

Hip fractures are one of the most serious causes of functional impairment and death in the elderly. The aim of this study was to evaluate prospectively the predictive value of functional performance, after rehabilitation, of hip fracture on long-term mortality in community-dwelling patients.

METHODS

One hundred and seventy-one patients aged 60 years and over, admitted to a geriatric rehabilitation day unit after inpatient rehabilitation, were followed for up to 4 years. Main outcome measures were Functional Independent Measure (FIM), Timed Get Up and Go test (GUAG), cognitive status using the Mini-Mental State Examination on admission, and mortality during the follow-up period. Kaplan-Meier analysis was carried out on survival curves.

RESULTS

All 24 deceased patients performed the GUAG test in > 20 seconds. Although approaching significance, the survival curves were not statistically different between patients performing the test in < or = 20 and those performing it in > 20 seconds (p = 0.08). Survival curves were significantly higher in patients with a FIM score of > or = 90 (p = 0.004), no cardio-cerebrovascular (CCV) diseases (p = 0.001) and no diabetes mellitus (p = 0.01). There were no differences in survival according to age, gender, educational level, marital status, surgical vs conservative treatment, and cognition. A multivariate analysis including FIM score, CCV diseases and diabetes mellitus, demonstrated that only CCV disease was an independent variable for survival (p = 0.02).

CONCLUSIONS

Performance, as evidenced by FIM scores after rehabilitation for hip fracture, may provide additional useful information on long-term survival. However, since functional status after rehabilitation is not an independent risk factor for long-term mortality, its predictive value must be interpreted in view of the comorbidities, mainly CCV diseases, which are more important to the risk of mortality than the event of hip fracture itself.

Management of intracapsular femoral neck fractures in the elderly; is it time to rethink our strategy?

We reviewed 100 adult patients who had a traumatic intracapsular femoral fracture internally fixed prior to 1998, with full clinical and radiological data available. End points were complete clinical and radiological union of the fracture, non-union, avascular necrosis or fixation failure. The incidence of non-union and avascular necrosis was found to be 13 and 11%, respectively. The following factors did not influence the development of avascular necrosis or non-union; fracture displacement, screws inserted (two or three), osteoporosis, parallelism of screws, presence of screws in each "quadrant" and the experience or seniority of the surgeon. The factors influencing a poor outcome were the age of the patient at injury, reduction gap at the fracture site, alignment after reduction of the fracture especially on AP view and having all screw threads crossing beyond the fracture site. We conclude that the incidence of non-union and avascular necrosis following fixation of femoral neck fractures in our study is less than generally reported with no statistical difference between displaced and undisplaced fractures. Traditional fixation factors such as screw position and number do not seem to significantly affect the outcome with the quality of reduction being most important. Thus, the majority of patients under the age of 70 with displaced intracapsular fracture should be considered for internal fixation.

Frailty and the biochemical effects of recombinant human growth hormone in women after surgery for hip fracture

We report a randomised double blind controlled trial investigating the short-term biochemical and adverse clinical responses to recombinant human growth hormone (r-hGH) after surgery for hip fracture. Hip fractures are common, dangerous and expensive, typically affecting frail women with osteoporosis and reduced muscle mass and strength, factors also associated with poor clinical outcomes. Growth hormone therapy increases IGF-I levels, promotes anabolism and increases muscle strength in well older people and selected patient groups and therefore has therapeutic potential to assist recovery of frail patients.Thirty-one women, mean age 86 years, received 14 nightly subcutaneous injections of r-hGH 0.05 mg/kg/day (high dose) or 0.025 mg/kg/day (low dose), or placebo from the 4th post-operative day. There were several serious adverse clinical events but no excess number of adverse events in the r-hGH treatment groups. The r-hGH treatment groups had similar serum IGF-I and IGFBP-3 responses, both significantly different from placebo. The large inter-individual variation of IGF-I responses were inversely correlated with pre-treatment indicators of frailty (body composition and functional abilities).

Gender differences in mortality after hip fracture: the role of infection

Possible explanations for the observed gender difference in mortality after hip fracture were examined in a cohort of 804 men and women. Mortality during 2 years after fracture was identified from death certificates. Men were twice as likely as women to die, and deaths caused by pneumonia/influenza and septicemia showed the greatest increase.

INTRODUCTION

Men are more likely to die after hip fracture than women. Gender differences in predisposing factors and causes of death have not been systematically studied.

MATERIALS AND METHODS

Participants (173 men and 631 women) in the Baltimore Hip Studies cohort enrolled in 1990 and 1991, at the time of hospitalization for hip fracture, were followed longitudinally for 2 years. Cause-specific mortality 1 and 2 years after hip fracture, identified from death certificates, was compared by gender and to population rates.

RESULTS AND CONCLUSIONS

Men were twice as likely as women to die during the first and second years after hip fracture (odds ratio [OR], 2.28; 95% CI, 1.47, 3.54 and OR, 2.21; 95% CI, 1.48, 3.31). Prefracture medical comorbidity, type of fracture, type of surgical procedure, and postoperative complications did not explain the observed difference. Greatest increases in mortality, relative to the general population, were seen for septicemia (relative risk [RR], 87.9; 95% CI, 16.5, 175 at 1 year and RR, 32.0; 95% CI, 7.99, 127 at 2 years) and pneumonia (RR, 23.8; 95% CI, 12.8, 44.2 at 1 year and RR, 10.4; 95% CI, 3.35, 32.2 at 2 years). The magnitude of increase in deaths caused by infection was greater for men than for women in both years. Mortality rates for men and women were similar if deaths caused by infection were excluded (3.46 [1.79, 6.67] and 2.47 [1.63, 3.72] at 1 year and 0.96 [0.48, 1.91] and 1.26 [0.80, 1.98] at 2 years). Deaths related to infections (pneumonia, influenza, and septicemia) seem to be largely responsible for the observed gender difference. In conclusion, an increased rate of death from infection and a gender difference in rates persists for at least 2 years after the fracture.

Thromboprophylaxis practice patterns in hip fracture surgery patients: experience in Perth, Western Australia

BACKGROUND

International guidelines recommend that all patients undergoing hip fracture surgery receive specific thromboprophylaxis. The purpose of the present study was to examine current thromboprophylaxis practice patterns in patients undergoing hip fracture surgery at Royal Perth Hospital.

METHODS

A total of 129 consecutive patients admitted to Royal Perth Hospital between 4 February and 21 July 2002 for surgical repair of a fractured neck of femur, was studied. The primary outcome was the frequency, type, and duration of thromboprophylaxis use during hospitalization.

RESULTS

Mean patient age was 79.4 +/- 13.4 years and 69.8% (90/129) were female. Seventy-four patients (57.8%; 95% confidence interval (CI): 48.8-66.8%) received specific thromboprophylaxis during hospitalization, including 50 patients (39.1%; 95%CI: 30.6-48.1%) who received pharmacological prophylaxis only, three (2.3%; 95%CI: 0.5-6.7%) who received mechanical prophylaxis only, and 21 (16.4%; 95%CI: 10.5-24.0%) who received both mechanical and pharmacological prophylaxis. Of those receiving pharmacological prophylaxis, 35 (49.3%; 95%CI: 37.2-61.4%) received low-molecular-weight heparin, 26 (36.6%; 95%CI: 25.5-48.9%) received low-dose unfractionated heparin, eight (11.3%; 95%CI: 5.0-21.0%) received warfarin, 35 (49.3%; 95%CI: 37.2-61.8%) received aspirin or clopidogrel, and 27 (38.0%; 95% CI: 26.8-50.3%) received combined anticoagulant and antiplatelet prophylaxis. The median duration of mechanical prophylaxis was 8 days (range: 6-12 days) and that of pharmacological prophylaxis was 12 days (range: 6-26 days). When the 32 patients already taking aspirin or warfarin at the time of admission were excluded, only 45 (46.9%; 95%CI: 36.6-57.3%) of the remaining 96 patients received specific thromboprophylaxis.

CONCLUSION

Specific thromboprophylaxis remains under-utilized in patients undergoing surgery for hip fracture at Royal Perth Hospital. These data should prompt the implementation of effective strategies to improve thromboprophylaxis practice patterns in high-risk orthopaedic patients.

Glucocorticoid-treated sheep as a model for osteopenic trabecular bone in biomaterials research

The purpose of this study was to determine the alterations in ovine trabecular bone induced by a combination of ovariectomy and steroid treatment. Twenty-four female skeletally mature Merino sheep were randomly assigned to ovariectomy alone (OVX), ovariectomy combined with glucocorticoid treatment for 6 months (OVX + GC), or no treatment (control). Biopsies of trabecular bone were harvested 6 and 12 months after the beginning of the study from the proximal tibia. The biopsies were scanned for apparent bone mineral density by quantitative computed tomography and were mechanically tested. Three-dimensional bone reconstructions were obtained by micro-computed tomography. Trabecular bone from the OVX + GC animals had a markedly reduced apparent bone mineral density (27% less than control), bone volume (34%), and elastic modulus (36%) at 6 months. At 12 months, the reductions in apparent bone mineral density (33%), bone volume (37%), and elastic modulus (62%) appeared to be even more pronounced. Ovariectomy alone did not result in a perceptible reduction in any parameter. The combination of ovariectomy and glucocorticoid treatment in sheep resulted in a successful induction of substantial loss of trabecular bone and thus may serve as a large-animal model for osteopenic trabecular bone for the development and testing of orthopedic implants and techniques under osteoporotic conditions.

Pins and plaster aren't enough: a call for the evaluation and treatment of patients with osteoporotic fractures

A history of an osteoporotic fracture is a powerful predictor of future fractures. Older patients who sustain low trauma fractures are candidates for interventions that should include confirmation of the diagnosis of osteoporosis, adequate calcium and vitamin D administration, and use of an osteoporosis therapy that is proven to lower fracture risk. Recently, however, several reports in the literature have indicated that, in general, those physicians who diagnose and treat fractures, i.e. radiologists, orthopedic surgeons, physiatrists, and those who provide general medical care to these fracture patients, the primary care physicians, are not evaluating patients with acute fractures for the presence of osteoporosis and are not prescribing calcium, vitamin D, or specific pharmacological therapy to reduce future fracture risk. These reports suggest that implementation of a standard of care for the subsequent medical management of the older patient with an acute fracture is needed urgently. Diagnostic tools and several effective therapies exist, but these are underused by the physicians who interface with these patients. A call to action is necessary to reduce the human and economic costs associated with this serious and treatable disease.

Predicting survival after treatment for fracture of the proximal femur and the effect of delays to surgery

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the prognosis after treatment for femoral neck fracture, to assess the impact of delay to surgery, and to devise a clinical prediction rule and score.

METHODS

A prospective observational study was conducted in which 1780 patients treated surgically in two teaching hospitals between 1 November 1997 and 31 October 1999 were followed over 12 months. Logistic regression was used to distinguish the effects of predictor variables on survival. Using a probit transformation of the predicted posterior probabilities of death, a prognostic score was devised with scores constrained so that a nominal score of approximately 90 represented a 50:50 chance of survival over 12 months.

RESULTS

Mortality was 30.1% in men and 19.5% in women. Increasing age, male gender, longer pre-operative delay, a higher American Society of Anesthesiology score, a lower Mental Test score, and a lower activities of daily living (Barthel) score were associated with increased risks of death. Of those waiting between 1 and 5 days for surgery, approximately 8 medium-risk and 17 high-risk patients (with prognostic scores of 90 and 120, respectively) would have to have their delay reduced to < 24 hours to yield one additional survivor.

CONCLUSION

The application of prediction rules must be guided by ethical, social, and scientific concerns.

A systematic review of protein and energy supplementation for hip fracture aftercare in older people

OBJECTIVES

To evaluate whether protein and energy supplementation influences recovery after hip fracture.

DESIGN

Systematic review of randomised and quasi-randomised trials in people aged 65 y and over.

DATA SOURCES

We searched seven electronic databases from 1966 to April 2002, four journals and reference lists of relevant articles. We contacted trial investigators and experts for details of other trials.

MAIN OUTCOME MEASURES

Mortality, complications and unfavourable outcome (mortality or survivors with complications) were the primary outcomes. We also sought data on length of hospital stay, functional status after hip fracture, quality of life and compliance with supplementation.

RESULTS

In total, 12 randomised trials involving 898 participants were included. Nine trials evaluated protein and energy supplementation (five oral and four nasogastric feeding), and a further three trials tested oral protein supplementation. Potential biases resulting from inadequate allocation concealment and lack of assessor blinding and intention-to-treat analysis, as well as the limited outcome data, mean that the results must be interpreted with caution. Pooled data from eight of the nine trials evaluating protein and energy supplements showed no evidence for an effect on mortality (relative risk 0.92, 95% CI 0.56-1.50). Limited data from only three trials showed that oral protein and energy supplements may reduce unfavourable outcome (relative risk 0.52, 95% CI 0.32-0.84).

CONCLUSION

Based on limited evidence, oral protein and energy supplementation after hip fracture may reduce unfavourable outcome. Further evidence from good-quality randomised trials is required to inform clinical practice.

Functional recovery and length of stay after hip fracture in patients with neurologic impairment

OBJECTIVE

To evaluate the functional recovery and the length of stay after hip fracture in patients with neurologic impairment.

DESIGN

A total of 577 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 71 of 577 were affected by neurologic impairment caused by stroke with hemiplegia (n = 37), Parkinson's disease (n = 25), or other diseases (n = 9).

RESULTS

Mean Barthel index was significantly lower in the patients with neurologic impairment than in the controls: 10.8 (95% confidence interval, 5.9-15.6; P < 0.001) at admission and 13.1 (95% confidence interval, 5.55-20.65; P < 0.001) at discharge. Multiple regression including eight confounding variables showed that neurologic impairment was negatively associated with the Barthel index. However, the mean increase in Barthel index through the course of rehabilitation was not affected by neurologic impairment. The length of stay was significantly higher in the patients with neurologic impairment, 3.84 days (95% confidence interval, 0.51-7.17; P < 0.05), and multiple regression showed that neurologic impairment was positively associated with the length of stay.

CONCLUSIONS

After hip fracture, the presence of neurologic impairment was associated with lower Barthel index and longer length of stay, but it did not affect the increase in Barthel index due to a course of rehabilitation.

Hip fractures among the elderly: causes, consequences and control

This review examines all pertinent literature sources published in the English language between 1966 to the present concerning hip fracture epidemiology, hip fracture injury mechanisms, and hip fracture management strategies. These data reveal hip fractures have several causes, but among these, the impact of falls and muscle weakness, along with low physical activity levels seems to be the most likely explanation for the rising incidence of hip fracture injuries. Related determinants of suboptimal nutrition, drugs that increase fall risk and lower the safety threshold and comorbid conditions of the neuromuscular system may also contribute to hip fracture disability. A number of interventions may help to prevent hip fracture injuries, including, interventions that optimize bone mass and quality, interventions that help prevent falls and falls dampening interventions. Rehabilitation outcomes may be improved by comprehensive interventions, prolonged follow-up strategies and ensuring that all aging adults enjoy optimal health.

Femur bone mineral density is independently associated with functional recovery after hip fracture in elderly women

OBJECTIVE

To evaluate the association between femur bone mineral density (BMD) and functional recovery after hip fracture.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation hospital in Italy.

PARTICIPANTS

A total of 233 of 263 white women with hip fracture consecutively admitted to a rehabilitation hospital.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients underwent BMD assessment by dual-energy x-ray absorptiometry (DXA) at the proximal femur (5 sites) on admission. Functional recovery was evaluated by using Barthel Index scores.

RESULTS

A positive correlation was found between BMD and Barthel Index scores assessed on both admission and discharge (r range,.16-.24, depending on the site of BMD measurement). Linear multiple regression showed that the association between BMD and Barthel Index score was independent of 10 confounding variables: age, body mass index, fracture type, pressure ulcers, cognitive impairment, neurologic diseases, total lymphocyte count as a nutritional index, time between fracture occurrence and DXA assessment, comorbidity, and surgical procedure. Conversely, no significant associations were found between BMD and the change in Barthel Index score attributable to rehabilitation.

CONCLUSIONS

In the study population, femur BMD was an independent predictor of the functional recovery assessed by Barthel Index score after hip fracture, but not of the change in the functional score resulting from rehabilitation.

Hip fracture surgery: is the pre-operative American Society of Anesthesiologists (ASA) score a predictor of functional outcome?

BACKGROUND AND AIMS

Many studies have identified specific demographic, social, health or life-style pre-operative indicators of long-term outcome among older hip fracture patients who underwent surgical treatment. The purpose of this study was to determine the predictive value of peri- and intra-operative factors, and more specifically of the pre-operative American Society of Anesthesiologists (ASA) score on functional outcome in these patients.

METHODS

A questionnaire designed to assess pre-fracture functional and health status was administered to surgically treated hip fracture patients. Post-fracture functional and health status was further ascertained by in-home interview one year after the operation. Among 140 consecutive eligible patients older than 65 years, 10 either refused subsequent interviews or could not be contacted; an additional 16 patients died during the year of follow-up, leaving 114 patients available for this study.

RESULTS

The average age of the patients was 82.4 years. Almost two-thirds of them suffered from severe systemic disease, whether or not incapacitating (ASA grades III-IV). Subjects classified in these categories presented more frequently with cardiovascular disorders, were more frequently disoriented, and already had some pre-fracture difficulty with ambulation. The mortality at one year was almost nine times higher in severely impaired patients (grades III-IV) than in healthy or mildly affected patients (grades I-II). Functional outcome and/or ambulatory ability assessed at one year did not reveal any statistically significant difference between the ASA I-II and III-IV groups. The most pronounced difference was noticed for the functional independence measured by the ADL score (p = 0.236). Better prognoses were consistently recorded for patients with an intracapsular fracture, for those who were operated within 24 hours, for those treated with a prosthesis as opposed to internal fixation, and for those whose operating time was less than 1 1/2 hours.

CONCLUSIONS

Although the ASA classification is a good predictor of long-term mortality, the findings of the present investigation do not conclusively associate ASA score with post-operative restoration of mobility and functional independence.

Patients with hip fracture: subgroups and their outcomes

OBJECTIVES

To present several alternative approaches to describing the range and functional outcomes of patients with hip fracture.

DESIGN

Prospective study with concurrent medical records data collection and patient and proxy interviews at the time of hospitalization and 6 months later.

SETTING

Four hospitals in the New York metropolitan area.

PARTICIPANTS

Five hundred seventy-one hospitalized adults aged 50 and older with hip fracture between July 1997 and August 1998.

MEASUREMENTS

Rates of return to function in four physical domains, mortality, and nursing home residence at 6 months. Cluster analysis was used to describe the heterogeneity among the sample and identify variations in 6-month mortality, nursing home residence, and level of functioning and to develop a patient classification tree with associated patient outcomes at 6 months postfracture.

RESULTS

In locomotion, transfers, and self-care, 33% to 37% of patients returned to their prior level of function by 6 months, including those needing assistance, but only 24% were independent in locomotion at 6 months. Cluster analysis identified eight patient subgroups that had distinct baseline features and variable outcomes at 6 months. The patient classification tree used four variables: atypical functional status (independent in locomotion but dependent in other domains); nursing home residence; independence/dependence in self-care; and age younger than 85 or 85 and older that identified five subgroups with variable 6-month outcomes that clinicians may use to predict likely outcomes for their patients.

CONCLUSION

Patients with hip fracture are heterogeneous with respect to baseline and outcome characteristics. Clinicians may be better able to give patients and caregivers information on expected outcomes based on presenting characteristics used in the classification tree.

The effects of time-to-surgery on mortality and morbidity in patients following hip fracture

PURPOSE

There is a perception that the standard of care is to repair hip fractures surgically within 24 hours of hospitalization. However, it is unclear whether this reduces mortality or morbidity.

SUBJECTS AND METHODS

We performed a retrospective study in consecutive hip fracture patients, aged 60 years or older, who underwent surgical repair. Patients with metastatic cancer, trauma, or a fracture occurring >48 hours before admission were excluded. The primary outcome was long-term (up to 18 years) mortality. Secondary outcomes included 30-day mortality and decubitus ulcers, serious bacterial infections, myocardial infarction, and thromboembolism. Analyses were adjusted for medical conditions; the comparison group comprised patients who underwent surgery for hip fracture repair within 24 to 48 hours because there were no patients with active medical problems who underwent surgery within 24 hours.

RESULTS

Of the 8383 patients, surgery was delayed for more than 24 hours in 2464 patients (29%) for medical reasons and in 1341 patients (16%) without active medical problems. Compared with those who underwent surgery 24 to 48 hours after admission to the hospital, patients who underwent surgery more than 96 hours after admission did not have increased long-term mortality (hazard ratio = 1.07; 95% confidence interval [CI]: 0.95 to 1.21), although the risk of decubitus ulcer was increased (odds ratio = 2.2; 95% CI: 1.6 to 3.1). There were no associations between time-to-surgery and the other secondary outcomes.

CONCLUSION

Time-to-surgery in hip fracture patients was not associated with short- or long-term mortality after adjusting for active medical problems. Other than increasing the risk of decubitus ulcer formation, waiting did not appear to affect patients' outcomes adversely.

Functional recovery and length of stay after recurrent hip fracture

OBJECTIVE

To evaluate the functional recovery and the rehabilitation length of stay after the sequential fracture of both hips in elderly patients.

DESIGN

A total of 372 in-patients with hip fractures consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 333 out of 372 were admitted for rehabilitation of their first hip fracture, and the other 39 patients had a second contralateral fracture. The functional recovery was evaluated by the Barthel index. The comparison between the two groups was performed by unpaired t test. Stepwise linear multiple regression analysis was performed, including nine prognostic factors together with the number of hip fractures (first or recurrent) as independent variables and the Barthel index score on discharge as the dependent variable. The statistical analysis was repeated, substituting hospital length of stay for Barthel index.

RESULTS

Both the functional recovery and the length of stay of the patients affected by recurrent fracture were similar to the ones of the patients suffering from a single fracture. Regression analysis showed that the previous hip fracture was associated neither with the Barthel index nor with the length of stay.

CONCLUSIONS

Our data suggest that the functional recovery in elderly patients with hip fractures is not significantly influenced by a previous fracture of the contralateral hip and that no significant prolonged rehabilitation length of stay is needed after the recurrent fracture.

Decreased bone mineral density is common after autologous blood or marrow transplantation

Survivors of autologous blood or marrow transplantation (ABMT) are predisposed to decreased bone mineral density (BMD), but data are lacking on the incidence and risk factors for this condition. Therefore, we measured BMD in 64 of 68 consecutive ABMT survivors (35 men and 29 women) attending the University of Toronto ABMT long-term follow-up clinic. Patients were evaluated a median of 4.2 years (range: 4.9 months-11.4 years) after ABMT. Median age at evaluation was 49.6 years (range: 23.5-68.2 years). At the L1-L4 vertebrae, 17 (26%) patients (eight men and nine women) had osteopenia and one male (2%) had osteoporosis. Mean BMD at L1-L4 did not differ from healthy young adults or age and sex matched controls. At the femoral neck, 30 patients (46%) (18 men and 12 women) had osteopenia and five (8%) (two men and three women) had osteoporosis. Mean BMD at the femoral neck was significantly lower than in healthy young adults and age- and sex-matched controls. By regression analysis, patients with decreased BMD were older than those with normal BMD (P = 0.02). Gender, body mass index, time from BMT to evaluation and presence of hypogonadism were not associated with decreased BMD. Treatment of decreased bone density was instituted and follow-up data were obtained 1 year after treatment in 22 of 39 patients with reduced BMD. Nineteen (86%) patients had stabilization or improvement of their bone density at follow-up. We conclude that, after ABMT, over half of the patients have evidence of osteopenia or osteoporosis. Men and women were equally affected. In our study, only older age at evaluation was predictive for loss of BMD. We recommend the measurement of BMD as an integral component to the follow-up of ABMT patients.

Outcome of medically unstable elderly patients admitted to a geriatric ward after hip fracture

Outcome of surgical treatment is superior to that of conservative treatment for hip fractures. Nevertheless, for a number of patients, the operation is either delayed or unfit due to their unstable medical conditions. We retrospectively reviewed patients admitted to a geriatric ward after hip fracture, and investigated complications, functional outcome and survival in different cognitive, pre-fracture functional and treatment groups. Patients hospitalized (N=78) from January 1993 to June 1999 were included (1/2 demented, 1/3 fully dependent in Basic Activities of Daily Living, and 2/5 high operative risk patients). Following stabilization, 14 subjects (17. 9%) were operated. The mean and range of surgical delay was 9+/-7.2, and 3 to 30 days, respectively. Comparison between surgical and conservative treatment groups, and cognitive and pre-fracture functional groups showed no differences in age, gender, chronic medical conditions, fracture type, reasons for surgical delay or conservative approach, complications, survival curves and laboratory results. Thirteen operated patients were in ASA I + II grades, only 1 in ASA grades III + IV (low and high operative risk, American Society of Anesthesiologists grading system) (p=0.004). Functional outcome was similar in the surgical vs the conservative group, and intracapsular vs extracapsular fractures. ASA I + II patients had a higher survival rate compared to ASA III + IV patients (p=0. 02). We conclude that after stabilization of acute medical conditions, the most important preoperative consideration is the anesthetic risk, and surgical and conservative approaches may be equally considered in selected groups of elderly, frail patients with hip fracture who are medically unstable for more than a few days.

[Dementia and falls]

INTRODUCTION

Dementia is now a frequent disease in elderly and may be a major risk of falling. Usually these falls are multiple and serious, but their consequences are not specific. All types of dementia (Alzheimer's disease, dementia with Lewy bodies, dementia in Parkinson's disease, fronto-temporal dementia, vascular dementiaellipsis) and all stages of evolution are concerned.

DISCUSSION

These falls result from cognitive and behavioural disorders, visual and motor problems, gait and balance disturbances, malnutrition, adverse effects of medication and fear of falling.

CONCLUSION

Prevention is possible. Attention must be given on the patient himself (keeping in good health, limitation in sedative treatment and mechanical restraintsellipsis) and on his environment (lighting, obstacles on the ground, stress levelellipsis). After a fall, especially after a complicated fall, rehabilitation modalities and aims must be adapted but caring must not be defeatist. Randomized studies need to be realized.

Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia

OBJECTIVE

To evaluate the effect of intensive geriatric rehabilitation on demented patients with hip fracture.

DESIGN

Preplanned subanalysis of randomised intervention study. Settting: Jyväskylä Central Hospital, Finland.

PARTICIPANTS

243 independently living patients aged 65 years or older admitted to hospital with hip fracture.

INTERVENTION

After surgery patients in the intervention group (n=120) were referred to the geriatric ward whereas those in the control group were discharged to local hospitals.

MAIN OUTCOME MEASURES

Length of hospital stay, mortality, and place of residence three months and one year after surgery for hip fracture.

RESULTS

The median length of hospital stay of hip fracture patients with moderate dementia (mini mental state examination score 12-17) was 47 days in the intervention group (n=24) and 147 days in the control group (n=12, P=0.04). The corresponding figures for patients with mild dementia (score 18-23) were 29 days in the intervention group (n=35) and 46.5 days in the control group (n=42, P=0.002). Three months after the operation, in the intervention group 91% (32) of the patients with mild dementia and 63% (15) of the patients with moderate dementia were living independently. In the control group, the corresponding figures were 67% (28) and 17% (2). There were no significant differences in mortality or in the lengths of hospital stay of severely demented patients and patients with normal mini mental state examination scores.

CONCLUSIONS

Hip fracture patients with mild or moderate dementia can often return to the community if they are provided with active geriatric rehabilitation.

Outcomes of older persons receiving rehabilitation for medical and surgical conditions compared with hip fracture and stroke

OBJECTIVE

Older persons with general medical and surgical conditions increasingly receive posthospital rehabilitation care in nursing homes and rehabilitation hospitals. This study describes the characteristics of such patients, contrasted with patients with traditional rehabilitation diagnoses of hip fracture and stroke.

DESIGN

Prospective cohort study.

SETTING

Seventeen skilled nursing facilities and six rehabilitation hospitals in seven states.

PARTICIPANTS

Medicare patients age 65 or older receiving posthospital rehabilitation.

METHODS

A total of 290 medical/surgical patients were compared with 336 hip fracture and 429 stroke patients. Data were collected prospectively from charts, nursing assessments, and patient interviews. Patient characteristics associated with functional recovery and mortality were estimated using multivariate regression.

RESULTS

Medical/surgical patients had greater premorbid activities of daily living (ADL) (P < .001) and instrumental activities of daily living (IADL) (P < .01) disability, but suffered less decline with the acute event than hip fracture or stroke patients (P < .001). Medical/surgical patients were more likely to recover premorbid ADL function (P < .05) but 1-year mortality was significantly greater (30% vs. 14% hip fracture; 18% stroke; P < .001). Predictors of functional recovery and mortality differed between the three groups. Among medical/surgical patients, premorbid ADL difficulty, cognitive impairment, a pressure ulcer at rehabilitation admission, and depression were associated with failure to recover premorbid function whereas increasing comorbidity and incontinence were associated with mortality.

CONCLUSIONS

Medical/surgical patients represent a unique rehabilitation population. They experienced greater premorbid functional disability, less acute decline, but greater mortality than patients with traditional rehabilitation diagnoses. Further study of this distinct rehabilitation population may help identify patients most likely to benefit from rehabilitation.

Fitness for reducing osteoporosis

The incidence and prevalence of osteoporosis and fractures increase substantially with age in both women and men ((1)), such that one in five women older than age 50 has osteoporosis ((2)). This translates to nearly 1.5 million fractures of all types attributable to osteoporosis each year in the United States, a total that exacts an astounding toll on healthcare costs. Postfracture outcomes are also disappointing. Less than one third of those who fracture their hip recover sufficiently to do basic and instrumental activities of life ((3)). Many become dependent on others for their care. Finally, the mortality rate of those with hip fractures from osteoporosis is higher than that of their unaffected peers ((4)).

Very old people can have favorable outcome after hip fracture: 58 patients referred to rehabilitation

We examined both impairment and disability of 58 patients who were referred to our rehabilitation center after surgery of hip fracture. The mean age was 86.7 years. The impairment was measured by the Motricity Index (MI) scale and disability by means of the Functional Independence Measure (FIM) scale. At admission, the MI median value was 64 and at discharge the value was 84 (range of scale, 0-100). The FIM median value was 57.5 at admission and 82 at discharge (range of scale, 18-126). Our data indicate that, on average, patients recover, even at very advanced age, but still require supervision at discharge. Twelve patients died after complications of previous risk factors. When general conditions were satisfactory, no complications arose.

Care of the older adult following hip fracture

Proximal femoral (hip) fractures are the leading cause of hospitalization for injuries among older persons and constitute a serious health problem. Research shows significant functional losses among older persons following surgery for hip fracture related to a wide range of problems. Because of the physiological, emotional, social, and psychological complications inherent in this particular population, a team approach using a holistic model of care is efficacious when attempting to improve functional outcomes and reduce morbidity and mortality.

Non-pharmacological interventions

The aim of non-pharmacological intervention for osteoporosis is to prevent, treat or alleviate the consequences of osteoporosis, the main one of which is fracture. Non-pharmacological interventions consist of a wide spectrum of treatment modalities to decrease pain, correct postural change, improve mobility, enable the patient to follow a normal social life and prevent (further) fracture. An exercise programme can increase bone mass in adolescents and adults, but in the elderly its main emphasis should be on improving muscle strength and balance in order to decrease the risk of falls. Physiotherapy is commonly prescribed to mobilize the patient after a fracture, to decrease muscle spasm and pain, and to improve balance and co-ordination. An orthesis or back support may be used to correct kyphosis and decrease pain. Medication for pain is often needed and should cover both acute severe pain following fracture and chronic pain caused by postural change. A hip fracture is the most severe consequence of osteoporosis. The risk of hip fracture can be decreased by pharmacological treatment to increase bone mass and bone strength. However, in the very elderly the occurrence of falling may be more important than the failure of bone strength. Hip protectors have recently become available and have been shown to decrease the risk of hip fracture after a fall. These shunt the energy from the trochanter away to the sides. Non-pharmacological approaches to treatment are often neglected in daily practice, the emphasis being instead on treatment with drugs that decrease bone resorption and thereby increase bone strength.