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

Does anatomical type of proximal hip fracture affect rehabilitation outcomes among older adults?

BACKGROUND AND PURPOSE

Numerous studies have detailed the potential benefits of inpatient geriatric rehabilitation for older adults with hip fractures. However, data regarding effect of fracture type (femoral neck, intertrochanteric, or subtrochanteric) on rehabilitation outcomes are limited. This study assessed whether the anatomical type of proximal hip fracture affects rehabilitation outcomes among disabled older adults.

METHODS

A population-based study was conducted comparing all patients with a recent hip fracture who were admitted to a geriatric rehabilitation facility in Israel. Data were collected retrospectively from an electronic database during a 5-year period (2014-2019). The Functional Independence Measure (FIM) was used to assess physical and cognitive function at admission and discharge.

RESULTS

The analyses included 624 older adults with hip fractures. We found significant differences in motor FIM score at admission, as patients with femoral neck fracture performed better than patients with intertrochanteric and subtrochanteric fracture did. The disparity in motor FIM score remained consistent through discharge, with all groups achieving a median gain of 14 points. Within one month of rehabilitation, about a third of all patients achieved a higher functional level.

CONCLUSIONS

Patients with femoral neck fracture have better motor ability than do those with intertrochanteric and subtrochanteric fractures, which were retained throughout the course of rehabilitation; yet, the level of improvement remained similar. Clinicians should be aware of such differences in functional ability when discussing goals of care with older adults with hip fractures and consider them when implementing individual rehabilitation programs .

C-Reactive Protein to Albumin Ratio May Predict Mortality for Elderly Population Who Undergo Hemiarthroplasty Due to Hip Fracture

BACKGROUND

Although the relationship of preoperative C-reactive protein (CRP) and albumin levels to mortality in elderly patients who have undergone surgery due to hip fracture has been previously investigated, the CRP to albumin ratio (CAR) has not been investigated. This study aimed to investigate the relationship between preoperative CAR and mortality.

METHODS

A total of 254 patients (mean age, 78.74 years) were retrospectively analyzed using the following data: age, gender, fracture type, American Society of Anesthesiologists (ASA) score, type of anesthesia, time between fracture and surgery, time between fracture and discharge, length of hospital stay, preexisting comorbidities, preoperative CRP and albumin levels, and mortality. The serum CRP level was divided by the serum albumin level to calculate the preoperative CAR. Multivariate logistic regression was used to evaluate the association between risk factors and 1-year mortality.

RESULTS

One-year mortality was 22.8% (58 patients). Age >85 years, male gender, ASA score ≥3, presence of ≥3 comorbidities, and CAR ≥2.49 were identified as mortality risk factors in the univariate analysis. The following factors were included in the binary logistic regression analysis to determine the major predictors of 1-year mortality: ASA score ≥3, presence of ≥3 comorbidities, and CAR ≥2.49.

CONCLUSION

Detection of CAR above 2.49 is a strong indicator for 1-year mortality in patients operated due to hip fracture in the elderly population. ASA score ≥3 and presence of ≥3 comorbid diseases were also related to mortality.

Survival and functionality in the elderly over 85 years of age with hip fracture

BACKGROUND

There is a tendency for the aging population to fracture their hips. Our aim was to compare survival and functionality at one year, among elderly and very elderly patients with hip fracture.

MATERIAL AND METHODS

A prospective cohort of patients included in the Institutional Registry of Elderly Patients with Hip Fracture between 2014 and 2017. We classified patients as elderly patients (EP) <65 and <85 years and very elderly patients (VEP) ≥85 years.

RESULTS

We included 952 patients, 43% were EP and 57% were VEP. The proportion of women was 84% and 86% (P=.33) and with 2 or more points in the Charlson comorbidities index (28 and 31%, P= .36), respectively. The VEP were more dependent according to the Barthel score (34% and 62%, P<.01) and frailer according to the Edmonton score (30% and 61%, P<.01). One-year survival was 91% (95% CI 86-93) in the EP and 76% (95% CI 70-89) in the VEP. In-hospital complications were more frequent in the VEP 12% (7% in the EP, P<.01). Age is an independent risk factor for one-year survival (HR 2.11; 95% CI 1.36-3.29, P<.001).

CONCLUSIONS

Age is a risk factor for the VEP group survival despite fragility and comorbidities. Because of their vulnerability, an appropriate care plan should be considered for VEP.

Risk factors for mortality and survival rates in elderly patients undergoing hemiarthroplasty for hip fracture

OBJECTIVE

The aim of this study was to analyze the relationship between mortality and possible risk factors in elderly patients surgically treated with hemiarthroplasty for hip fracture and to determine mortality rates and yearly survival outcome in a selected cohort.

METHODS

A total of 92 patients (51 men (55.4%) and 41 women (44.6%); mean age: 76.47 years) who underwent hemiarthroplasty for hip fracture were included into the study. The following data associated with risk factors were recorded for 92 patients: age, gender, pre-fracture activities of daily living (ADL), type of fracture, American Society of Anesthesiologists (ASA) score, therapeutic procedure, type of anesthesia, length of time after fracture until operation, postoperative mobility, and duration of hospitalization. A multivariate logistic regression test was used to evaluate the correlation between the risk factors and first- and second-year mortality rates. Third-year mortality rate after surgery was analyzed and compared with the general mortality rate in a similar population of the same age group living in the same city.

RESULTS

The mortality rate was 18.5% (17 patients) after the first-year follow-up and 25% (23 patients) after the second year. The mortality risk after hip fracture was found to be 11.7 times greater than the similar age group population in the third year. In addition, there was a significant relationship between a low (dependent) preoperative ADL score, advanced age (>80 years), male gender, high ASA score and poor ability to walk (unable to walk), and first- and second-year mortalities (p<0.05). However, no significant relationship was found between fracture type, fracture side, anesthesia type, time from fracture to surgery, or duration of hospitalization and mortality (p>0.05).

CONCLUSION

Advanced age, male gender, a high ASA score, a dependent preoperative ADL score, and a postoperative inability to walk were determined to be the most important risk factors affecting mortality in elderly patients with hip fracture. The mortality risk was 11.7 times greater than that of a population with similar characteristics.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Alanine aminotransferase blood levels and rehabilitation outcome in older adults following hip fracture surgery

Low alanine aminotransferase (ALT) blood levels are associated with frailty and poor outcome in older adults. Therefore, we studied the association between ALT blood levels before rehabilitation and rehabilitation outcome in older adults following hip fracture surgery. A total of 490 older adults (age>60 years, mean age: 82.9±6.7 years, 82.0% women) admitted to rehabilitation following hip fracture surgery were included. The rehabilitation outcome was assessed by Functional Independence Measure (FIM) scores. ALT blood levels were documented between 1 and 6 months before rehabilitation. Patients with ALT blood levels over 40 IU/l possibly consistent with liver injury were excluded. The cohort was divided into two groups: patients with ALT more than 10 IU/l and patients with ALT less than or equal to 10 IU/l. Upon rehabilitation discharge, the FIM outcome measures (motor, cognitive, gain, efficiency) were significantly higher in patients with ALT more than 10 IU/l relative to patients with ALT less than or equal to 10 IU/l (P<0.05). A logistic regression analysis adjusted for age and sex showed that patients with ALT more than 10 IU/l were more likely to have higher (second to fourth upper quartiles) total FIM scores (>50), cognitive FIM scores (>16), and FIM efficiency (>0.228) upon rehabilitation discharge (odds ratio=1.56-1.78). However, this association was no longer significant following adjustment also for admission total FIM score, cognitive impairment, cancer, and albumin serum levels. High-normal ALT blood levels before rehabilitation are associated with a better rehabilitation outcome in older adults following hip fracture surgery. It may be used when data on admission FIM score, cognitive impairment, cancer, and albumin serum levels are not available.

Incidence of and Risk Factors for Inpatient Stroke After Hip Fractures in the Elderly

Although uncommon, stroke can be a catastrophic inpatient complication for patients with hip fractures. The current study determines the incidence of inpatient stroke after hip fractures in elderly patients, identifies risk factors associated with such strokes, and determines the association of stroke with short-term inpatient outcomes. A retrospective review of all patients aged 65 years or older with isolated hip fractures in the 2011 and 2012 National Trauma Data Bank was conducted. A total of 37,584 patients met inclusion criteria. Of these patients, 162 (0.4%) experienced a stroke during their hospitalization for the hip fracture. In multivariate analysis, a history of prior stroke (odds ratio [OR], 13.24), coronary artery disease (OR, 2.05), systolic blood pressure 180 mm Hg or higher (OR, 1.66), and bleeding disorders (OR, 1.65) were associated with inpatient stroke. Inpatient stroke was associated with increased mortality (OR, 7.17) and inpatient serious adverse events (OR, 6.52). These findings highlight the need for vigilant care of high-risk patients, such as those with a history of prior stoke, and for an understanding that patients who experience an inpatient stroke after a hip fracture are at significantly increased risk of mortality and inpatient serious adverse events. [Orthopedics. 2018; 41(1):e27-e32.].

Factors Affecting Mortality and Hospital Admissions after Hip Surgery among Elderly Patients with Hip Fracture in Hong Kong - Review of a Three-Year Follow-Up. Hong Kong J Occup Ther 2017;30:6-13. [PMID: 30186075 PMCID: PMC6092006 DOI: 10.1016/j.hkjot.2017.10.004]

Objective

Hip fracture is associated with excess mortalities and high rate of hospital re-admission after discharge from the indexed episode. To improve related post-discharge care, we aimed to find out characteristics that were associated with related higher rates of mortality and hospital re-admission.

Methods

This was a historical cohort study with following up of 273 patients recruited in a local rehabilitation hospital for 3 years. The outcome of interest was cumulative mortalities and hospital re-admissions in the 1st 3 years after their discharge from the rehabilitation hospital. These outcomes were collected in the hospital data warehouse - the Clinical Data Analysis and Reporting System (CDARS). Eighteen predictors, as proposed by similar studies and our own review, were retrieved from our standard clinical forms as well as from the CDARS. Binary logistic regression was used to test their association with the outcomes and to generate the respective odd ratios.

Results

The cumulative overall mortality rates at 0.5-, 1-, 2- and 3- year after hip fracture were 7.2%, 14.0%, 24.6% and 33.4% respectively, while the cumulative "1st ever hospital read-mission" at 0.5-, 1, 2- and 3- years after hip fracture were 29.4%, 41.6%, 59.4% and 71.7% respectively. The most significant predictors i) for mortality at 3- year were: "Being male" (OR 5.33), "Delayed surgery >48 hours" (OR 2.65), "pre-operation albumin level <3.5 g/dl" (OR 2.66), and, ii) for "1st ever hospital readmission" at 0.5-year was "Being Assisted walker or non-walker (after rehabilitation)" (OR 3.83).

Conclusions

Characteristics that define the groups of patients with hip fractures with higher mortality and rate of hospital re-admission were identified. This could help healthcare professionals to focus on target patient groups for closer monitoring and more intensive post-discharge care.

Predictors for rehabilitation outcome in Asian geriatric hip fracture patients

PURPOSE

To identify predictors for rehabilitation outcome in Asian geriatric hip fracture patients.

METHODS

Records of 153 consecutive Asian patients aged 61 to 99 years who underwent surgery for hip fracture and were followed up for at least one year were reviewed. They were stratified into 4 agegroups: 60-69 years (n=27), 70-79 years (n=70), 80-89 years (n=50), and ≥90 years (n=6). Any comorbidity, regardless of severity, was recorded. Pre-injury and postoperative functional status was evaluated using the 36-item Short Form Health Survey. Relative functional gain (RFG) is equal to absolute functional gain (physical component summary [PCS] score at one year minus PCS score at 6 weeks) divided by the maximum potential gain (maximum PCS score minus PCS score at 6 weeks). RFG of <0.5 and ≥0.5 is defined as poor and good rehabilitation outcome, respectively.

RESULTS

In univariate analysis, age 80-89 years (p=0.026), arthritis (p=0.082), and hypercholesterolaemia (p=0.014) were predictors for RFG. In multivariate analysis, age 80-89 years (p=0.016) remained a predictor for poor RFG, and hypercholesterolaemia remained a predictor for good RFG.

CONCLUSION

Poor rehabilitation outcome was associated with patient age of 80-89 years; an orthogeriatric approach may be beneficial in optimising rehabilitation outcome in elderly hip fracture patients.

HIP FRACTURE: POST-OPERATIVE EVALUATION OF CLINICAL AND FUNCTIONAL OUTCOMES

Objective: To evaluate the clinical and functional outcomes from patients undergoing surgery to treat hip fractures, with regard to the ASA score and time spent waiting for definitive surgical treatment. Method: Over a one-year period, 154 patients with hip fractures, aged 65 years and over, underwent operations. Data on the preoperative ASA score and the time spent waiting for the operation were obtained. Two years after the operation, Zuckerman‘s Functional Recovery Score (FRS) questionnaire was used to assess the patients' current functional capacity. Results: Mortality during the first postoperative year differed between patients with ASA 3 or 4 and those classified as ASA 1 or 2 (significant data; p < 0.05). Mortality up to the end of the second postoperative year was significantly higher (p < 0.05) in the ASA 3 or 4 group. The preoperative ASA score did not demonstrate any significant relationship with the patients' current functional capacity (p > 0.05). There was no significant difference between the group operated within 48 hours of admission and the group operated after 48 hours, in relation to mortality or current functional capacity (p > 0.05). The group aged 80 years and over showed significantly higher mortality (p < 0.05) than the group aged 65 to 79 years up to the end of the second postoperative year. Conclusion: The preoperative ASA score and an age of 80 years or over may be considered to be factors associated with higher mortality two years after hip fracture surgery. In isolation, time spent waiting for surgery was not significant.

A prognostic model predicting recovery of walking independence of elderly patients after hip-fracture surgery. An experiment in a rehabilitation unit in Northern Italy

A score for identifying post-hip-fracture surgery patients at various levels (high, medium, and low) of risk for unsuccessful recovery of pre-fracture walking ability was developed. Three hundred ninety-eight HF patients were enrolled in the study. The score significantly and independently predicted failure to walk independently at discharge, failure to walk independently after 12 months, and death after 12 months. The score may be useful for clinicians and healthcare administrators to target populations for rehabilitative programs.

INTRODUCTION

To develop a model predicting at the time that elderly hip-fracture (HF) patients undergo rehabilitation if they will have recovered walking independence at discharge.

METHODS

Data from all patients admitted to a Department of Rehabilitation in Italy between January 2001 and June 2008 after HF surgery were used. Variables concerning cognitive, clinical, functional, and social parameters were evaluated. Predominant measures were identified through correspondence analysis, and a variable score was defined. Three risk classes (minimum, moderate, and high) were identified and univariate and multivariate logistic regressions were used to assess the model's predictivity and risk classes for the various outcomes.

RESULTS

Three hundred ninety-eight HF patients were enrolled. The variables selected to construct the score were age, gender, body mass index, number of drugs being taken, the Mini Mental State Examination, the Instrumental Activity of Daily Living, and the pre-fracture Barthel index. According to univariate analysis, the score was not better than the pre-fracture Barthel's index, but, according to multivariate analysis, it was an independent predictor for all the outcomes, while the pre-fracture Barthel index predicted only outcomes at discharge. In particular, the score significantly predicted failure to walk independently at discharge, failure to walk independently after 12 months, and death after 12 months.

CONCLUSIONS

A method of identifying post-HF surgery patients at various levels (high-, medium-, and low-) of risk for unsuccessful recovery of pre-fracture walking ability has been designed. The method may be useful for clinicians and healthcare administrators to target populations for rehabilitative programs.

Exposure to medicines among patients admitted for hip fracture and the case-fatality rate at 1 year: a longitudinal study

PURPOSE

To describe the demographic and clinical characteristics and the pre-fracture exposure to medicines of patients admitted for a hip fracture, and to explore their association with fatal outcome 1 year after the fracture.

METHODS

All patients ≥ 65 years old admitted for a hip fracture in a tertiary hospital in Barcelona between January 1 and December 31 2007 were included. Data on the patients' clinical characteristics before and during hospital admission and on pre-fracture exposures to medicines were collected from the clinical records. One-year mortality was checked by approaching the patients and their families and was cross-checked with the national mortality statistics database. A Cox proportional hazards analysis was carried out.

RESULTS

Four hundred and fifty-six patients [mean age (SD) 82.9 (7.2) years, 73.5 % female], were admitted with hip fracture during the study period. Almost 80 % of the patients (363, 79.6 %) had three or more associated conditions, and 41.7 % received pre-fracture treatment with five or more drugs. The case-fatality rate during hospital admission was 4.6 % (21 patients). One hundred and seven patients died within 1 year (23.5 %). Advanced age, male gender, two or more associated chronic conditions, cancer, severe cognitive impairment, and treatment with opiates before fracture were significantly associated with the risk of dying. An inverse association was recorded between mortality and pre-hospital exposure to medicines for osteoporosis.

CONCLUSIONS

One-quarter of patients admitted for hip fracture died within 1 year after the fracture. Exposure to opiates before hip fracture was associated with an increased 1-year death rate, whereas treatment with drugs for osteoporosis was associated with a decrease in death rate. These results should be confirmed in studies with detailed prospective collection of information on exposure to medicines.

Proximal femoral fractures in the elderly: how are we measuring outcome?

INTRODUCTION

Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.

METHODS

Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.

RESULTS

ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.

DISCUSSION

A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.

CONCLUSION

There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.

Factors affecting mortality of frail hip-fractured elderly patients

Hip fracture in the elderly may lead to increased morbidity and mortality. We assessed factors affecting mortality of frail elderly hip-fractured patients during the first 2 years after discharge from a post-acute rehabilitation program. Included were 376 patients admitted from 1/2006 to 9/2007. Kaplan-Meier curves were used for survival analysis. During the 2 years after discharge 68 patients (20.8%) died. Sex, fracture type, operation versus conservative treatment, time to surgical intervention, presence of depression, impaired neurological function or comorbidity burden were not found to be significant predictors of mortality. Comparisons of survival curves showed significantly higher mortality in patients with admission albumin level of <3.5 g/dl compared to patients with levels of > or =3.5 g/dl (p=0.017); demented versus cognitively intact patients (p<0.001); patients with admission FIM score of <40 versus those with scores of 40-79 and > or =80 (p=0.012); very old patients (>84) compared with old (75-84) and young-old patients (<75) (p=0.003). Multivariate analysis showed that only dementia and age were independent predictors of mortality in the studied group. Multidisciplinary teams should be aware of treatable variables affecting these patients' survival and should endeavor to improve their functional and nutritional level. Moreover, expectation coordination should be carried out with very old and cognitively impaired patients.

Does cognitive performance affect physical therapy regimen after hip fracture surgery?

BACKGROUND AND AIMS

To evaluate whether and which clinical factors affect the regimen of physical therapy (PT) treatment in elderly patients after hip fracture (HF).

METHODS

HF patients consecutively admitted to a rehabilitation unit (from January 2002 to May 2004) without adverse clinical events on admission or during hospital stay were considered (n=80). All patients underwent multidimensional assessment including demographic, clinical, cognitive, affective and functional status. Outcome measure was the number of rehabilitative procedures (NRP), computed as the ratio between sum of rehabilitative procedures and length of hospital stay.

RESULTS

Patients received 3.8+/-1.3 NRP on average, although with large variability. Age and impairment of cognitive and pre-fracture functional status were significantly higher in those receiving fewer NRP. In a multiple regression model, only the Mini Mental State Examination (MMSE) significantly predicted NRP: compared with patients with MMSE < or =17, those with MMSE = 18-23, 24-26 and > or =27 received 0.3 (95% CI - 0.5-1.1, p=0.46), 1.5 (95% CI 0.6-2.4, p=0.001), and 1.6 (95% CI 0.7-2.5, p=0.001) more NRP.

CONCLUSIONS

Cognitive performance affects NRP in elderly HF patients. Specific rehabilitative approaches, according to baseline cognitive performance, should be considered.

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.