Characteristics of fall-related hip fractures in community-dwelling elderly patients according to cognitive status

Characteristics of fragility hip fracture-related falls in the older adults: A systematic review

BACKGROUND AND OBJECTIVES

With the global aging trend, the incidence of falls and hip fractures is projected to rise, leading to an increased associated burden. Over 90% of hip fractures result from falls, yet not all falls cause fractures, suggesting specific fall characteristics may contribute to hip fractures. This review provides insights into fragility hip fracture-related falls among the older adults, aiding in understanding and developing effective fall prevention strategies for this population.

METHODS

Searches encompassed PubMed, OVID, EMBASE, Cochrane Library, and Web of Science, supplemented by citation checks. We included non-randomized studies detailing characteristics of fragility hip fracture-related falls in the older individuals, with or without a non-hip fracture control. Evaluated fall characteristics included height, location, direction, time, mechanism, activity during the fall, hip impact, protective responses, walking aid use, and impact surface. Results were analyzed using a narrative synthesis approach. The quality of these studies was assessed using the revised Risk of Bias Assessment tool for Non-randomized Studies 2 (RoBANS2).

RESULTS

A total of 30 articles were reviewed, comprising 23 non-case control and 7 case-control studies, with a mean age of 75.6 years. Studies presented varied details on fall characteristics. Hip-fracture related falls typically occur indoors at or around standing height during daytime, often involving sideways or backward motions with inadequate protective responses. Slipping is predominant, yet lost balance and weakness/collapse are notable. Walking precedes many falls, but stationary activities (lack of forward motion, changing positions, sitting or standing still, transfer) also contribute. Low usage of walking aids and impact on hard surfaces are common features of these falls.

CONCLUSIONS

This review underscores fall characteristics associated with fragility hip fractures in older adults, highlighting features more aligned with age-related physical frailty than general falls. Such insights can guide healthcare providers in implementing tailored interventions to reduce hip fractures and related challenges.

Hip Fractures in Patients with Dementia: An Emerging Orthopedic Concern

Hip fractures are a very common injury in the elderly population associated with an increased mortality rate. Currently, more and more elderly patients are diagnosed with dementia. Demented patients are more prone to falls and hip fractures compared to the general population because of conditions related to their disease such as instability, osteoporosis, poor muscle control and weakness. The coexistence of dementia and hip fractures is a difficult situation for both the patients and the treating physicians because of postoperative complications in this frail subgroup of patients and their inability to stand up and walk. To enhance the literature, we reviewed published studies of hip fracture patients suffering from dementia to discuss why they have more frequent hip fractures, to review their associated in-hospital complications, and to emphasize on their postoperative management to be able to reach the pre-injury activity level and optimal quality of life.

The Role of Abdominal and Pelvic Computed Tomography Scans for Geriatric Blunt Trauma Patients on Antiplatelet and/or Anticoagulation Medications

Blunt trauma is the most common mechanism of injury in the geriatric population. The benefits of computed tomography (CT) scanning have demonstrated improved outcomes for blunt trauma patients with head injuries. The purpose of our study is to evaluate the clinical value of using a CT scan of the abdomen and pelvis on geriatric blunt trauma patients on antiplatelet/anticoagulation (AP/AC) therapy. A retrospective study reviewing geriatric patients admitted to our urban level 1 trauma center from December 2012 to September 2014 was performed. The inclusion criteria for the study included patients older than 65 years of age, admission after a blunt trauma, and on AP/AC therapy. Male and female patients with dementia were more likely to have a CT scan of the abdomen and pelvis (P = 0.002 and P = 1 × 10−6, respectively). There was no statistical significance in the difference in outcomes between the demented patients who received a CT scan of the abdomen and pelvis and the ones who did not. Our study demonstrated that there is no benefit in terms of length of stay, morbidity, or mortality, regardless of sex, after a CT scan of the abdomen and pelvis.

Advanced 2D image processing technique to predict hip fracture risk in an older population based on single DXA scans

A new technique to enhance hip fracture risk prediction in older adults was presented and assessed. The new method dramatically improved prediction at high specificity levels using only a standard clinical diagnostic scan. This has the potential to be implemented in clinical practice to enhance patient fragility diagnosis.

INTRODUCTION

Diagnosis of osteoporosis is based on the measurement of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) scans. However, studies have shown this to be insufficient to accurately predict hip fractures. Therefore, complementary methods are needed to enhance hip fracture risk prediction to identify vulnerable patients.

METHODS

Hip DXA scans were obtained for 192 subjects from the Canadian Multicenter Osteoporosis Study (CaMos), 50 of whom had experienced a hip fracture within 5 years of the scan. 2D statistical shape and appearance modeling was performed to account for the effect of the femur's geometry and BMD distribution on hip fracture risk. Statistical shape modeling (SSM), and statistical appearance modeling (SAM) were also used separately to predict the fracture risk based solely on the femur's geometry and BMD distribution, respectively. Combined with BMD, age, and body mass index (BMI), logistic regression was performed to estimate the fracture risk over the 5-year period.

RESULTS

Using the new technique, hip fractures were correctly predicted in 78% of cases compared with 36% when using the T-score. The accuracy of the prediction was not greatly reduced when using SSM and SAM (78% and 74% correct, respectively). Various geometric and BMD distribution traits were identified in the fractured and non-fractured groups.

CONCLUSION

2D SSAM can dramatically improve hip fracture prediction at high specificity levels and estimate the year of the impending fracture using standard clinical images. This has the potential to be implemented in clinical practice to estimate hip fracture risk.

[Multidisciplinary geriatric rehabilitation in the patient with hip fracture and dementia]

Hip fracture and dementia rates increase with age, and both groups of patients suffer increased morbidity and mortality and functional impairment. The management of these patients is a challenge for the orthogeriatric and rehabilitation team process, as despite the evidence on the benefit, the results analysed are still worse than in patients without cognitive impairment. For this reason, and due to the limitation in health resources, many of them have problems in accessibility to them, or are limited to a less intense rehabilitation. There are insufficient studies on the best rehabilitation interventions in this group of patients, but it is suggested: 1) to use a multidisciplinary rehabilitation model adapted to the patient with dementia, and 2) to redefine results of the rehabilitation of these patients not only in terms of functional improvement, without highlighting other concepts, such as quality of life, decrease in complications or improved social support.

Clinical evidence of diabetes mellitus end-organ damage as risk factor for falls complicated by hip fracture: A multi-center study of 1225 patients

AIMS

To identify the differential characteristics of patients with type 2 diabetes mellitus (T2DM) complicated by end-organ damage who experience a fall-related hip fracture.

METHODS

We analyzed the socio-demographic data and index fall clinical characteristics of a group of patients with nephropathy, neuropathy or retinopathy related to T2DM consecutively admitted to six hospitals in Barcelona, Spain because of a fall-related hip fracture.

RESULTS

Out of 1225 patients admitted because of a fall-related hip fracture, 107 (8.7%) had clinical evidence of end-organ damage related to T2DM. Among this cohort the mean number of falls during the year prior to the index admission was 2.6±3.2; and 29 of them (27.1%) had already experienced three or more falls. Most falls leading to the index admission took place at the patients' home, from a standing position, and during daylight time. An intrinsic cause of falling was identified in all but one of these patients. Multiple stepwise logistic regression analysis showed that, compared to patients without this diagnosis, patients with complicated T2DM were younger (odds ratio 0.762), had less prevalence of dementia (odds ratio 0.078), but had experienced a higher number of falls in the previous year (odds 1.183).

CONCLUSIONS

A significant amount of patients with clinical evidence of end-organ damage due to T2DM who experience a fall-related hip fracture have a history of recurrent falling in the previous year. These patients should be identified and offered preventive actions aimed at reducing their risk of falling.

The approach to patients with cognitive impairment and hip fracture: the role of orthogeriatric care

Hip fracture is very common among older patients, who are characterized by increased co-morbidities, including cognitive impairment. These patients have an increased risk of falls and fractures, poorer functional recovery and lower survival both in hospital and 12 months after discharge. We review the survival and functional outcomes of older patients with cognitive impairment and hip fracture managed in orthogeriatric units, and highlight the gaps in our knowledge of the efficacy and efficiency of specific orthogeriatric programmes for such patients and the future research perspectives in this field.

Age as a risk factor of nosocomial infection after hip fracture surgery

Surgery for the treatment of hip fractures is considered the gold standard even among nonagerians with a heavy comorbidity burden. Therefore, a study of an association between surgical complications and some variables in elderly individuals appears to be very important. We designed a transverse study in which we determined patient age at the time of development of a nosocomial infection (NI) in patients who underwent surgery to treat a hip fracture. Univariate and multivariate analyses were performed by simple and multiple logistic regression. We found that age was a determinant in NI after surgical treatment for hip fracture. The older the patient was, the higher the risk of development of an NI after surgical treatment for hip fracture (operative hypothesis). However, the risk of infection changed depending on the treatment. No association with other variables was found.

Fall-related hip fracture hospitalisations and the prevalence of dementia within older people in New South Wales, Australia: an analysis of linked data

INTRODUCTION

Dementia and fall-related hip fractures both contribute significantly to the burden of illness within elderly populations in Australia and elsewhere. The research presented here uses a large probabilistically linked dataset from NSW, Australia to estimate the prevalence of dementia within hip fracture patients and investigate the impact of dementia on hospitalisation length of stay (LOS) and survival.

METHOD

The cases considered were NSW residents aged 65 years and above who experienced a fall related hip fracture between 1 July 2000 and 30 June 2009. The prevalence of dementia was calculated for the incident hip fracture using two methods to infer dementia status. Cox proportional hazards regression modelling was used to estimate the relative rate of discharge from a hospitalisation episode, and the relative mortality rate of hip fracture patients suffering dementia versus those who were cognitively intact. Additional covariates used in the models included sex, age group at admission, the Charlson Comorbidity Index and separation mode.

RESULTS

Of the 44,143 fall-related incident hip fracture cases considered, between 24% (observed diagnosis) to 29% (inferred diagnosis) of these people had dementia. The median LOS for patients with dementia was shorter than those without dementia, but there was a strong interaction with age. The rate of discharge from the fracture-related hospitalisation episode of the cases with dementia was 40% greater (95% CI 1.4-1.5) than the non-demented group. Similarly, the relative mortality rate of those with dementia was greater (2.4, 95% CI 2.3-2.6) than the non-demented group. Both Cox analyses indicated evidence for main effects of age at admission and comorbidity, as well as interaction effects between age group and dementia status.

CONCLUSION

The use of linked datasets with tens of thousands of cases enables the calculation of precise estimates of various parameters. People with dementia constitute a significant proportion of the total population of elderly hip fracture patients in hospitals (up to 29%). Their mortality rate is greater than those without a diagnosis of dementia and their hospital length of stay is shorter, particularly if they are discharged to a residential aged care facility.

Cognitive dysfunction in hip fracture patients

Hip fractures represent a widespread morbidity among the geriatric population. In North America, more than 320,000 hip fractures are sustained annually, a number that is expected to increase dramatically as the population continues to age. Disorders of cognition, primarily dementia and delirium, also have a higher-than-average incidence and prevalence among the geriatric population. The co-occurrence of cognitive dysfunction and hip fracture is an important entity for orthopedic surgeons and other clinicians involved in hip fracture care to recognize. This article provides an overview of the currently available evidence regarding cognitive dysfunction, specifically dementia and delirium, in patients with hip fractures.

Incident hip fractures among community dwelling persons with Alzheimer's disease in a Finnish nationwide register-based cohort

BACKGROUND

Previous cohort studies have shown that persons with Alzheimer's disease (AD) have a higher risk of hip fractures but recent data from large representative cohorts is scarce.

METHODS

We investigated the association between AD and prevalent and incident hip fractures in an exposure-matched cohort study conducted in Finland 2002-2009 (the Medication and Alzheimer's disease in 2005 study; MEDALZ-2005). The study population included all community-dwelling persons with verified AD diagnosis in Finland on December 31, 2005 and one matched comparison person per AD case (N = 56,186, mean age 79.9 (SD 6.8) years, range 42-101 years). The diagnosis of AD was extracted from a special reimbursement register. Data on hip fractures during 2002-2009 was extracted from the Finnish National hospital discharge register. Analyses of incident hip fractures (n = 2,861) were restricted to years 2006-2009.

RESULTS

Persons with AD were twice as likely to have previous hip fracture in 2005 (odds ratio, 95% confidence interval 2.00, 1.82-2.20) than matched aged population without AD. They were also more likely to experience incident hip fracture during the four-year follow-up (hazard ratio, 95% confidence interval 2.57, 2.32-2.84, adjusted for health status, psychotropic drug and bisphosphonate use). The AD-associated risk increase decreased linearly across age groups. Although people with AD had higher risk of hip fractures regardless of sex, the risk increase was larger in men than women.

CONCLUSION

Findings from our nationwide study are in line with previous studies showing that persons with AD, regardless of sex or age, have higher risk of hip fracture in comparison to general population. Although there was some suggestion of effect modification by age or sex, AD was consistently associated with doubling of the risk of incident hip fracture.

Prevalence of dementia in elderly patients with hip fracture

Hip fractures occur commonly and are a cause of disability for older adults and lead to increased dependence and requirements for social support. Dementia is one of the possible risk factors for falling and hip fracture, a potential source for complications during surgery and during the postoperative period, difficulties in rehabilitation and a risk factor for hip fracture reccurence. However, in previous studies of hip fracture patients, cognitive status has not been formally assessed during the inpatient stay and diagnosis was based only on previous history. Additionally, no previous studies have compared prevalence of dementia between elderly patients with hip fracture and patients with other surgical pathology. Our aim was to define whether dementia was more prevalent in older subjects with hip fracture than in other elderly patients undergoing surgery. In this study, we prospectively assessed all patients aged 68 and older admitted to our hospital for hip fracture surgery during a one year period and compared them with age and gender matched patients attending other surgical departments. 80 hip fracture patients and 80 controls were assessed for dementia. Dementia was common in both groups, presumably reflecting the advanced mean age of both groups and cognitive deterioration due to hospitalization-status. Dementia was significantly higher in the hip fracture group (85%) compared to the control group (61.5%; p=0.002). Dementia is very common in older patients admitted for surgery to a general hospital and extremely common in those with hip fracture. It seems that dementia is under diagnosed in elderly hospitalised patients. Our data confirm that dementia is a major risk factor for hip fracture in the elderly.

Physical activity and hip fracture disability: a review

Objective. The present paper examines pertinent literature sources published in the peer-reviewed English language between 1980 and November 1, 2010 concerning hip fractures. The aim was to highlight potential intervention points to offset the risk of incurring a hip fracture and its attendant disability. Methods. An in-depth search of the literature using the key terms: disability, epidemiology, hip fracture, prevention, and risk factors was conducted, along with data from the author's research base detailing the disability associated with selected hip fracture cases. All articles that dealt with these key topics were reviewed, and relevant data were tabulated and analyzed. Results. Hip fractures remain an important but potentially preventable public health problem. Among the many related remediable risk factors, low physical activity levels are especially important. Related determinants of suboptimal neuromuscular function also contribute significantly to hip fracture disability. Conclusion. Physical activity participation can help to reduce the prevalence and excess disability of hip fractures and should be encouraged.

Prevalence of dementia and cognitive impairment among older adults with hip fractures

BACKGROUND

Dementia and cognitive impairment are known to be risk factors for hip fractures and are associated with increased postoperative morbidity and mortality. Little is known of the prevalence of dementia and cognitive impairment among older adults with hip fractures.

METHODS

We completed searches of the electronic databases for observational studies and report the prevalence of either dementia or cognitive impairment among individuals with hip fractures. We included studies that reported the prevalence of dementia using standard diagnostic criteria or cognitive impairment as measured on cognitive screening tests. We used random-effects meta-analysis to arrive at pooled estimates of the prevalence of dementia and cognitive impairment.

RESULTS

Five studies reported the prevalence of dementia and 34 studies reported the prevalence of cognitive impairment in older adults with hip fractures. The estimated prevalence of dementia among older adults with hip fractures was 19.2% (95% confidence interval [CI]: 11.4% to 30.6%), whereas the prevalence of cognitive impairment was 41.8% (95% CI: 37.0% to 46.8%). In subgroup analyses, individuals admitted from long-term care were more likely to have dementia when compared with individuals admitted from the community, whereas there were no significant differences in the prevalence of cognitive impairment according to gender or study setting.

CONCLUSIONS

We conclude that dementia and cognitive impairment are common among older adults with hip fractures. Clinicians providing care for individuals with hip fractures should be aware of the high prevalence of cognitive impairment in this population. Effective strategies to prevent hip fractures and improve postoperative outcomes for older adults with dementia are needed.

Role of mental disorders in nosocomial infections after hip fracture treatment

The association between mental disorders (MDs) and iatrogenic complications after hip fracture surgery has been poorly studied. Among iatrogenic complications, nosocomial infections (NIs) are a major factor in hip fracture surgery. The aim of this paper was to determine whether patients with a MD and a hip fracture develop more NIs after hip surgery than patients with no MD. We studied 912 patients who underwent surgery for a hip fracture (223 patients with a MD who underwent surgery for a hip fracture and 689 control patients without a MD who also underwent surgery for a hip fracture) and followed them after surgery. Univariable and multivariable analyses were performed using simple and multiple logistic regression analysis (confidence interval, crude and adjusted odds ratios, and P value). We found that MDs, gender, and comorbidities were not associated with a higher risk of developing a NI after surgery for a hip fracture. Only age increases the risk of a NI.