Men Recover Ability to Function Less Than Women Do: An Observational Study of 1094 Subjects After Hip Fracture

Sex differences in mobility recovery after hip fracture: a time series analysis

Introduction

Sex differences are commonly reported for hip fracture incidence rates and recovery. Current knowledge about mobility recovery after hip fracture involves clinical assessments of physical capacity or patient-reported outcomes. Information on mobility performance during daily life is missing but relevant to evaluate patients' recovery. Hence, it remains unclear whether sex differences exist in the longitudinal progression of mobility performance in hip fracture patients. To investigate this, we pooled data from four studies in Germany and Norway.

Methods

In all studies, real-world mobility was assessed continuously over 1 to 7 days using a sensor fixed to the unaffected frontal thigh. All studies assessed mobility at different time points that were allocated to three distinct phases: Acute and post-acute phase (week 1-6), extended recovery (7-26), and long-term recovery (27-52). Sex-specific continuous trajectories of the median (50th percentile) as well as the 1st (25th percentile) and 3rd quartile (75th percentile) were estimated using quantile regression models with splines for daily walking and standing duration; number of sit-to-stand-to-walk transfers and walking bouts; mean walking bout duration; maximum number of steps per walking bout.

Results

There were 5,900 valid observation days from n = 717 participants (mean age = 83.4 years, SD 6.1). The majority was female (75.3%), with similar sex distribution across all studies. Demographics of both sexes were comparable, but a higher percentage of women was living alone (69.0% compared to 40.9% in men) and had experienced an indoor fall leading to the fracture (74.3% compared to 67.4% in men). There were clear sex differences in mobility recovery. Women improved their mobility faster than men, but men showed larger increases later in the year after surgery. At the end of the first year, both sexes reached comparable levels in almost all mobility parameters.

Conclusion

We identified varying aspects of mobility recovery between men and women, i.e., timely development of mobility recovery shows different patterns. Our findings support the consideration of sex differences in planning and implementing rehabilitation measures for hip fracture patients and highlight the need to provide adapted support at different time points. The underlying mechanisms of these sex differences need further investigation.

Sex differences in recovery of quality of life 12 months post-fracture in community-dwelling older adults: analyses of the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS)

In this study of 695 Australian older adults (aged ≥50 years), we found that men and women had a similar trajectory of health-related quality of life (HRQoL) recovery following fragility fracture at any skeletal site. These results provide us with critical knowledge that improves our understanding of health outcomes post-fracture.

INTRODUCTION

Mortality is higher in men than that in women following a fragility fracture, but it is unclear whether recovery of patient-reported outcomes such as health-related quality of life (HRQoL) differs between sexes. This study aimed to identify sex differences in HRQoL recovery 12 months post-fracture.

METHODS

Data were from the Australian arm of the International Costs and Utilities Related to Osteoporotic Fractures Study (AusICUROS). Participants recruited to AusICUROS were adults aged ≥50 years who sustained a fragility fracture. HRQoL was measured using the EQ-5D-3L at three time-points post-fracture: within 2 weeks (including pre-fracture recall) and at 4 and 12 months. Multivariate logistic regression analyses were undertaken, adjusting for confounders including age, education, income, and healthcare utilization post-fracture.

RESULTS

Overall, 695 AusICUROS participants (536 women, 77.1%) were eligible for analysis with fractures at the hip (n = 150), distal forearm (n = 261), vertebrae (n = 61), humerus (n = 52), and other skeletal sites (n = 171). At the time of fracture, men were younger, reported a higher income, and were more likely to be employed, compared with women. For all fracture sites combined, there were no differences between men and women in recovery to pre-fracture HRQoL at 12-month follow-up (adjusted OR = 1.09; 95% CI: 0.75-1.61). When stratified by fracture site, no significant sex differences were seen for hip (OR = 1.02; 95% CI: 0.42-2.52), distal forearm (OR = 1.60; 95% CI: 0.68-3.78), vertebral (OR = 2.28; 95% CI: 0.61-8.48), humeral (OR = 1.62; 95% CI: 0.16-9.99), and other fractures (OR = 1.00; 95% CI: 0.44-2.26).

CONCLUSION

Community-dwelling men and women who survived the 12 months following fragility fracture had a similar trajectory of HRQoL recovery at any skeletal site.

Sex Differences in Recovery Across Multiple Domains Among Older Adults With Hip Fracture

BACKGROUND

Hip fractures are a public health problem among older adults, but most research on recovery after hip fracture has been limited to females. With growing numbers of hip fractures among males, it is important to determine how recovery outcomes may differ between the sexes.

METHODS

168 males and 171 females were enrolled within 15 days of hospitalization with follow-up visits at 2, 6, and 12 months postadmission to assess changes in disability, physical performance, cognition, depressive symptoms, body composition, and strength, and all-cause mortality. Generalized estimating equations examined whether males and females followed identical outcome recovery assessed by the change in each outcome.

RESULTS

The mean age at fracture was similar for males (80.4) and females (81.4), and males had more comorbidities (2.5 vs 1.6) than females. Males were significantly more likely to die over 12 months (hazard ratio 2.89, 95% confidence interval: 1.56-5.34). Changes in outcomes were significantly different between males and females for disability, gait speed, and depressive symptoms (p < .05). Both sexes improved from baseline to 6 months for these measures, but only males continued to improve between 6 and 12 months. There were baseline differences for most body composition measures and strength; however, there were no significant differences in change by sex.

CONCLUSIONS

Findings confirm that males have higher mortality but suggest that male survivors have continued functional recovery over the 12 months compared to females. Research is needed to determine the underlying causes of these sex differences for developing future prognostic information and rehabilitative interventions.

Predictors for functional decline after an injurious fall: a population-based cohort study

Background

The functional consequences of injurious falls are well known. However, studies of the factors that can modify trajectories of disability after an injury from a fall are scarce.

Aims

We aimed to investigate whether sociodemographic and health-related factors may impact this association.

Methods

The study population consisted of 1426 community-dwelling older adults (≥ 60 years) from the SNAC-K cohort study in Stockholm, Sweden. Functional status over 12 years of follow-up was assessed using the number of limitations in basic and instrumental activities of daily living. Sex, cohabitation status, physical activity, and self-rated health were assessed at baseline. Injurious falls were defined as falls requiring healthcare and were assessed over 3 years starting at baseline. Data were analyzed using linear-mixed effects models.

Results

The fastest increase in the number of disabilities was observed in those who had endured an injurious fall and were living alone (β coefficient = 0.408; p < 0.001), been physically inactive (β coefficient = 0.587; p < 0.001), and had poor self-rated health (β coefficient = 0.514; p < 0.001). The negative impact of these factors was more pronounced among fallers compared to non-fallers.

Discussion

Living alone, being physically inactive, and having poor self-rated health magnifies the negative effect of an injurious fall on functional status. Among individuals who endure an injurious fall, the heterogeneity in long-term functional status is substantial, depending on the individuals’ characteristics and behaviors.

Conclusions

These findings emphasize the need for a person-centered approach in care provision and can guide secondary prevention within health care.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01747-1) contains supplementary material, which is available to authorized users.

Application of SDOC Cut Points for Low Muscle Strength for Recovery of Walking Speed After Hip Fracture

BACKGROUND

Sarcopenia is often conceptualized as a precursor to loss of mobility, but its effect on recovery of mobility after a hip fracture is unknown. We determined the prevalence of low muscle strength (weakness) after hip fracture using putative sarcopenia metrics (absolute grip strength, and grip strength normalized to body mass index, total body fat, arm lean mass, and weight) identified by the Sarcopenia Definitions and Outcomes Consortium (SDOC).

METHODS

We examined two well-characterized hip fracture cohorts of community-dwelling older adults from the Baltimore Hip Studies (BHS). The prevalence of muscle weakness was assessed using the SDOC cut points compared to published definitions at 2 and 6 months postfracture. We assessed associations of 2-month weakness with 6-month walking speed <0.6 m/s and calculated the sensitivity and specificity in predicting lack of meaningful change in walking speed (change < 0.1 m/s) at 6 months.

RESULTS

Two hundred and forty-six participants (192 women; 54 men) were included; mean (SD) age of 81 (8) for women and 78 (7) for men. At 2 months, 91% women and 78% men exhibited slow walking speed (< 0.6 m/s). SDOC grip strength standardized by weight (<0.34 kg women, <0.45 kg men) was the most prevalent measure of weakness in men (74%) and women (79%) and provided high sensitivity in men (86%) and women (84%) predicting lack of meaningful change in walking speed at 6 months, although specificity was poor to moderate.

CONCLUSIONS

SDOC cut points for grip strength standardized to weight provided consistent indication of poor walking speed performance post-hip fracture.

Association between patients' state upon admission and decline in activities of daily living

[Purpose] In this study, we aimed to determine the components of activities of daily living that decline easily during hospitalization. [Participants and Methods] We performed a prospective cohort study of 2,819 inpatients who were hospitalized and discharged. We prospectively evaluated the Barthel Index at admission and discharge, age, length of hospital stay, clinical department, and rehabilitation type. We divided the inpatients into two groups based on the Barthel Index score at admission and compared the items of the index at admission and discharge to analyze the characteristics of decline in activities of daily living. [Results] Forty-nine inpatients (2.0%) had declined in activities of daily living. There were no significant between-group differences in age, length of hospital stay, clinical department, or ratio of individual rehabilitation. However, transfer and toilet use remarkably decreased in the group with Barthel Index scores at admission <85, and bathing and ascending/descending remarkably decreased in the group with Barthel Index at admission ≥85. [Conclusion] The characteristics of decrease in each activity of daily living vary, and our results suggested the components that easily declined when inpatients were divided based on their performance of activities of daily living at admission.

Examining Differences in Recovery Outcomes between Male and Female Hip Fracture Patients: Design and Baseline Results of a Prospective Cohort Study from the Baltimore Hip Studies

BACKGROUND

Incidence of hip fractures in men is expected to increase, yet little is known about consequences of hip fracture in men compared to women. It is important to investigate differences at time of fracture using the newest technologies and methodology regarding metabolic, physiologic, neuromuscular, functional, and clinical outcomes, with attention to design issues for recruiting frail older adults across numerous settings.

OBJECTIVES

To determine whether at least moderately-sized sex differences exist across several key outcomes after a hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study (Baltimore Hip Studies 7th cohort [BHS-7]) was designed to include equal numbers of male and female hip fracture patients to assess sex differences across various outcomes post-hip fracture. Participants were recruited from eight hospitals in the Baltimore metropolitan area within 15 days of admission and were assessed at baseline, 2, 6 and 12 months post-admission.

MEASUREMENTS

Assessments included questionnaire, functional performance evaluation, cognitive testing, measures of body composition, and phlebotomy.

RESULTS

Of 1709 hip fracture patients screened from May 2006 through June 2011, 917 (54%) were eligible and 39% (n=362) provided informed consent. The final analytic sample was 339 (168 men and 171 women). At time of fracture, men were sicker (mean Charlson score= 2.4 vs. 1.6; p<0.001) and had worse cognition (3MS score= 82.3 vs. 86.2; p<0.05), and prior to fracture were less likely to be on bisphosphonates (8% vs. 39%; p<0.001) and less physically active (2426 kilocalories/week vs. 3625; p<0.001).

CONCLUSIONS

This paper provides the study design and methodology for recruiting and assessing hip fracture patients and evidence of baseline and pre-injury sex differences which may affect eventual recovery one year later.

The use of Barthel index for the assessment of the functional recovery after osteoporotic hip fracture: One year follow-up

The Barthel index evolution was analyzed in a sample of older people with osteoporotic hip fracture in order to verify the influence of comorbidities and cognitive impairment on the physical recovery of those patients, during the first year following the fracture. A prospective observational study was carried out between October 1, 2012 and March 31, 2013. A sample of 247 individuals was initially selected. After a primary revision, 39 participants were excluded (clearly not meeting inclusion criteria, lack of data, or not agree to participate in the study), and finally a total of 208 participants were included in the analysis, 166 women, with an average age of 84.59 years, and 42 men, with an average age of 82.05. 54.80% of all cases were older than 85 years. The mean Barthel index value prior to fracture was 76.63, decreasing to 64.91 at one-year follow-up. Only 22.12% of patients achieved a full recovery for activities of daily living. A statistical analysis was performed by comparing Barthel index recovery depending on the values of Charlson and Pfeiffer indexes, respectively. The mean differences in Barthel index drop between the one-year follow-up and the hospital admission values were found statistical significant (p<0.01). These findings indicate that Charlson and Pfeiffer indexes clearly influence the Barthel index recovery. Low values of Charlson and Pfeiffer indexes resulted in better Barthel index recovery. In conclusion, the Barthel index is a good tool to evaluate the physical recovery after osteoporotic hip fracture.

Is there a definition of low lean mass that captures the associated low bone mineral density? A cross-sectional study of 80 men with hip fracture

BACKGROUND AND AIMS

Subjects with osteosarcopenia, the concurrent presence of sarcopenia and osteoporosis, have prognostic disadvantages and can benefit from treatments targeted at both the conditions. Our aim was to elucidate whether the available definitions of low appendicular lean mass (aLM) capture or not the men with associated low bone mineral density (BMD) following a hip fracture.

METHODS

80 men admitted to our rehabilitation hospital underwent a dual-energy X-ray absorptiometry scan 19.1 ± 4.1 (mean ± SD) days after hip fracture occurrence. Low aLM was identified according to either Baumgartner's definition (aLM/height² < 7.26 kg/m²) or the criteria from the Foundation for the National Institutes of Health (FNIH): aLM < 19.75 kg, or aLM adjusted for body mass index (BMI) < 0.789. Low BMD was diagnosed with a T-score < - 2.5 at the unfractured femur.

RESULTS

We found a significant positive correlation between aLM and BMD assessed at either femoral neck (r = 0.44; p < 0.001) or total hip (r = 0.50; p < 0.001). After categorization according to the FNIH threshold for aLM, we found a significant association between low aLM and low BMD: χ²(1, n = 80) = 5.4 (p = 0.020), which persisted after adjustment for age and fat mass. Conversely, categorization according to neither Baumgartner's threshold for aLM/height² nor to the FNIH threshold for aLM/BMI was associated with low BMD.

CONCLUSIONS

The association between low aLM and low BMD in men with hip fracture dramatically depends on the adopted definition of low aLM. FNIH threshold for aLM (< 19.75 kg) emerges as a useful tool to capture men with damage to both the components of the muscle-bone unit.

Risk Factors for Injurious Falls in Older Adults: The Role of Sex and Length of Follow-Up

OBJECTIVES

To identify sex-specific associations between risk factors and injurious falls over the short (<4 years) and long (4-10 years) term.

DESIGN

Longitudinal cohort study between 2001 and 2011.

SETTING

Swedish National Study on Aging and Care, Kungsholmen, Sweden.

PARTICIPANTS

Community-dwelling adults aged 60 and older (N = 3,112).

MEASUREMENTS

An injurious fall was defined as a fall that required inpatient or outpatient care. Information was collected on participant and exposure characteristics using structured interviews, clinical examinations, and physical function tests at baseline.

RESULTS

The multivariate model showed that, in the short term, living alone (hazard ratio (HR)=1.83, 95% confidence interval (CI)=1.13-2.96), dependency in instrumental activities of daily living (IADLs) (HR=2.59, 95% CI=1.73-3.87), and previous falls (HR=1.71, 95% CI=1.08-2.72) were independently associated with injurious falls in women. Low systolic blood pressure (HR=1.96, 95% CI=1.04-3.71), impaired chair stands (HR=3.00, 95% CI=1.52-5.93), and previous falls (HR=2.81, 95% CI=1.32-5.97) were associated with injurious falls in men. Long-term risk factors were underweight (HR=2.03, 95% CI=1.40-2.95), cognitive impairment (HR=1.49, 95% CI=1.08-2.06), fall-risk increasing drugs (HR=1.67, 95% CI=1.27-2.20 for ≥2 drugs), and IADL dependency (HR=1.58, 95% CI=1.32-5.97) for women and smoking (HR=1.71, 95% CI=1.03-2.84), heart disease (HR=2.20, 95% CI=1.5-3.24), impaired balance (HR=1.68, 95% CI=1.08-2.62), and a previous fall (HR=3.61, 95% CI=1.98-6.61) for men.

CONCLUSION

Men and women have different fall risk profiles, and these differences should be considered when developing preventive strategies. Some risk factors were more strongly predictive of injurious falls over shorter than longer periods and vice versa, suggesting that it may be possible to identify older men and women at short- and long-term risk of injurious falls. J Am Geriatr Soc 67:246-253, 2019.

The impact of body composition, pain and resilience on physical activity, physical function and physical performance at 2 months post hip fracture

The purpose of this study was to test a model of the factors influencing physical activity, physical function and physical performance at 2 months post hip fracture and compare model fit between men and women. Age, cognitive status, comorbidities, pain, resilience, bone mineral density, total body lean mass, total body fat and grip strength were hypothesized to be directly and/or indirectly related to physical activity, physical function and physical performance. This analysis used data from the seventh Baltimore Hip Studies (BHS-7), a prospective cohort study that included 258 community-dwelling participants, 125 (48%) men and 133 (52%) women, hospitalized for treatment of a hip fracture; survey and objective data were obtained at 2 months post hip fracture. In addition to age, sex and comorbidities (modified Charlson scale), data collection included body composition from dual-energy x-ray absorptiometry (DXA) scans, grip strength, and physical activity, function and performance based on the Yale Physical Activity Survey, the Short Physical Performance Battery and the Lower Extremity Gain Scale. Age, cognition, and comorbidities were not significantly associated with resilience; and, resilience was not associated with pain. In addition, bone mineral density was not associated with physical activity, physical performance or physical function. Total lean body mass, resilience and pain were associated with physical activity, physical function and physical performance in women, but were not consistently associated with physical and functional outcomes in men. Future research should consider evaluation of muscle quality and additional psychosocial factors (e.g., depression, social supports) in model testing.

Lean Mass and Functional Recovery in Men With Hip Fracture: A Short-Term Prospective Pilot Study

OBJECTIVE

The aim of the study was to assess the capability of different definitions of low appendicular lean mass (aLM) to predict the short-term functional recovery in men with hip fracture.

DESIGN

We investigated 80 of 95 men with hip fracture admitted consecutively to a rehabilitation hospital. Body composition was assessed by dual-energy x-ray absorptiometry. Functional recovery after inpatient rehabilitation was evaluated using Barthel Index scores.

RESULTS

The patients with aLM above the cutoff value of 19.75 kg indicated by the Foundation for the National Institutes of Health (FNIH) had significantly higher Barthel Index scores than those with aLM below the cutoff value (P = 0.002). Patients' categorization according to the same threshold (aLM = 19.75 kg) was significantly associated with a Barthel Index score of 85 or higher after adjustment for age, cognitive impairment, hip fracture type, co-morbidities, and medications (odds ratio = 7.17, 95% confidence interval = 1.43-35.94, P = 0.017). Conversely, patients' categorization according to neither Baumgartner's cutoff value (7.26 kg/m(2)) for aLM/height(2) nor Foundation for the National Institutes of Health cutoff value (0.789) for aLM divided by body mass index was significantly associated with the Barthel Index scores.

CONCLUSIONS

Categorization according to the Foundation for the National Institutes of Health threshold for aLM, but not to the Foundation for the National Institutes of Health threshold for aLM/body mass index or Baumgartner's threshold for aLM/height, was associated with the short-term recovery in activities of daily living after a hip fracture in men.

Relationship between obesity, sarcopenia, sarcopenic obesity, and bone mineral density in elderly subjects aged 80 years and over

Objective

This study sought to analyze the relationship between the components and aggravations of body composition (obesity, sarcopenia, and sarcopenic obesity) and bone mineral density in elderly subjects aged ≥80 years.

Methods

A cross-sectional study design was utilized to assess 128 subjects aged between 80 and 95 years. Body composition and bone mineral density were measured by dual energy X-ray absorptiometry. Gait speed was assessment by walking test. The statistical analyses included Spearman's correlation, one-way analysis of variance, the chi-squared test, and binary logistic regression analysis.

Results

The elderly subjects with sarcopenia had lower bone mineral density compared to the obesity group, with higher risk for presence of osteopenia/osteoporosis in the spine (OR: 2.81; CI: 1.11-7.11) and femur (OR: 2.75; CI: 1.02-7.44). Obesity was shown to be a protective factor for osteopenia/osteoporosis in the spine (OR: 0.43; CI: 0.20-0.93) and femur (OR: 0.27; CI: 0.12-0.62).

Conclusion

It was found that lean mass is more directly related to bone mineral density (total, femur, and spine) and sarcopenia is associated with osteopenia/osteoporosis. Obesity represents a possible protective factor for osteopenia/osteoporosis in elderly subjects aged 80 years and over.

Inpatient Rehabilitation Outcomes in a National Sample of Medicare Beneficiaries With Hip Fracture

Effects of patient characteristics on rehabilitation outcomes (functional status at discharge, discharged home) were assessed in a retrospective study of Medicare beneficiaries admitted to Medicare-certified inpatient rehabilitation facilities (IRFs) following hospitalization for hip fracture in 2009 (N = 34,984). Hierarchical regression analysis showed significantly higher functional status at discharge (p < .0001) for patients with these characteristics: White or Asian, younger, female, lived alone, higher functional status at admission, fewer comorbidities, no tier comorbidities, and longer IRF length of stay (LOS). Likelihood of discharged home was higher for patients with these characteristics: Hispanic (1.49 [1.32, 1.68]), Asian (1.35 [1.04, 1.74]), or Black (1.28 [1.12, 1.47]); younger (0.96 [0.96, 0.96]); female (1.14 [1.08, 1.20]); lived with others (2.12 [2.01, 2.23]); higher functional status at admission (1.06 [1.06, 1.06]); fewer comorbidities, no tier comorbidities; and longer LOS (1.61 [1.56, 1.67]). Functional status at admission, tier comorbidities, and race/ethnicity contributed the most to variance in functional status at discharge. Living with others contributed the most to variance in discharged home.

State of origin: Australian states use widely different resources for hospital management of hip fracture, but achieve similar outcomes

Objective Hospital management of hip fracture varies widely with regard to length of stay, delivery of post-surgical care and costs. The present study compares the association between hospital utilisation and costs and patient outcomes in the six Australian states. Methods The present study was a retrospective cohort study of linked administrative databases for 2530 Australian veterans and war widows aged ≥65 years, hospitalised for hip fracture in 2008–09. Department of Veterans’ Affairs datasets for hospital episodes, residential aged care admissions and date of death were linked. Patient characteristics, hospital utilisation and process data, rates of mortality and residential care placement and delivery of community services were compared for patients from each of the states. Results There were no significant differences in fracture incidence, patient demographics or fracture type among the states. Adjusted total mean length of hospital stay ranged from 24.7 days (95% confidence interval (CI) 22.3–27.5 days) to 35.0 days (95% CI 32.6–37.6 days; P < 0.001) and adjusted total hospital cost ranged between A$24 792 (95% CI A$22 191–A$27 700) and A$35 494 (95% CI A$32 853–A$38 343; P < 0.001). Rates of referral to rehabilitation ranged from 31.7% to 50.4% (P = 0.003). At 1 year, there were no significant differences between states for key outcome determinants of mortality (P = 0.71) or for the proportion of patients who retained their independent living status (P = 0.66). Conclusion Hospital resources for management of hip fracture differ substantially among the Australian states. Key medium-term patient outcomes do not show significant differences. A potential for substantial cost-efficiencies without increased risk to patient welfare is suggested. What is known about this topic? Hospital resources deployed in the initial management of hip fracture differ widely between countries, regions and individual hospitals. Patient outcomes also vary widely, but are inconsistently associated with resource outlays. What does this paper add? The paper describes the different resource outlays for management of hip fracture in six Australian jurisdictions and the absence of equivalent differences in medium-term patient outcomes. What are the implications for practitioners? Efficiencies in hospital management of hip fracture may be achievable without negative consequences for patients. The elements of models of care should be examined for their contribution to early and later patient outcomes.

Recovery of Walking Ability and Return to Community Living within 60 Days of Hip Fracture Does Not Differ Between Male and Female Survivors

OBJECTIVES

To compare risk-adjusted differences between men and women 30 and 60 days after hip fracture surgery in not walking, ability to return home in a community-dwelling subset, not walking in a nursing home resident subset, and mortality within 60 days.

DESIGN

Cohort study.

SETTING

Data were from a randomized clinical trial that compared two blood transfusion protocols after hip fracture.

PARTICIPANTS

Individuals with hip fracture (N = 2,016; 489 (24%) male).

MEASUREMENTS

Walking, dwelling, and mortality were determined in telephone follow-up 30 and 60 days after randomization, which occurred within 3 days of surgery. Sex differences for each outcome were compared using univariate and multivariate regression adjusting for potential confounders.

RESULTS

Men were younger (P < .001) and more likely to have comorbidity (P = .003) than women at the time of hip fracture and to die within 60 days, even after risk adjustment (odds ratio (OR) = 1.76, 95% confidence interval (CI) = 1.15-2.69). After risk adjustment, male survivors were as likely as female survivors not to walk (OR = 1.03, 95% CI = 0.78-1.34) and no less likely to return home (OR = 0.90, 95% CI = 0.69-1.17) 60 days after hip fracture. No differences were noted between male and female nursing home residents in not walking within 60 days (OR = 0.95, 95% CI = 0.32-2.86).

CONCLUSION

Although men experience higher mortality, male survivors can expect recovery of walking ability similar to that of female survivors and are as likely to return to community living.

Concomitant upper limb fractures and short-term functional recovery in hip fracture patients: does the site of upper limb injury matter?

OBJECTIVE

The aim of this study was to evaluate functional recovery in a subgroup of hip fracture patients who sustained a simultaneous fracture at the upper limb, taking into account the site of upper limb injury.

DESIGN

Of 760 patients admitted consecutively to the authors' rehabilitation hospital because of a fall-related hip fracture, 700 were retrospectively investigated. Functional outcome was assessed using Barthel Index scores.

RESULTS

In 49 of the 700 patients, a single fall resulted in both a hip fracture and a fracture of either wrist (n = 34) or proximal humerus (n = 15). The patients with concomitant shoulder fractures had lower median Barthel Index scores after rehabilitation (70 vs. 90, P = 0.003), lower median Barthel Index effectiveness (57.1 vs. 76.9, P = 0.018), and prolonged median length of stay (42 vs. 36 days, P = 0.011) than did the patients with isolated hip fractures. Significant differences persisted after adjustment for six potential confounders. The adjusted odds ratio for achieving a Barthel Index score lower than 85 was 6.71 (95% confidence interval, 1.68-26.81; P = 0.007) for the patients with concomitant shoulder fractures. Conversely, no prognostic disadvantages were associated with concomitant wrist fractures.

CONCLUSIONS

Data show a worse functional recovery and a prolonged length of stay in the subgroup of hip fracture patients who sustained a concomitant fracture at the proximal humerus, but not at the wrist.

Fracture incidence in a large cohort of men age 30 years and older with osteoporosis

In this large retrospective study of men with presumed osteoporosis, we estimate the rate of osteoporosis-related fractures in men age ≥30 years. Our results suggest that spine and hip fractures continue to be a considerable disease burden for osteoporotic men of all ages.

INTRODUCTION

The purposes of this study were to describe a cohort of men with presumed osteoporosis and estimate the incidence rates of fractures by age.

METHODS

Using US administrative claims data, we identified 43,813 men ≥30 years old with an osteoporosis diagnosis or use of an osteoporosis medication. Men were followed for a minimum of 12 months after diagnosis or treatment of osteoporosis (index date), until the earliest of fracture (hip, spine, pelvis, distal femur, humerus, wrist, forearm), disenrollment, or study end date.

RESULTS

During the study period, there were 3834 first fractures following the index date and 3303 fractures in the 6-month period prior to the diagnosis/treatment of osteoporosis. Incidence rates of osteoporosis-related fracture, estimated from the index date onward, increased with age, although did not significantly differ from one another in younger age groups (30-49 and 50-64 years). Spine fractures had the highest incidence rate in men across all age groups, increasing from 10.8 per 100,000 person-years (p-yrs) (95% confidence interval (CI) 9.1, 12.7), 12.2 per 100,000 p-yrs (95% CI 11.2, 13.3), and 15.3 per 100,000 p-yrs (95% CI 13.8, 16.9) in men 30-49, 50-64, and 65-74 years to 33.4 per 100,000 p-yrs (95% CI 31.5, 35.4) in men ≥75 years. Hip fractures were the second most common, with the incidence rate reaching 16.2 per 100,000 (95% CI 14.9, 17.6) in the ≥75-year group.

CONCLUSION

These incidence rates suggest that spine and hip fractures are a considerable disease burden for men of all ages diagnosed and/or treated for osteoporosis.

Handgrip strength is an independent predictor of functional outcome in hip-fracture women: a prospective study with 6-month follow-up

The objective of this study was to investigate the contribution of handgrip strength in predicting the functional outcome after hip fracture in women.We prospectively investigated white women (N = 193 of 207) who were consecutively admitted to a rehabilitation hospital after a hip fracture. We measured handgrip strength with a Jamar dynamometer (Lafayette Instrument Co, Lafayette, IN), on admission to rehabilitation. Ability to function in activities of daily living was assessed by the Barthel index both on discharge from rehabilitation and at a 6-month follow-up.We found significant correlations between handgrip strength measured before rehabilitation and Barthel index scores assessed both on discharge from rehabilitation (ρ = 0.52, P < 0.001) and after 6 months (ρ = 0.49, P < 0.001). Significant associations between handgrip strength and Barthel index scores persisted after adjustment for age, comorbidities, pressure ulcers, medications in use, concomitant infections, body mass index, hip-fracture type, and Barthel index scores assessed both preinjury and on admission to rehabilitation (P = 0.001). Further adjustments for both Barthel index scores and Timed Up-and-Go test assessed at rehabilitation ending did not erase the significant association between handgrip strength and the Barthel index scores at the 6-month evaluation (P = 0.007). To define successful rehabilitation, we categorized the Barthel index scores as either high (85 or higher) or low (<85). The adjusted odds ratio for 1 SD increase in grip strength was 1.73 (95% confidence interval [CI] 1.05-2.84, P = 0.032) for having a high Barthel index score at the end of inpatient rehabilitation and 2.24 (95% CI 1.06-5.18) for having a high Barthel index score at the 6-month follow-up.Handgrip strength assessed before rehabilitation independently predicted the functional outcome both after inpatient rehabilitation and at a 6-month follow-up in hip-fracture women.

Total hospital stay for hip fracture: measuring the variations due to pre-fracture residence, rehabilitation, complications and comorbidities

BACKGROUND

Hospital treatment for hip fracture is complex, often involving sequential episodes for acute orthopaedics, rehabilitation and care of contingent conditions. Most reports of hospital length of stay (LOS) address only the acute phase of care. This study identifies the frequency and mean duration of the component episodes within total hospital stay, and measures the impacts of patient-level and clinical service variables upon both acute phase and total LOS.

METHODS

Administrative datasets for 2552 subjects hospitalised between 1 July 2008 and 30 June 2009 were linked. Associations between LOS, pre-fracture accommodation status, age, sex, fracture type, hospital separation codes, selected comorbidities and complications were examined in regression models for acute phase and total LOS for patients from residential aged care (RAC) and from the community.

RESULTS

Mean total LOS was 30.8 days, with 43 per cent attributable to acute fracture management, 37 per cent to rehabilitation and 20 per cent to management of contingent conditions. Community patients had unadjusted total LOS of 35.4 days compared with 18.8 days for RAC patients (p <0.001). The proportion of transfers into rehabilitation (57 per cent vs 17 per cent, p <0.001) was the major determinant for this difference. In multivariate analyses, new RAC placement, discharge to other facilities, and complications of pressure ulcer, urinary or surgical site infections increased LOS by at least four days in one or more phases of hospital stay.

CONCLUSION

Pre-fracture residence, selection for rehabilitation, discharge destination and specific complications are key determinants for acute phase and total LOS. Calculating the dimensions of specific determinants for LOS may identify potential efficiencies from targeted interventions such as orthogeriatric care models.

Male osteoporosis: clinical approach and management in family practice

In Singapore, male osteoporosis is gaining greater importance due to our ageing population. Family physicians should screen for osteoporosis in elderly men and men with risk factors or secondary causes for the condition. A bone mineral density (BMD) test is used for diagnosis. FRAX® can be used to predict the absolute ten-year fracture risk. Management includes reduction of risk factors or secondary causes, fall prevention, appropriate physical activity and a diet adequate in calcium and vitamin D. Referrals to specialists for evaluation and therapy can be considered, particularly for younger men with more severe disease. Current first-line drug treatment includes bisphosphonates and teriparatide. Testosterone increases BMD of the spine, but data on fracture risk reduction is unavailable. Public and physician education with the involvement of health authorities can create greater awareness of this silent condition, which can lead to complications, morbidity and death, if left untreated.

Maximising functional recovery following hip fracture in frail seniors

This review discusses factors affecting recovery following hip fracture in frail older people as well as interventions associated with improved functional recovery. Prefracture function, cognitive status, co-morbidities, depression, nutrition and social support impact recovery and may interact to affect post-fracture outcome. There is mounting evidence that exercise is beneficial following hip fracture with higher-intensity/duration programmes showing more promising outcomes. Pharmacologic management for osteoporosis has benefits in preventing further fractures, and interest is growing in pharmacologic treatments for post-fracture loss of muscle mass and strength. A growing body of evidence suggests that sub-populations - those with cognitive impairment, residing in nursing homes or males - also benefit from rehabilitation after hip fracture. Optimal post-fracture care may entail the use of multiple interventions; however, more work is needed to determine optimal exercise components, duration and intensity as well as exploring the impact of multimodal interventions that combine exercise, pharmacology, nutrition and other interventions.

Association between bone mass and functional capacity among elderly people aged 80 years and over

OBJECTIVE

Analyzed the association of bone mass with the functional capacity of elderly aged 80 or more.

METHODS

The sample consisted of 93 elderly aged 80 and 91 years (83.2±2.5 years) being 61 women (83.3±2.7 years) and 32 men (83.1±2.2 years) living in the city of Presidente Prudente - São Paulo/Brazil. The assessment of bone mass was realized by absorptiometry dual-energy X-ray (DXA), where have been measured values bone mineral content (BMC) and bone mineral density (BMD) of the femur and spine (L1-L4). The functional capacity was evaluated by means of walking speed tests, static equilibrium and strength of lower limbs contained in the questionnaire Wellness Health and Aging (SABE). The variables of bone mass and functional capacity were categorized according to the median values and score tests, respectively. For statistical analysis we carried out the chi-square test, the software used was SPSS (13.0) and the significance level was set at 5%.

RESULTS

Elderly male with higher performance in the functional tests showed higher femur BMC compared to lower performance, result not found when evaluated women.

CONCLUSION

Thus, the bone of the femur for the oldest old male is associated with functional capacity. The constant assessment of the bone mineral mass and practive of physical activity throughout life would be measures to prevent falls in the elderly.

Parathyroid hormone is significantly associated with body fat compartment in men but not in women following a hip fracture

BACKGROUND AND AIMS

Parathyroid hormone (PTH) exerts several actions beyond mineral metabolism and may affect body composition. The aim of our study was to assess the association between serum PTH and body fat compartment in hip fracture patients.

METHODS

We studied 575 of 630 inpatients with hip fracture consecutively admitted to our Rehabilitation ward. Dual-energy X-ray absorptiometry (DXA) was used to measure body composition. DXA scan was performed 18.5 ± 8.6 (mean ± SD) days after hip fracture occurrence. A blood sample was collected within 4 days after DXA scan. In each subject, we evaluated PTH, 25-hydroxyvitamin D, calcium, phosphate, albumin, magnesium, and creatinine. Glomerular filtration rate was estimated by a conventional formula.

RESULTS

In the 57 men, we found a significant correlation between PTH and both body mass index (BMI) (ρ = 0.37; p = 0.020) and trunk fat percentage (ρ = 0.62; p < 0.001). After multiple adjustments, we confirmed a significant association between PTH and BMI (r = 0.38; p = 0.004) or trunk fat percentage (r = 0.51; p < 0.001). In the 518 women, we found a slightly significant correlation between PTH and BMI (ρ = 0.09; p = 0.047), but after adjustments the correlation coefficient dropped to 0.02 (p = 0.69). We found no significant relationships between PTH and trunk fat percentage at bivariate correlation (ρ = 0.04; p = 0.35) or after adjustments (r = 0.04; p = 0.38).

CONCLUSIONS

PTH serum levels were robustly associated with body fat compartment in men, but not in women following a fracture of the hip. A role of PTH in affecting body composition in hip fracture men is suggested. Its potential role in male prognostic disadvantage needs further investigation.