Multidisciplinary studies of illness in aged persons: III. Prognostic Indices in Fracture of the Hip

Abstract

In continuing studies at The Benjamin Rose Hospital, data were accumulated concerning the course of chronic illnesses. This report deals with patients who were admitted with fracture of the hip. Certain nursing, physical, and psychologic characteristics were prognostically related to mortality and to deterioration in activities of daily living, in walking, and in nature of residence. The significance of the relationships is discussed. Deterioration in activities of daily living and in walking increased in frequency with increasing age, and a relatively large proportion of the youngest study patients showed deterioration in activities of daily living. Thirty per cent of surviving study patients 50 to 79 years old were at deteriorated levels in activities of daily living 1 year after the occurrence of the fracture, and 68 per cent of those 80 years or older were at deteriorated levels. Among surviving patients at 1 year after fracture, all but 1 (97 per cent) in the 60 to 79 years of age group were walking independently, while more than 40 per cent of those older than 79 were not. The mortality rate was 14 to 18 per cent at 1 year in patients aged 80 or more. Patients who required relatively more nursing aid during the ninth and tenth weeks after fracture had a higher mortality rate and more frequent deteriorations in activities of daily living and in walking. Mortality was 27 per cent at 1 year in the more dependent group. At both 6 months and 1 year after fracture, the proportions of deteriorations were greater in patients with congestive heart failure or with recent or remote myocardial infarction than in patients without any of these abnormalities; however, the differences were not statistically significant. At 1 year, the proportions of deterioration in the cardiac group were 67 per cent in activities of daily living, 40 per cent in walking, and 20 per cent in residence. The mortality rate reached a maximum of 21 per cent at 1 year in the cardiac group. There was a trend toward more frequent deterioration in activities of daily living in patients with lower intelligence quotients as determined by the Wechsler Adult Intelligence Scale. Of interest were the high mortality rate and frequent deteriorations among the few patients in whom testing was incomplete because they were psychotic or aggressively hostile in refusing testing. The frequency of deterioration in activities of daily living was greater in patients who had been disabled prior to fracture than in those who had not, and such prior disability was more common in the youngest and oldest patients. The presence of prior disability in the youngest group was, furthermore, closely related to the presence of rheumatoid arthritis or prior stroke. Continuing efforts are being made to define other primary disabilities associated with fracture of the hip as a preliminary step toward defining groups of aged persons with increased susceptibility to this fracture. In such groups, it might be possible to initiate mechanical or educational measures that would decrease the number of fractures and hence the number of instances of chronic mobility limitation in the United States.