POOR RETURN OF FUNCTIONAL MOBILITY AFTER HIP FRACTURE IN OLDER PATIENTS—IT'S TIME TO IMPROVE ON HIP FRACTURE PREVENTION

Abstract

To the Editor: Hip fractures are the most devastating of fragility fractures and are a major source of disability and mortality, because the individuals who experience them are frequently frail. The high cost of hip fractures includes perioperative, rehabilitative, and long-term nursing care and the need for community supports if individuals who experience them are discharged home. Up to three-quarters of total economic costs incurred by hip fracture are because of postoperative complications, rehabilitation, and nursing home placement, with up to one-third of costs incurred by physical rehabilitation alone.1,2 Hip fractures can significantly affect the functional ability of older people and their potential for independent living. This reduction in independence affects quality of life in community-dwelling older adults after hip fracture.3 The aim of this study was to examine the change in functional mobility and the discharge destination after hip fracture of older adults admitted to a large Dublin hospital. Demographic details, discharge destination, and functional outcome for all people experiencing hip fracture admitted over 15 months were reviewed from the hip fracture database. Patient mobility level was recorded at baseline and 30 and 120 days after fracture using a simple mobility scale to record the level of assistance needed. The need for walking aids was also documented at the same times. Place of residence and discharge destination were also recorded. Statistical analysis was done using SPSS version 9 (SPSS, Inc, Chicago, IL). Regression analysis and chi-square tests were performed. Details on 107 consecutive individuals were reviewed. Mobility data were available at 120 days for 78 individuals (73%). Results from this subgroup were analyzed. Mean age was 82 (range 53–100); 76% were female. Of individuals admitted to the hospital from home, 21% had been discharged to a nursing home for long-term care by 120 days. At 120 days, the overall number of individuals using one or more aids was 54% less than at baseline, but the number of individuals requiring more-supportive ambulatory aids (crutches, rollator, wheelchair) was 96% greater. Overall, 64% of patients required more aids at discharge than they were using on admission, and the number of patients who were wheelchair bound was four times as great. Of individuals who were fully independent outdoors at baseline, only 55% maintained this independence at 120 days. At follow-up, 16% of this group required help mobilizing indoors, and 8% were wheelchair bound. Regression analysis found age to be the only significant factor affecting mobility, with older age related to a worse mobility outcome (P=.008). Initial residence or place of rehabilitation did not significantly affect functional outcome. A previous study comparing patients admitted from long-term care and the community concluded that most long-term care residents did not regain prefracture function,4 but nursing home residents in this study were older and had more comorbidities including dementia that were likely to affect their rehabilitation potential. All patients in the current study participated in a coordinated multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their prefracture living arrangements. Despite this, a large proportion of individuals did not regain premorbid functional status, and not all returned to their premorbid residence; 38% were discharged to a long-term care facility, a figure that compares with other studies.5,6 These higher levels of care are costly and contribute to the hidden health economic burden of hip fracture. Furthermore, the reduction in social independence and function in these patients discharged to the community can significantly affect their quality of life.3,7 Although the current study had short follow-up, function at hospital discharge is a strong predictor of functional status at 1 year.8 The rising incidence of hip fractures reinforces the importance of preventing falls and fractures in older people. In 2008, the World Health Organization introduced the FRAX tool, which can be used to better identify people at high risk of fracture,9 and there is currently good evidence to support the use of many antiresorptive and anabolic drugs for fracture risk reduction. FRAX incorporates several known risk factors for fracture, along with bone mineral density T-score, if available, and calculates fracture probabilities from which treatment thresholds can be determined in individual countries. To encourage primary prevention of fracture at a national level, the use of FRAX should be encouraged among health professionals. To meet the challenges of increasing numbers of hip fracture in the future, strategies for management should encompass guidelines on prevention. Ongoing close liaison with orthopedic colleagues should continue to enhance the quality of care and recovery of older adults with hip fracture. Conflict of Interest: The authors report no conflicts of interest. No funding was received for this study. Author Contributions: Linda Brewer: data analysis and manuscript preparation. Ross Kelly: data analysis. Ciaran Donegan and Alan Moore: study design and acquisition of data. David Williams: manuscript preparation. Sponsor's Role: No sponsor.