Hip Fracture In Older People Research Articles

Effect of comorbidity on relative survival following hospitalisation for fall‐related hip fracture in older people

To assess the effect of comorbidity on relative survival after hip fracture. Relative survival analysis was undertaken in 16 838 fall-related hip fracture hospitalisations in New South Wales, Australia. Comorbidity was measured on the basis of additional diagnosis codes on the same hospital separation as the hip fracture using the Charlson Comorbidity Index (CCI). Interval-specific relative survival and relative excess risk of death were calculated. Comorbidity was more frequently documented in men than women across the age groups. Survival decreased with increasing age and increasing comorbidity, but the relative impact of comorbidity was greater in the younger-old age group (65-74 years). The excess mortality in men was not accounted for by age or comorbidities. This study demonstrates an association between increasing comorbidity and death particularly in the first 3 months post hip fracture. It also highlights a relative excess risk of death in men after hip fracture after adjusting for age and comorbidity.

Role of comprehensive geriatric assessment in the management of osteoporotic hip fracture in the elderly: an overview

Purpose: To highlight the advantages of comprehensive geriatric assessment (CGA) over usual care in the management of elderly patients with fragility hip fractures in terms of reducing the related mortality and disability. Method: An overview of publications on the topic was conducted using the MEDLINE and EMBASE databases. Results: Several models of geriatric and orthopedic comanagement have been developed in recent years, all characterized by a variable degree of integration, and they have been shown to reduce complications, disability and mortality in elderly hip-fracture patients. Preoperatively, CGA should identify the comorbidities that need to be treated in view of surgery, so as to reduce the related risks. After surgery, CGA should deal with medical complications and assure patients an early mobilization in order to reduce short-term mortality and contain functional decline. Before discharge, the orthogeriatric team should draw up a tailored program to promote the patient’s functional recovery and satisfactory quality of life, also covering the secondary prevention of fragility fractures by improving bone quality and reducing the risk of falls. Conclusions: Fragility hip fractures in the elderly people need to be managed by different professionals working in close cooperation and adopting a CGA.Implications for RehabilitationOrthogeriatric managementFragility hip fracture in older people is burdened by an elevated incidence of complications, mortality and disability.The global complexity of elderly people with hip fracture requires an orthopedic and geriatric comanagement.The application of the comprehensive geriatric assessment during hospital stay is the best approach for the management of the elderly people with hip fracture.Before discharge the multidisciplinary team should design a tailored rehabilitation plan and should also consider the secondary prevention of hip fracture.

A comparison between two co-managed geriatric programmes for hip fractured elderly patients

Hip fracture in older people is an event associated with a high incidence of morbidity and mortality. In this study we compared the clinical outcomes of two groups of orthogeriatric patients in an orthogeriatric care (OC) programme. The OC course, developed into the GeriatricWard, starts from the Emergency Department (OC-1, n=174) or from the Orthopaedic Department after surgery (OC-2, n=87). For this purpose, OC patients were prospectively enrolled from March 2007 to June 2009, following OC criteria. Door-to-bed time, time to surgery, mobilisation time, length of stay, and post-operative complications were compared between the OC groups. OC-1 patients differ from OC-2 ones only for residence at admission (14.4% vs 4.6% lived in nursing homes, p=0.02). Concerning outcomes, in the OC-1 group only mobilization time was significantly lower (p=0.01). No differences were observed in post-operative complications. In frail older people, hip fracture co-management, with the geriatrician as primary attendant, leads to satisfying outcomes. The OC-1 and OC-2 courses exhibit similar clinical results. An improvement in several organisational aspects, including coordination between hospital and rehabilitation services, is warranted.

Fracture de l’extrémité supérieure du fémur du patient âgé : aspect épidémiologique, facteurs de risque

Health care administration is concerned about the escalating cost of geriatric trauma care and more specifically hip fracture (HF). By 2050, the wordwide annual incidence of HF among elderly people will be 4.5 million (predictible incidence in France: 150,000) and prevention will be more important than ever. The risk of hip fracture in older people increases exponentially with age. The main other risk factors are osteoporosis and osteopenia, gender, weight, physical activity. The most important cause of osteoporosis is the gradual bone loss that occurs after the menopause. Similarly, there is a strong association with gender: the female-to-male ratio of HF is greater than 2/1 in people over 50 years of age (mean age: 83.2 yrs in female and 79.6 yrs in male in France). One year mortality after hip fracture is remarkably high, around 20 to 30%.

Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture. The protocol of the Trondheim Hip Fracture Trial

BackgroundHip fractures in older people are associated with high morbidity, mortality, disability and reduction in quality of life. Traditionally people with hip fracture are cared for in orthopaedic departments without additional geriatric assessment. However, studies of postoperative rehabilitation indicate improved efficiency of multidisciplinary geriatric rehabilitation as compared to traditional care. This randomized controlled trial (RCT) aims to investigate whether an additional comprehensive geriatric assessment of hip fracture patients in a special orthogeriatric unit during the acute in-hospital phase may improve outcomes as compared to treatment as usual in an orthopaedic unit.Methods/designThe intervention of interest, a comprehensive geriatric assessment is compared with traditional care in an orthopaedic ward. The study includes 401 home-dwelling older persons >70 years of age, previously able to walk 10 meters and now treated for hip fracture at St. Olav Hospital, Trondheim, Norway. The participants are enrolled and randomised during the stay in the Emergency Department. Primary outcome measure is mobility measured by the Short Physical Performance Battery (SPPB) at 4 months after surgery. Secondary outcomes measured at 1, 4 and 12 months postoperatively are place of residence, activities of daily living, balance and gait, falls and fear of falling, quality of life and depressive symptoms, as well as use of health care resources and survival.DiscussionWe believe that the design of the study, the randomisation procedure and outcome measurements will be of sufficient strength and quality to evaluate the impact of comprehensive geriatric assessment on mobility and other relevant outcomes in hip fracture patients.Trials registrationClinicalTrials.gov, NCT00667914

Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people

Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people

Treatment and prevention of depression after surgery for hip fracture in older people: Cost-effectiveness analysis

Objective For older people who have had hip fracture surgery, to evaluate the cost-effectiveness of a nurse-led intervention in treating depression compared to treatment as usual (TAU), and to evaluate the cost-effectiveness of a psychological treatment for the prevention of depression. Design Two linked cost-effectiveness studies for the treatment and prevention of depression after hip surgery, from the perspective of health, social care, voluntary sector agencies and unpaid carers. Setting Orthopaedic units in Manchester, England. Participants One hundred and twenty-one patients with Geriatric Depression Scale (GDS) scores greater than 6 were included in the treatment study and 172 patients with GDS scores less than or equal to 6 were enrolled in the prevention study. Interventions Nurse-led intervention for treating depression versus TAU; and cognitive behaviour therapy (CBT) for preventing depression following surgery for hip fracture. Main outcome measures Outcomes were changes in HADS-depression scores at 6 weeks. Costs covered treatment and all service impacts. Results After 6 weeks, there were no significant differences in cost. However, the nurse-led intervention group had a lower mean HADS-depression score compared to TAU. In the prevention study, there were no significant differences in cost and depression score between patients treated with CBT and TAU. Conclusion The results for this parallel randomized controlled study show that after hip fracture surgery a nurse-led intervention may be a cost-effective option for the treatment of depression in older people with depression. However CBT does not appear to be a cost-effective option for the prevention of depression in this population.

Rehabilitation interventions for improving physical and psychosocial functioning after hip fracture in older people

Social and psychological factors such as fear of falling, self-efficacy and coping strategies are thought to be important in the recovery from hip fracture in older people. To evaluate the effects of interventions aimed at improving physical and psychosocial functioning after hip fracture. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 4), MEDLINE and EMBASE (to December 2008), other databases and reference lists of related articles. Randomised and quasi-randomised trials of rehabilitation interventions applied in inpatient or ambulatory settings to improve physical or psychosocial functioning in older adults with hip fracture. Primary outcomes were physical and psychosocial function and 'poor outcome' (composite of mortality, failure to return to independent living and/or readmission). Two authors independently selected trials based on pre-defined inclusion criteria, extracted data and assessed risk of bias. Disagreements were moderated by a third author. Nine small heterogeneous trials (involving 1400 participants) were included. The trials had differing interventions, including 'usual care' comparators, providers, settings and outcome assessment. Although most trials appeared well conducted, poor reporting hindered assessment of their risk of bias.Three trials testing interventions (reorientation measures, intensive occupational therapy, cognitive behavioural therapy) delivered in inpatient settings found no significant differences in outcomes. Two trials tested specialist-nurse led care, which was predominantly post-discharge but included discharge planning in one trial: this trial found some benefits at three months but the other trial found no differences at 12 months. Coaching (educational and motivational interventions) was examined in two very different trials: one trial found no effect on function at six months; and the other showed coaching improved self-efficacy expectations at six months, although not when combined with exercise. Two trials testing interventions (home rehabilitation; group learning program) started several weeks after hip fracture found no significant differences in outcomes at 12 months. Some outcomes may be amenable to psychosocial treatments; however, there is insufficient evidence to recommend practice changes. Further research on interventions described in this review is required, including attention to timing, duration, setting and administering discipline(s), as well as treatment across care settings. To facilitate future evaluations, a core outcome set, including patient-reported outcomes such as quality of life and compliance, should be established for hip fracture trials.

Spatial temporal modeling of hospitalizations for fall-related hip fractures in older people

The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization and sociodemographic data. There was significant spatial temporal variation in hospitalized hip fracture rates in New South Wales, Australia. The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization data. All New South Wales (NSW), Australia residents aged 65+ years who were hospitalized for a fall-related hip fracture between 1 July 1998 and 30 June 2004 were included. Bayesian Poisson regression was used to model rates in local government areas (LGAs), allowing for the incorporation of spatial, temporal, and covariate effects. Hip fracture rates were significantly decreasing in one LGA, and there were no significant increases in any LGAs. The proportion of the population in residential aged care facilities was significantly associated with the rate of hospitalized hip fractures with a relative risk (RR) of 1.003 (95% credible interval 1.002, 1.004). Socioeconomic status was also related to hospitalized hip fractures with those in the third and fourth quintiles being at decreased risk of hip fracture compared to those in the least disadvantaged (fifth) quintile [RR = 0.837 (0.717, 0.972) and RR = 0.855 (0.743, 0.989) respectively]. There was significant spatial temporal variation in hospitalized hip fracture rates in NSW, Australia. The use of Bayesian methods was crucial to allow for spatial correlation, covariate effects, and LGA boundary changes.

The Impact of Cognitive Impairment on Rehabilitation Outcomes in Elderly Patients Admitted with a Femoral Neck Fracture

To evaluate the evidence of rehabilitation outcomes after the surgical repair of a hip fracture in older people with cognitive impairment. Systematic review. Searches were conducted in MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, and Cochrane Controlled Trials Register), ProQuest Dissertations, and Theses Database and bibliographies of extracted publications in the English language between 1990 and June 2007. Search terms included: dementia/Alzheimer disease/cognitive impairment, hip fracture, rehabilitation, outcome assessment/treatment outcome. Two independent reviewers undertook screening and methodological quality assessment, using the Downs and Black rating scale, of the extracted articles. Only studies evaluating rehabilitation outcomes with data analysis specific for cognitive status were evaluated. Sackett's levels of evidence were used to summarize the main findings. Eleven studies met the inclusion criteria. Methodological quality of the studies ranged from fair to poor. The generalizability of study findings was limited by multiple rehabilitation settings in the acute and subacute phase postsurgery, multiple methods with varying thresholds for determining cognitive impairment and multiple functional outcome scales. There is some evidence that older adults with cognitive impairment who receive intensive inpatient rehabilitation after surgical repair of a hip fracture may be able to gain comparable benefit in physical function as cognitively intact patients. There is not enough information to guide recommendations of specific physical therapy interventions to optimize outcomes in this patient population. Further work is needed.

Weight bearing orders after hip fracture surgery: A quality assurance project

Summary Hip fractures are common injuries that occur primarily in the elderly. For many, it means a loss of their prior level of mobility, or the permanent loss of the ability to live independently. The mortality rate is high; approximately 30% at one year [SIGN: Scottish Intercollegiate Guidelines Network, 2002. Prevention and Management of Hip Fracture in Older People: A National Clinical Guideline. SIGN Executive: Royal College of Physicians, Edinburgh]. Although many aspects of care for the hip fracture patient is evidence based, there is still uncertainty regarding weight bearing status after surgical fixation. This paper outlines a quality assurance project that was conducted in Calgary, Alberta, Canada, to review local practice regarding weight bearing orders after hip fracture fixation, primarily with the use of screws or nails, and compare that to what is suggested in the literature.

Benzodiazepine and Risk of Hip Fractures in Older People: A Nested Case-Control Study in Taiwan

To examine the characteristics of benzodiazepines usage and their associations with hip fractures. All subjects were aged 65 and older and enrolled in the National Health Insurance program in Taiwan, 2001-2004. Cases (N = 217) were elderly patients who were identified with hip fractures for the first time in their outpatient claims. They were individually matched to 1,214 comparison patients based on age, gender, and index year. Benzodiazepine usage (doses, duration, half-life) and the other covariates including comorbidities, health care utilization, and psychotropic medications used in the 180 days before index events were constructed. Using nonusers as reference group, use of benzodiazepines was significantly associated with hip fractures (adjusted odds ratio [AOR] = 1.7, 95% confidence interval [CI] = 1.2-2.5). Such risks appear to be particularly high during the first month (AOR = 5.6, 95% CI = 2.7-11.8) of exposure, doses higher than 3.0 mg/day in diazepam equivalents (AOR = 1.8, 95% CI = 1.1-3.1), and using short-acting benzodiazepines (AOR = 1.8, 95% CI = 1.3-2.7). Benzodiazepine exposure in the elderly increases the risk of hip fractures. This is true even with modest dosage, short-acting agents and short-term exposures. Clinicians should prescribe benzodiazepines judiciously with the elderly to minimize drug-related hip fractures.

Relative survival after hospitalisation for hip fracture in older people in New South Wales, Australia

Survival after hospitalisation for hip fracture by age group and sex relative to survival in the general population was assessed in people aged 65+. Men had double the risk of death compared with women to 1 year, but age effects lasted only to 3 months. Clinical outcomes need to be improved. We assessed the relative survival of hospitalised fall-related hip fracture patients aged 65+ years leaving hospital in New South Wales, Australia, between July 2000 and December 2003. We carried out a population-based study of all hospital separations for NSW residents with a principal diagnosis of hip fracture (ICD-10-AM S72.0 to S72.2) and first external cause of fall (ICD-10-AM codes W00 to W19), linked to NSW death data. A total of 16,836 cases were included. Relative survival 3 to 36 months post-admission by 10-year age groups and sex was calculated, using NSW life tables for 2002-2004. Relative excess risk was modelled using a generalised linear model with Poisson error structure, using the life table data. One-year cumulative relative survival in 65- to 74-year-olds was 82% (men), 90% (women); in 85+-year-olds 65% (men), 80% (women). Men have a relative excess risk of death of 2.2 (95% CI 2.03-2.38) times that of women. Only 21% of deaths mention the hip fracture as contributing to death. There is a need to reduce the number of hip fractures and improve clinical outcomes for older people hospitalised with hip fractures.

Treatment and Prevention of Depression After Surgery for Hip Fracture in Older People: Randomized, Controlled Trials

To evaluate the effect of a psychiatric intervention in treating depression (treatment study) and the effect of a psychological treatment in preventing depression (prevention study) after hip fracture in older people. Two linked randomized, controlled trials. Orthopedic units in Manchester, England. Two hundred ninety-three older people who had undergone surgery for a fractured hip: 121 in the treatment study and 172 in the prevention study. The Geriatric Depression Scale and Hospital Anxiety and Depression Scale for mood, functional tests for mobility and pain measures. There was a slight reduction in depressive symptoms in the active arm of the treatment study. In the prevention study, there was no significant difference in incident depression between the psychological intervention and treatment as usual. There were no differences in the functional and pain outcomes. The results from these two randomized, controlled trials show that, after hip fracture surgery, no statistically significant benefits can be achieved from a psychiatric intervention in people who are depressed or a psychological intervention to prevent the onset of depression.

DEPRESSION AFTER HIP FRACTURE

DEPRESSION AFTER HIP FRACTURE

Fear of falling more important than pain and depression for functional recovery after surgery for hip fracture in older people

Depression and cognitive functioning have a negative impact on functional recovery after hip fracture surgery in older people, and the same has been suggested for pain and fear of falling. These variables, however, have never been studied together, nor has the timing of psychiatric assessment been taken into account. Two parallel, randomized controlled trials were undertaken aiming to prevent and treat depression after hip fracture surgery in older people. Multiple logistic regression analyses corrected for age and pre-morbid level of functioning were performed to evaluate the effect of depressive symptoms (15-item Geriatric Depression Scale, GDS), pain (Wong-Baker pain scale), cognitive functioning (Mini-mental State Examination, MMSE) and fear of falling (Modified Falls Efficacy Scale, MFES) within 2 weeks after surgery and 6 weeks later on functional recovery at 6 months. Main outcome measures were performance-based measures (up-and-go test, gait test, functional reach) and the self-report Sickness Impact Profile (SIP) questionnaire to assess the impact of the hip fracture on activities of daily living (ADL). Two hundred and ninety-one patients participated and outcome measures for 187 (64%) patients were available at 6 months. All mental health variables interfered with functional recovery. However, in the final multivariate model, cognitive functioning and fear of falling assessed 6 weeks after surgery consistently predicted functional recovery, whereas pain and depressive symptoms were no longer significant. Fear of falling and cognitive functioning may be more important than pain and depression to predict functional recovery after hip fracture surgery. Rehabilitation strategies should take this into account.

Claims Data Studies of Sedative-Hypnotics and Hip Fractures in Older People: Exploring Residual Confounding Using Survey Information

Claims Data Studies of Sedative-Hypnotics and Hip Fractures in Older People: Exploring Residual Confounding Using Survey Information

Claims Data Studies of Sedative‐Hypnotics and Hip Fractures in Older People: Exploring Residual Confounding Using Survey Information

To identify the magnitude of confounding bias caused by factors not measured in claims data studies of sedative-hypnotic use and fractures. Cross-sectional survey data. Medicare Current Beneficiary Survey (MCBS). Eight thousand seven hundred eighty-five survey participants aged 65 and older. To determine the association between sedative-hypnotic use and potential confounding factors, five factors not measured in Medicare claims data but measured in the MCBS were assessed: body-mass index, smoking, activity of daily living (ADL) score, cognitive impairment, and Rosow-Breslau physical impairment scale. The association between benzodiazepine or zolpidem use and these five factors was estimated. Combined with literature estimates of the associations between confounders and fractures, it was possible to compute the extent of residual confounding bias caused by a failure to adjust for them. Comparing zolpidem users with nonusers, there was considerable overestimation of an association with hip fractures if ADL scores (21.5% bias) or Rosow-Breslau impairment scales (10.6%) were unobserved in claims data. All five unmeasured confounders together resulted in net confounding of 9.8% (range 0-39%). Comparing benzodiazepine users with nonusers, effect estimates were moderately biased (6.1%). After correction for this bias, the association observed in claims data (relative risk (RR)=1.38; 95% confidence interval (CI)=1.14-1.66) was comparable with that found in a recent study using clinical data (RR=1.20, 95% CI=0.72-2.00). In contrast to the clinical study, the claims data study achieved formal statistical significance because of its much larger size (288 vs 1,222 hip fractures). Claims data studies tend to overestimate the relationship between benzodiazepine use and hip fractures. After correcting for such bias, a statistically significant association persists. Concluding that there is no relationship at all based on small clinical studies that did not reach statistical significance may be misleading.

Visual risk factors for hip fracture in older people.

To determine the association between poor vision and risk of hip fracture in the Blue Mountains Eye Study. Prospective population-based cohort study. Two post code areas in the Blue Mountains, west of Sydney, Australia. Three thousand six hundred fifty-four community-dwelling Australians aged 49 and older. At baseline, subjects had an extensive eye examination, including refraction, contrast sensitivity and visual field testing, photographs of the lens and retina, and an interview. Hip fractures during the 5-year follow-up were identified by self-report and review of medical records and were radiologically confirmed. For 2-year follow-up (17 hip fractures), the adjusted hazard ratio (HR) for risk of hip fracture in those with corrected visual acuity worse than 20/60 was 8.4 (95% confidence interval (CI) = 1.5-48.5, population attributable risk (PAR) = 27%); for presence of posterior subcapsular cataract, the adjusted HR was 5.0 (95% CI = 1.1-23.0, PAR = 24%); and for visual field loss, the adjusted HR was 5.5 (95% CI = 1.0-29.8, PAR = 55%). In those aged 75 and older, visual acuity worse than 20/60 gave an adjusted HR of 40.6 (95% CI = 5.6-292.5, PAR = 49%). Visual impairment of any type did not predict risk of hip fracture after a 2-year follow-up. Visual impairment is strongly associated with risk of hip fracture in the next 2 years but not over a longer period of time.

Visual factors should be assessed in older people presenting with falls or hip fracture.

Visual impairment, although not routinely assessed, is an important risk factor for falls and hip fracture in older people. Impaired vision is highly prevalent and commonly unreported in the elderly population particularly in women and those living in nursing homes. Measurement of visual functions such as visual acuity, contrast sensitivity and depth perception may identify older people at risk of falls and hip fracture. Visual loss in older people is correctable in most cases. Intervention strategies, for example, change of glasses or cataract extraction may have the potential of improving visual function and preventing falls in older people.