Why hip fractures in the elderly are often a death sentence

There are many reasons elderly people who fracture their hip often don’t recover. Credit: shutterstock.com

The news an elderly relative has broken a hip tends to sound alarm bells, perhaps more than breaking another bone would. That's because a hip fracture dramatically increases an older person's risk of death.
One in three adults aged 50 and over dies within 12 months of suffering a hip fracture. Older adults have a five-to-eight times higher risk of dying within the first three months of a hip fracture compared to those without a hip fracture. This increased risk of death remains for almost ten years.

14 jun 2018--Beyond suffering pain, a hip fracture results in a loss of physical function, decreased social engagement, increased dependence, and worse quality of life. Many people who have a hip fracture need to change their living conditions, such as relocating from their home into a residential aged care facility.
Ultimately, the often rapid regression of an older person's health following a hip fracture means outcomes are poor.

Risk factors for hip fractures

Age is a key risk factor, with hip fractures more likely to occur in those aged 65 or older. They're primarily a result of a fall, or when the hip collides with a solid object such as a kitchen bench. However, they can also occur when there has been little or no trauma, such as standing up.
Cognitive impairment such as dementia is a common factor that increases the risk of falling. Frailty, poor vision, the use of a combination of medications, and trip hazards in the home also increase the likelihood of falls. Osteoporosis, a disease characterised by low bone mass and degradation of bone tissue, is another significant risk factor for hip fractures.
Osteoporosis and osteopenia (where bone mass is lower than normal, but not yet osteoporotic) are reported to affect more than one million Australians aged 65 and older. Worldwide, one in three women and one in five men experience a fracture caused by such bone fragility, with a fracture occurring every three seconds. Compared to a fracture of any other bone, a hip fracture results in the most serious of all consequences.
While the reasons remain unclear, hip fractures also disproportionately affect those at the disadvantaged end of the social scale.
Previous research has reported around 30% of people with hip fractures have had a prior fracture; this is known as the "fracture cascade". The increased risk of subsequent fracture may persist for ten years, which highlights the importance of treating the initial fracture promptly and effectively.

Increased risk of death

In Australia, standard clinical care following a hip fracture begins with timely assessment, including X-rays, and pain and cognitive assessments. Australian data indicate more than three-quarters of people who sustain a hip fracture undergo surgery, the most common procedure being a joint replacement. Surgical intervention will generally occur within 48 hours.

Immobility after a hip fracture can lead to poor patient outcomes. Credit: shutterstock.com

But some patients may prefer not to undergo surgery. Or, their medical team may determine the risks are too great to expose the person to surgery.
Combined with the trauma of a fracture and surgery, an existing health condition may significantly increase the risk of death. Death after a hip fracture may also be related to additional complications of the fracture, such as infections, internal bleeding, stroke or heart failure.
One study showed heart disease, stroke and pneumonia resulted in a long-term doubling of risk of death after hip fracture, and this risk remained high for up to ten years in women and 20 in men.
Studies suggest issues related to the hospitalisation, surgery, or immobility (which could put patients at risk of pneumonia) after a fracture lead to other complications that ultimately result in earlier death.

How can patient outcomes be improved?

Together with controlling immediate post-surgery pain and symptoms, patients should receive therapeutic rehabilitation and functional training for the best chance of regaining mobility.
Taking individual capabilities, physical health and function into account, therapeutic rehabilitation may include improving the range of motion, pool therapy, and strengthening and progressive resistance exercises. Functionaltraining will include gait training, and resistance and balance exercises.
Even if the patient has not had surgery, rehabilitation is necessary to begin moving as quickly as possible to avoid the serious complications of being immobilised.
Some data suggest beginning physical activity as soon as possible post-surgery will reduce the likelihood of death. What we don't yet know is the type, intensity and duration of physical activity that will give the best results.
Nutrition can also help recovery. Some data has shown poor nutrition at the time of the fracture reduced people's ability to walk unaided six months after the fracture, compared to those with good nutrition.
There are mixed messages regarding whether nutritional supplements help improve function after a hip fracture. But the combination of protein intake and physical activity is known to increase muscle mass and function. Good muscle mass and function reduce frailty and improve balance, thereby reducing the risk of falls and subsequent fracture.
And there are additional benefits to be gained from being physically active, such as reducing depression – particularly when exercising with other people.

This article was originally published on The Conversation. Read the original article.

Provided by The Conversation

Hip fracture guidelines tackle 'considerable variations' in UK and Irish hospital care

All patients with hip fractures should be fast-tracked through hospital emergency departments and operated on within 48 hours of admission, according to new consensus guidelines developed by UK experts in anaesthesia, orthopaedics, geriatrics and emergency medicine and published in the January issue of Anaesthesia.

13 jan 2012--However, patients in one in five hospitals in England and Wales currently wait longer than two days, risking lengthier inpatient stays, increased health problems - such as pressure sores, pneumonia and blood clots - and even an increased chance of death if the delay is prolonged.

The Association of Anaesthetists of Great Britain and Ireland teamed up with a number of other organisations, including the Age Anaesthesia Association and British Orthopaedic Association, to develop the new ten-point plan for the Management of Proximal Femoral Fractures.

"Unlike existing guidelines, they review the current clinical evidence and also recommend best practice in numerous circumstances where evidence is controversial or incomplete, based on expert consensus" says consultant anaesthetist Dr Richard Griffiths, who chaired the working party.

"These are the first guidelines to cover some of the difficult clinical problems faced by anaesthetists on a daily basis.

"For example, we recommend that if any investigations need to be carried out on patients with systolic heart murmurs, this should be done as a matter of urgency to avoid delaying their operations.

"The management of patients on antiplatelet drugs to avoid blood clots forming is another controversial area. Evidence is incomplete, but the expert consensus is to proceed with surgery without stopping the drugs, as operating delays pose a greater risk to the patient."

Hip fractures present unique challenges for anaesthetists as they often occur in elderly patients with significant health problems, stresses Dr Griffiths.

"Despite the fact that guidance has been in place since the early 1990s concerning best practice management for these vulnerable patients, there remain considerable variations in models of post-operative care, rehabilitation and orthogeriatric input" he says.

"Bringing together experts in anaesthesia, orthopaedics, geriatrics and emergency medicine has enabled us to look at the journey of the hip fracture patients from admission to discharge and recommend how their care can be maximised by everyone involved."

Approximately 77,000 patients break their hips in the UK every year, spending an average of 16 days in hospital and costing the National Health Service £785 million. The majority (95 per cent) occur in people over 60 years of age and 75 per cent occur in females.

More than eight per cent of patients will die within 30 days of a hip fracture, especially if they are older, sicker or male, and this figure rises to up to 30 per cent within a year. It has been suggested that half of postoperative deaths are potentially preventable.

Only 44 per cent of UK patients admitted from home are discharged back to their home within 30 days of surgery. A further 22 per cent are discharged to a residential or nursing home and they can often spend a long time in hospital waiting for admission to these facilities, blocking much needed beds.

The ten-point action plan advises that:

1. There should be protocol-driven, fast-track admission of patients with hip fractures through the emergency department.
2. Patients with hip fractures require multidisciplinary care, led by orthogeriatricians.
3. Surgery is the best analgesic for hip fractures.
4. Surgical repair of hip fractures should occur within 48 hours of hospital admission.
5. Surgery and anaesthesia must be undertaken by appropriately experienced surgeons and anaesthetists.
6. There must be high-quality communication between clinicians and allied health professionals.
7. Early mobilisation is a key part of the management of patients with hip fractures.
8. Pre-operative management should take into consideration plans for the patient's discharge from hospital.
9. Measures should be taken to prevent secondary falls.
10. Continuous audit and targeted research is required in order to inform and improve the management of patients with hip fracture.

"We hope that our guidelines will address current variations in clinical practice so that patients can all benefit from a more consistent approach" concludes Dr Griffiths, who is also lead clinician for the National Health Service Hip Fracture Perioperative Group, an initiative started by anaesthetists, but with increasing membership from orthogeriatricians.

More information: Management of proximal femoral fractures 2011. Griffiths et al. Anaesthesia. 67, pp85-98. (2012). doi:10.1111/j.1365-2044.2011.06957.x

Provided by Wiley

Women who break a hip at increased risk of dying within a year

Women ages 65-69 who break a hip are five times more likely to die within a year than women of the same age who don't break a hip, according to a Kaiser Permanente Center for Health Research study funded by the National Institutes of Health and published online today in the Archives of Internal Medicine.

27 sept 2011--This paper breaks down death risk by age group. In addition to the finding for women ages 65-69, it finds that for women ages 70-79, a hip fracture doubles the risk of dying within a year. Most women 80 and older have the same risk of dying within a year whether they fracture their hip or not, but for women 80 and older who are in excellent health, a hip fracture nearly triples the risk of dying within a year.

"This study is a wake-up call that the first year after a hip fracture is a critical time for all elderly women, but especially for younger women, ages 65-69, who face a much higher death rate compared to their peers," said Erin S. LeBlanc, MD, MPH, lead author and investigator at the Kaiser Permanente Center for Health Research in Portland, Ore. "We need to do more to prevent hip fractures from occurring, and we need to study how best to care for women after fracture to prevent these deaths."

Other studies have found that women who break a hip are at higher risk for earlier death, but most of those studies concluded that the increased risk was not because of the fracture, but because of underlying health conditions such as heart disease, stroke, or diabetes. This study controlled for these underlying health conditions and also matched each woman who broke her hip with four women of the same age who didn't break a hip.

"Our study suggests that it is the hip fracture, and not just poor health, that puts these women at higher risk of dying," said Teresa Hillier, MD, MS, co-author and senior investigator at the Kaiser Permanente Center for Health Research. "We also found women are at the highest risk of dying within the first three months after hip fracture, which leads us to hypothesize that hospitalization, surgery and immobility lead to other complications that ultimately result in their death."

Another reason researchers think that hip fractures, and not other underlying health conditions, put women at higher risk of death is their finding involving women aged 80 and older. These women are often sicker to begin with and most of them face the same risk of dying within a year whether they break their hip or not. But when researchers looked at a subset of women who were 80 and older and were also in excellent health, they found that those who fractured a hip were almost three times more likely to die compared to their counterparts who didn't break a hip.

"This finding suggests that it is the hip fracture itself that ultimately leads to death in these women. Even though they start out in excellent health the hip fracture is so devastating that many of them don't recover," said LeBlanc.

The study is part of the Study of Osteoporotic Fractures that has been ongoing for more than two decades. During 1986-88 SOF enrolled nearly 10,000 community-dwelling, ambulatory women ages 65 and older from Baltimore; Minneapolis; Portland, Ore.; and the Monongahela Valley near Pittsburgh.

Over the next 20 years, 1,116 of those women suffered hip fractures. Researchers categorized the women by age and then matched 4,464 women of the same age who didn't break a hip to serve as controls. They followed all of the women, sending out postcards every four months to check on their health status, and asking them to come in for clinic visits every 2 to 3 years. During the visits women were given a medical exam and asked to fill out questionnaires about their health status. Cause of death was determined by death certificates and other supporting documentation where available. The leading causes of death among all women in the study were heart disease, cancer and stroke.

Among women who broke a hip, more than half of the short-term deaths occurred within three months after the fracture and nearly three-quarters occurred within six months. The only women who had a higher long-term risk of death (within 10 years) after hip fracture were the women ages 65-69.

According to the National Osteoporosis Foundation, about half of women over age 50 will break a bone because of osteoporosis, which is a thinning or weakening of the bone that can cause bones to break more easily. The foundation recommends that women 65 and older, and pre-menopausal women with risk factors such as low body weight, smoking or long-term steroid use, should get a bone density scan to determine if they have or are at risk for developing osteoporosis. Once diagnosed, many women start taking medication to strengthen their bones and decrease the risk of fracture.

Other tips to prevent hip fractures include:

• Ensure adequate calcium and vitamin D intake
• Do weight-bearing and balancing exercises
• Avoid cigarette smoking
• Have a home assessment to make sure your home is fall proof

Provided by Kaiser Permanente

In Elderly Women, Hip Fractures Often Follow Arm Breaks

03 mar 2009-- Elderly women who suffer a broken upper arm are five times more likely than normal to break a hip within a year after the arm fracture, a finding from a new study that might help in efforts to prevent both types of fractures.

"There have been studies in the past showing a relationship between upper arm fractures and hip fractures, but we wanted to determine when that risk is greatest," Dr. Jeremiah Clinton, an orthopedic surgeon and associate professor of orthopedics at the University of Washington in Seattle, said in an American Academy of Orthopaedic Surgeons news release. "By recognizing when that period of increased risk occurs, physicians have a window of opportunity to take steps that may possibly prevent a subsequent fracture."

The study was published in the March issue of The Journal of Bone & Joint Surgery.

The exact relationship between arm and hip fractures isn't clear, but "there is evidence to support that both fractures stem from similar reactions to a fall," Clinton said. "When patients age, their reflexes slow down, and they may not have the time or ability to correctly position themselves as they fall. Rather than trying to catch themselves as a younger person would do, studies show that elderly people have a tendency to simply tuck and roll, which causes greater force on the shoulder and hip."

Causes of falls among elderly people include: effects of medications, neurological disorders, loss of an ability to maintain balance and decreased reaction time.

"One of the first steps a patient should take following a fall is to talk with their orthopedist and other physicians to determine the cause," Clinton said. "Once the cause is more clearly understood, the proper steps can be taken to decrease a patient's risk of having another fall and potentially future fractures."

Inactivity in Men Is Linked to Broken Bones, Study Says

By NICHOLAS BAKALAR
Inactive men may have a substantially increased risk for broken bones of all kinds, and especially for hip fractures, a new Swedish study has found.
Even after controlling for health and behavioral variables, researchers reported, sedentary men were more than one and a half times as likely as active ones to suffer a broken bone, and more than two and a half times as likely to break a hip.
Although they are unsure of the mechanism, the authors theorize that exercise may work by increasing skeletal strength and muscle mass, and improving balance. The active men in the study did three or more hours a week of intense physical activity.
The researchers studied health records of 2,205 men beginning at age 49 to 51, and then followed them for up to 35 years, during which 482 men had at least one fracture. The men were interviewed and examined again at ages 60, 70, 77 and 82. At the end of the follow-up period (last Dec. 31), 896 of the men were still living. The study appears online in the June issue of PLoS Medicine.
At each of the five interviews, the scientists posed the same questions about watching television and movies, engaging in other sedentary activities, walking or cycling for pleasure, and engaging in sports. They also administered exercise tests and performed muscle biopsies to measure physical fitness, confirming that the men who reported higher levels of exercise were in fact more fit. By linking records with job titles, they were also able to include information on physical activity at work.
The researchers found that the men who maintained the highest levels of activity had the fewest fractures, and that those with the lowest levels had the most. The association held true for all fractures, but was especially strong for broken hips. Moreover, men who increased their exercise saw a corresponding decrease in the number of fractures.
“It’s never too late to start exercising,” said Dr. Karl Michaelsson, the lead author and a professor of surgery and epidemiology at Uppsala University in Uppsala, Sweden. But he was reluctant to offer specific exercise advice.
“You can’t say to an 85-year-old that he should start vigorous exercise three hours a week,” Dr. Michaelsson said. “Also, we only asked if the men were engaged in physical activity regularly. What kind of physical activity has the greatest effect, we don’t really know.”
The scientists controlled for a large range of variables that might influence physical activity and fracture risk: smoking; marital status; education; alcohol use; body mass index; self-reported chest, joint, or back pain; plus a large number of illnesses including cardiovascular, gastrointestinal, neurological, inflammatory and others.
Dr. Elizabeth Shane, a professor of medicine and osteoporosis specialist at Columbia who was not involved in the study, said she was impressed with the methodology.
“The stress testing and muscle biopsies increase the biological plausibility of the results,” Dr. Shane said. “We always recommend physical activity to our patients, and it’s helpful to know that it does seem to be associated with a decreased risk of fracture.”
The study has other significant strengths, even though it was not a randomized trial. The researchers began monitoring the men before the age when most fractures occur, and the data, gathered from registers using the individual personal registration number given to all Swedish citizens, is highly reliable. Finally, the long follow-up allowed researchers to take health and lifestyle changes over time into account.