Mortality and Institutionalization Following Hip Fracture
abstract & commentary
Synopsis: Impaired mental status on admission was found to increase the chance of both mortality and institutionalization in older hip fracture patients, and each additional 10 years of age increased institutionalization risk 2.5 times in this large, one-year, population-based study of Canadian residents in Edmonton older than 64 years of age. Male gender also increased mortality risk fourfold, while socioeconomic factors did not influence the outcomes.
Source: Cree M, et al. J Am Geriatr Soc 2000;48:283-288.
Previous studies of hip fracture outcomes in community-living elderly have shown surprisingly high rates of mortality and institutionalization, leading to further research on which variables might be modifiable to improve our current treatments. A 1993 British study following 1000 consecutive acute proximal femoral fractures found 33% mortality overall at one year; six-month mortality was similar at 28% for all fractures (the overall rates included 8 patients < 65). For older patients, the mortality was higher: 38% for extracapsular fractures with a mean age of 80 years on admission. This figure rose to more than 50% mortality for those older than the age of 90. Intracapsular fractures gave a slightly lower overall mortality of 29% at one year. Institutionalization at one year was 30% for extracapsular fractures and 10% for intracapsular. More than 15% of patients died before leaving the hospital.1
In the United States, the New Haven Established Population for Epidemiologic Studies of the Elderly (EPESE) project followed 2812 residents 65 years of age and older for six years and tracked 120 persons suffering acute hip fractures with 18% mortality and 29% institutionalization at six months. They also found that fracture site (worse for subtrochanteric and femoral neck fractures compared to intertrochanteric) predicted worse outcomes, and additionally identified that poor mental status, male gender, comorbid conditions, and complications were statistically associated with more deaths. Patients who had four or more errors on the 10-item Short Portable Mental Status Questionnaire died at a rate of 36% compared to 12% for those with three or fewer errors.2
Now this Canadian study from Edmonton, Alberta, has extended the previous research by tracking more variables including demographics, social support, and health perception in a prospective inception cohort study in 1996-1997 that assessed new fractures both in the hospital and at three-month follow-up. The three-month period was chosen based on existing literature that shows little change in the mortality curve between three and 12 months. Fractures from pathological conditions such as Paget’s disease or bone cancer were excluded, as well as recurrent fractures on the same hip within five years.
Starting with an elderly population in Edmonton of approximately 67,500, over the year 610 acute fractures were admitted to one of two available facilities, and 470 were interviewed for the study with an average age of 81 years. Three-quarters were female, 60% of all were widowed. Early deaths of 36 prevented inclusion in the study. By three months, the total mortality was 44 (or 8% of the group) of 558 analyzed. Of the group that died, one-half were male and 39% had previously resided in long-term care institutions.
Mental status was measured using the Mini-Mental State Exam (MMSE) scored between 0-30 (low to high mental functioning) as part of an in-person baseline interview in the hospital within the first week following the acute fracture. Follow-up was by telephone interview. Sixty-five percent of participants were able to be interviewed personally, and information was obtained for the remainder from caregivers. When patients of the same age were paired by MMSE results, the lower scores (£ 20) were eight times as likely to be institutionalized as higher scores. For patients of different ages with identical MMSE scores, each additional 10 years of age tripled the risks of institutionalization.
Additional variables were evaluated that might be thought to influence better outcomes: social support, health perception and physical function both prefracture and three months postfracture were assessed by interview using the widely accepted Barthel Index, SF-12, and OARS scales. Years of education and preretirement occupation were used to calculate an "occupational prestige score." None of these appeared to contribute to institutionalization risk except postfracture physical function (prefracture status was not significant), including no effect from comorbidities obtained from the medical record. Even prefracture residence in a long-term care facility was not significant. The only variables in this study significantly related to the 17% risk of institutionalization were low cognitive function, increasing age, and postfracture physical function.
Mortality for hip fracture patients was only related to low cognitive function and male gender. Other studies have also confirmed gender as a higher risk and have speculated that males may have more serious falls, more comorbidities, or less social support to explain the difference. In this study, however, male gender was still associated with higher mortality even after controlling for social support and comorbidities.
COMMENT BY MARY ELINA FERRIS, MD
Given the high frequency of hip fractures in the elderly (> 200,000 annually in the United States), and the devastating consequences and costs that they incur, research such as this article that contribute to our understanding of patient outcomes is most welcome. Although the different studies noted above are not completely comparable in populations used or variables analyzed (such as whether fracture patients were previously residing in the community or what type of mental status testing was used), they all reveal startling high mortality rates after acute fractures and high rates of subsequent institutionalization. Cree and colleagues did not comment on the lower mortality rates they found compared to previous studies, but perhaps advancing medical knowledge is having an effect here.
Since operative treatment of hip fractures was introduced in the 1950s, surgical experience provides a variety of options depending on the type of fracture and the degree of the patient’s prefracture mobility, from simple percutaneous pinning to total hip replacement. A recent article suggests that surgery is not advisable for bedridden or moribund patients, or those with osteoporotic bones and extensively comminuted fractures.3 An extensive evidence-based review comparing conservative vs. operative treatment for extracapsular hip fractures revealed surprisingly limited evidence for improved outcomes from surgical management. No differences in medical complications or mortality were found, although surgery did result in shorter hospital stays and possibly a higher return to the patient’s original residence. Conservative treatments produced less surgical complications but longer rehabilitation.4
There seems little doubt that poor mental function is associated with worse outcomes, leading to speculation that specialized rehabilitative services for this group might be beneficial. Or should we dare to suggest that an entirely different treatment approach, such as nonsurgical conservative comfort measures for low functioning fracture patients, might actually be the better choice? The lack of statistical association most variables contribute to better outcomes in this study stimulates creative thinking on what should be the treatment and rehabilitation of hip fractures. New approaches with appropriate outcome research are needed to provide more guidance for clinicians, patients, and their families facing difficult decisions on the most humane and beneficial treatments for the common condition of acute hip fracture.
References
1. Keene GS, et al. BMJ 1993;307:1248-1250.
2. Marottoli RA, et al. Am J Public Health 1994;84:807-812.
3. Lichtblau S. Geriatrics 2000;55(4):50-52, 55-56.
4. Parker MJ, et al. Cochrane Database Syst Rev 2000;2:CD000337.
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